Prediction of early-onset asthma in genetically at-risk children

Phenotypes of atopic dermatitis and the risk for subsequent asthma: a systematic review and meta-analysis

BACKGROUND

Various atopic dermatitis (AD) phenotypes showed an enormously heterogenic risk for subsequent asthma development.

OBJECTIVE

We aimed to investigate the association between AD phenotypes and the risk for progression to asthma.

METHODS

We searched PubMed, Embase, and Web of Science databases for relevant publications. Pooled relative risks (RR) with 95% confidence intervals (CI) were calculated using the CMA-3.0 software. This study has been registered with PROSPERO (CRD42019129273).

RESULTS

We analyzed 39 publications with 458,810 participants. The RR for asthma in AD was 2.16 (95% CI, 1.88-2.48). The risk in persistent AD (RR, 3.36; 95% CI, 2.83-3.99) was higher than in transient AD (RR, 1.52; 95% CI, 1.34-1.73), and in severe AD (RR, 2.40; 95% CI, 1.96-2.94) was higher than mild (RR, 1.82; 95% CI, 1.03-3.23) or moderate (RR, 1.51; 95% CI, 1.30-1.75) AD. The risk for asthma in early-onset AD was slightly higher than in late-onset AD and in boys higher than girls.

LIMITATIONS

The AD and asthma definitions differed across the included studies.

CONCLUSION

Patients with persistent or severe AD were at a higher risk for developing asthma. These findings further elucidate the atopic march and identify target populations for asthma prevention.

A systematic review of parenting interventions for child chronic health conditions

This systematic review summarizes the parenting intervention literature for parents of children with chronic health conditions and evaluates intervention effects on parenting (parenting skills and parenting efficacy) and child (behaviour, illness severity/control and quality of life) outcomes. Systematic searches using seven electronic databases (including CINHAL, MEDLINE and PsycINFO) were used to identify relevant papers published in English between 1997 and 2017, and reference lists were searched for additional relevant articles. Ten papers reporting on eight separate studies met inclusion criteria: three studies evaluated stand-alone parenting interventions, while the remaining five studies included parenting components in broader interventions that also targeted medically oriented aspects of illness management. Results suggest that parenting interventions may lead to improved parent self-efficacy, parenting behaviour, illness severity/control, child quality of life and child behaviour; however, intervention effects were mixed and confined to parent-report outcome measures. A paucity of studies using rigorous randomized controlled trial study designs limits the conclusions that can be drawn regarding intervention efficacy. Achieving adequate enrolment and retention of families in parenting intervention trials appears to be problematic within these clinical groups. Larger samples and more diverse clinical populations will support the reliability of future evaluations of parenting interventions in this context and improve generalizability of results.

Maternal distress across the postnatal period is associated with infant secretory immunoglobulin A

Employing a longitudinal design, relationships between maternal distress (i.e., perceived stress, negative affect, depressive symptomology), and infant secretory immunoglobulin A (sIgA) across the peripartum period were examined in 51 mother-infant dyads. Indices of maternal distress were assessed at four time periods: third trimester of pregnancy and 1, 3, and 6 months postpartum. Infant saliva samples were collected at each of the three time points in the postpartum period to assess sIgA levels. No relationships were found between prenatal maternal distress and infant sIgA. Results indicated that during the postnatal period, higher concurrent maternal distress was associated with reduced infant sIgA. Maternal distress did not prospectively predict infant sIgA. These findings advance our understanding of the social-context of infant development, highlighting the significance of maternal regulation of infant immunity.

In-Home Secondhand Smoke Exposure Among Urban Children With Asthma: Contrasting Households With and Without Residential Smokers

CONTEXT

Secondhand smoke exposure (SHSe) affects up to half of all children in the United States. Many studies have identified factors associated with in-home SHSe, but few have contrasted these factors between households with and without residential smokers. In the latter case, exposure occurs from only external sources that enter the home, such as visitors or environmental incursion.

OBJECTIVE

Among children with SHSe at home, to examine demographic and psychosocial differences between households with and without residential smokers.

DESIGN

Baseline analysis of an observational cohort.

SETTING

Baltimore City, Maryland.

PARTICIPANTS

A total of 157 children with asthma, aged 5 to 12 years.

MEASURES

At-home airborne nicotine, caregiver-reported depression, asthma-related quality of life, functional social support, and demographics. Univariable comparisons were performed between SHS-exposed households with and without residential smokers. Multivariable logistic regression models were fit to examine associations between measured factors and absence of residential smokers.

RESULTS

Children (78.3%) had at-home SHSe. Of these, 40.7% lived in households without residential smokers. Compared with households with residential smokers, these caregivers endorsed stronger beliefs in SHS harms and also worse functional social support and asthma-related stress, despite no differences in asthma morbidity. In adjusted models, SHS-exposed children with caregivers in the lowest tertile of functional social support (adjusted odds ratio, 3.50; 95% confidence interval, 1.12-10.99), asthma-related quality of life (2.90; 1.06-7.95), and those living alone (5.28; 1.26-22.15) had at least twice higher odds of having exclusively external SHSe than the highest tertile (P trends < .05).

CONCLUSIONS

In-home SHS exposure remains alarmingly high in urban environments. However, a substantial proportion of this exposure appears to be occurring only from external sources that enter the home. Caregivers in these homes had higher desire but lower agency to avoid SHSe, driven by lack of functional support and physical isolation. Public policies targeting these factors may help remediate exposure in this especially vulnerable population.

The effects of caregiver depression on childhood asthma: Pathways and mechanisms

OBJECTIVE

To review the literature regarding the effects of caregiver depression on childhood asthma and integrate the findings into a multilevel model of pathways by which these effects occur to further the understanding of the complex biopsychosocial nature of childhood asthma and the key role that is played by caregiver depression.

DATA SOURCES

PubMed was searched for articles published from 2007 to the present (10-year search), and Google Scholar was searched for articles published in 2017 and 2018 to identify the most recent publications.

STUDY SELECTIONS

Studies selected were recent, empirical, or meta-analytic, conducted in humans, and had specific relevance to one or more of the identified pathways. Articles published before 2007 were included if deemed essential because they addressed key pathways, for which there were no more recent articles.

RESULTS

Review of the literature substantiates that caregiver depression plays a key role in the socioeconomic, familial, psychological, and biological cascade of effects on childhood asthma. Childhood asthma outcomes are affected indirectly by socioeconomic status and family stress mediated by caregiver depression, which affects disease management, and/or stress and depression in the child, which, in turn, affect asthma through alterations in immune modulation and autonomic regulation.

CONCLUSION

Findings indicate that future research should concentrate on mediators and moderators to further clarify the complex interplay of these factors that affect childhood asthma. The findings also have substantial translational implications. Given that child stress and depression contribute to asthma disease activity and that treating caregiver depression improves child stress and depression, there is strong rationale for treating depressed caregivers of children with asthma as a component means of improving childhood asthma control.

Maternal sensitivity and social support protect against childhood atopic dermatitis

BACKGROUND

Many studies have identified associations between qualities of maternal-child relationships and childhood asthma, but few have examined associations with childhood atopic dermatitis (AD), a common precursor to asthma. Moreover, maternal psychological distress, including prenatal and postnatal depression, anxiety and stress, may increase risk, while social support from partners may reduce risk for childhood AD. We sought to uncover the association between maternal-infant relationship qualities (maternal sensitivity towards infant behavioral signals, controlling behavior, and unresponsiveness) and child AD after accounting for risk (i.e., prenatal and postnatal maternal depression, anxiety and stress) and protective (i.e., social support) factors.

METHODS

We conducted a secondary analysis of data collected on a subsample of 242 women and their infants enrolled during pregnancy in the ongoing Alberta Pregnancy Outcomes and Nutrition cohort study. Inclusion criteria required mothers to be >16 years of age, English speaking and <22 weeks gestational age at enrollment. Data on depression, anxiety and stress in the prenatal and postnatal periods and physician diagnosis of childhood AD at 18 months were gathered via maternal report. Maternal sensitivity, unresponsiveness and controlling behaviours were assessed via videotaped observations using the Child-Adult Relationship Experimental (CARE)-Index at 6 months of infant age.

RESULTS

Higher maternal sensitivity, or the inability of the mother to appropriately understand and respond to infant needs based on behavioral signals, predicted reduced odds of AD independent of and in combination with low prenatal and postnatal anxiety and high paternal support. After adjustment, higher maternal controlling behaviours and unresponsiveness also predicted greater odds of AD.

CONCLUSIONS

Low maternal sensitivity is a risk factor for childhood AD, independently and in combination with perinatal anxiety and low social support. Thus, interventions that improve maternal-infant relationship quality, especially sensitivity, reduce anxiety and improve social support from partners could reduce odds of childhood AD.

Asthma, Food Allergy, and How They Relate to Each Other

The association between atopic diseases is well known, and previous research has shown that having one atopic disease can predispose to having another. The link between asthma and food allergy has been well researched, but the exact relationship between the two atopic conditions is not fully understood. Food allergic infants are at increased risk for the development of asthma and are at risk of food-induced asthmatic episodes and also anaphylaxis. Having a diagnosis of both food allergy and asthma has also been shown to have an effect on the severity of a patient's disease including being at greater risk of severe asthmatic episodes. Therefore, understanding the relationship between these two conditions in order to treat and manage these children safely is crucial to clinicians.

Associations between postpartum depressive symptoms and childhood asthma diminish with child age

BACKGROUND

Affecting 19% of women, postpartum depression is a major concern to the immediate health of mothers and infants. In the long-term, it has been linked to the development of early-onset asthma at school entry, but only if the depression persists beyond the postnatal period. No studies have tested whether associations with postpartum depressive symptoms and early-onset asthma phenotypes persist into later school age.

OBJECTIVE

To determine associations between maternal postpartum depressive symptoms and childhood asthma between the ages of 5-10 by using a nested longitudinal design.

METHODS

Data were drawn from the 1994-2004 administrations of the Canadian National Longitudinal Survey of Children and Youth, which tracks the health of a nationally representative sample of children in Canada. Child asthma was diagnosed by a health professional, and maternal depressive symptoms were assessed by the Centre for Epidemiological Studies Depression scale. Analyses were conducted by using a multilevel modelling approach, in which longitudinal assessments of asthma in 1696 children were nested within the exposure of postpartum depression.

RESULTS

Postpartum depressive symptoms had a 1.5-fold significant association with childhood asthma between the ages 6-8. This was independent of male sex, maternal asthma, non-immigrant status, low household socioeconomic status, being firstborn, low birthweight, low family functioning and urban-rural residence, of which the first 4 covariates elevated the risk of asthma. Statistical significance was lost at age 8 when maternal prenatal smoking replaced urban-rural residence as a covariate. At ages 9-10, an association was no longer evident.

CONCLUSIONS AND CLINICAL RELEVANCE

Women affected by postpartum depressive symptoms are concerned about long-term health effects of their illness on their infants. Although postpartum depressive symptoms were associated with school-age asthma at ages 6 and 7, this association diminished later. Both home and school life stress should be considered in future studies on asthma development later in childhood.

Effects of Triple P parenting intervention on child health outcomes for childhood asthma and eczema: Randomised controlled trial

Childhood chronic health conditions have considerable impact on children. We aimed to test the efficacy of a brief, group-based parenting intervention for improving illness-related child behaviour problems, parents' self-efficacy, quality of life, parents' competence with treatment, and symptom severity. A 2 (intervention vs. care as usual) by 3 (baseline, post-intervention, 6-month follow-up) design was used, with random group assignment. Participants were 107 parents of 2- to 10-year-old children with asthma and/or eczema. Parents completed self-report questionnaires, symptom diaries, and home observations were completed. The intervention comprised two 2-h group discussions based on Triple P. Parents in the intervention group reported (i) fewer eczema-related, but not asthma-related, child behaviour problems; (ii) improved self-efficacy for managing eczema, but not asthma; (iii) better quality of life for parent and family, but not child; (iv) no change in parental treatment competence; (v) reduced symptom severity, particularly for children prescribed corticosteroid-based treatments. Results demonstrate the potential for brief parenting interventions to improve childhood chronic illness management, child health outcomes, and family wellbeing. Effects were stronger for eczema-specific outcomes compared to asthma-specific outcomes. Effects on symptom severity are very promising, and further research examining effects on objective disease severity and treatment adherence is warranted.

AUSTRALIA NEW ZEALAND CLINICAL TRIALS REGISTRATION

ACTRN12611000558921.

Evaluating the effectiveness of a family empowerment program on family function and pulmonary function of children with asthma: A randomized control trial

BACKGROUND

Empowerment can be an effective strategy for changing an individual's health behaviours. However, how to empower whole families to manage their children's asthma is a challenge that requires innovative nursing intervention based on family-centred care.

AIMS

To evaluate the effectiveness of a family empowerment program on family function and pulmonary function of children with asthma compared to those receiving traditional self-management only.

DESIGN

A randomized control trial.

METHODS

Sixty-five families were recruited from one asthma clinic in a medical centre in Taiwan. After random assignment, 34 families in the experimental group received the family empowerment program consisting of four counselling dialogues with the child and its family. We empowered the family caregiver's ability to manage their child's asthma problems through finding the problems in the family, discovery and discussion about the way to solve problems, and enabling the family's cooperation and asthma management. The other 31 families received the traditional care in asthma clinics. The Parental Stress Index and Family Environment Scale of family caregivers, and pulmonary function, and asthma signs of children with asthma were collected at pre-test, 3-month post-test, and one-year follow-up. We utilized the linear mixed model in SPSS (18.0) to analyze the effects between groups, across time, and the interaction between group and time.

RESULTS

The family empowerment program decreased parental stress (F=13.993, p<.0001) and increased family function (cohesion, expression, conflict solving, and independence) (F=19.848, p<.0001). Children in the experimental group had better pulmonary expiratory flow (PEF) (F=26.483, p<.0001) and forced expiratory volume in first second (FEV1) (F=7.381, p=.001) than children in the comparison group; however, no significant change in forced expiratory volume in first second (FEV1)/forced vital capacity (FVC) was found between the two groups. Sleep problems did not show significant changes but cough, wheezing, and dyspnoea were significantly reduced by family caregiver's observations.

CONCLUSION

We empowered families by listening, dialogues, reflection, and taking action based on Freire's empowerment theory. Nurses could initiate the families' life changes and assist children to solve the problems by themselves, which could yield positive health outcomes.

Postpartum depression, a direct and mediating risk factor for preschool wheeze in girls

BACKGROUND

Postpartum depression affects over 1 in 10 child-bearing women. A growing body of evidence links maternal distress during the key developmental stages of infants with poor health outcomes, including wheeze and asthma.

OBJECTIVE

We sought to investigate whether postpartum depression had an independent association with the development of wheeze in preschool-aged children. A second a priori objective was to ascertain whether postpartum depression functioned as a mediating factor for associations between wheeze, and prenatal distress and nutrition.

METHODS

Data from the Community Perinatal Care Trial on maternal postpartum depression (Edinburgh Postnatal Depression Scale), the dependent variable, wheeze at age 3, and possible confounding factors were obtained for 791 women and their children in Calgary, Canada. Adjusted gender-specific logistic regression analyses were performed to test the association between postpartum depression and child wheeze, which was independent of maternal distress and vitamin use during pregnancy, pre/postnatal smoking, preterm birth, exclusive breastfeeding duration, daycare attendance, and maternal education. The potential mediating effects of postpartum depression were investigated in a path analysis.

RESULTS

Wheeze at age 3 was almost 5 times more likely in girls of mothers who experienced postpartum depression. Results from a path analysis suggested that postpartum depression has a direct effect on wheeze (beta-coefficient=0.135, P < 0.05), and also mediates the effects of prenatal distress and vitamin use on wheeze in preschool girls. In boys, only prenatal smoking was a statistically significant predictor of wheeze, mainly through the effects of postnatal smoking.

CONCLUSIONS & CLINICAL RELEVANCE

Postpartum depression may be a risk factor for preschool wheeze among girls in a low risk population, directly and indirectly through prenatal distress and vitamin use. Interventions which target postpartum depression and promote a healthy pregnancy may also reduce the risk of wheeze in children.

Review of family relational stress and pediatric asthma: the value of biopsychosocial systemic models

Asthma is the most common chronic disease in children. Despite dramatic advances in pharmacological treatments, asthma remains a leading public health problem, especially in socially disadvantaged minority populations. Some experts believe that this health gap is due to the failure to address the impact of stress on the disease. Asthma is a complex disease that is influenced by multilevel factors, but the nature of these factors and their interrelations are not well understood. This paper aims to integrate social, psychological, and biological literatures on relations between family/parental stress and pediatric asthma, and to illustrate the utility of multilevel systemic models for guiding treatment and stimulating future research. We used electronic database searches and conducted an integrated analysis of selected epidemiological, longitudinal, and empirical studies. Evidence is substantial for the effects of family/parental stress on asthma mediated by both disease management and psychobiological stress pathways. However, integrative models containing specific pathways are scarce. We present two multilevel models, with supporting data, as potential prototypes for other such models. We conclude that these multilevel systems models may be of substantial heuristic value in organizing investigations of, and clinical approaches to, the complex social-biological aspects of family stress in pediatric asthma. However, additional systemic models are needed, and the models presented herein could serve as prototypes for model development.

Association between adverse childhood experiences in the home and pediatric asthma

BACKGROUND

Numerous studies suggest that psychosocial factors could contribute to pediatric asthma.

OBJECTIVE

To examine the relation between single and cumulative adverse childhood experiences (ACEs), a measurement of household dysfunction, on parent report of lifetime asthma in children.

METHODS

This cross-sectional study used data from the 2011 to 2012 National Survey of Children's Health, a nationally representative sample of children 0 to 17 years old (n = 92,472). The main exposure was parent or guardian report of 6 ACE exposures (eg, witnessing domestic violence). The relation between ACE exposures and parent-reported diagnosis of childhood asthma was examined using multivariable logistic regression after controlling for demographic, socioeconomic, and behavioral covariates.

RESULTS

Overall asthma prevalence was 14.6%. Exposure prevalence to any ACE was 29.2%. Increased number of ACE exposures was associated with increased odds of asthma. In the adjusted model, the odds of reporting asthma were 1.28 (95% confidence interval [CI] 1.14-1.43) for those reporting 1 ACE, 1.73 (95% CI 1.27-2.36) for those with 4 ACEs, and 1.61 (95% CI 1.15-2.26) for those with 5 or 6 ACEs compared with those with no ACE exposures. Effects were moderated by Hispanic ethnicity. Hispanic children exposed to 4 ACEs had a 4.46 times increase in lifetime asthma (95% CI 2.46-8.08); white children had a 1.19 times increase (95% CI 0.80-1.79) compared with those exposed to 0 ACE.

CONCLUSION

This study supports the growing evidence for the biopsychosocial model of asthma onset. Future studies should examine the association between ACEs and specific asthma-related health outcomes.

Parental stress and the onset and course of childhood asthma

The influence of a caregiver’s stress on the development of childhood asthma is an important aspect of the treatment and prevention of illness. Many cross-sectional studies have investigated the association between parenting attitude and/or caregiver’s stress and childhood asthma morbidity, but prospective studies are more advantageous than cross-sectional studies in interpreting a causal relationship from the results. We here present an overview of prospective studies that have reported a relationship between parental stress and the morbidity or course of childhood asthma and discuss the role of parental mental health in its prevention and treatment. Almost all of the studies referred to in this paper show that caregiver (mostly mothers) stress contributed to the onset and to a poor prognosis, while only a few studies have examined the adverse effect of paternal stress on childhood asthma. Their results are inconsistent, and there is insufficient data examining specific stress-related properties that can be targeted in intervention studies. Not only maternal but also paternal influence should be considered in future studies, and it will be important to assess specific stress-related properties that can be the foundation of specific intervention methods.

The use of a collaborative structured methodology for the development of a multifaceted intervention programme for the management of asthma (the MIA project), tailored to the needs of children and families of South Asian origin: a community-based, participatory study

Background

Asthma is one of the most common chronic childhood illnesses in the UK. South Asian children are more likely to suffer from their asthma and be admitted to hospital. While this inequality needs to be addressed, standard behaviour-change interventions are known to be less successful in minority ethnic groups. Evidence suggests a need to enhance services provided to ethnic minority communities by developing culturally sensitive tailored interventions.

Objectives

The Management and Interventions for Asthma (MIA) project aimed to test an iterative multiphase participatory approach to intervention development underpinned by the socioecological model of health, producing an intervention-planning framework and enhancing an evidence-based understanding of asthma management in South Asian and White British children.

Design

Interviews and focus groups facilitated by community facilitators (CFs) were used to explore knowledge and perceptions of asthma among South Asian communities, children, families and healthcare professionals (HCPs). A smaller comparison group of White British families was recruited to identify aspects of asthma management that could be addressed either by generic interventions or by a tailored approach. Collaborative workshops were held to develop an intervention planning framework and to prioritise an aspect of asthma management that would be used as an exemplar for the development of the tailored, multifaceted asthma intervention programme.

Setting

The community study was based in a largely urban environment in Leicester, UK.

Participants

Participants were recruited directly from the South Asian (Indian, Pakistani and Bangladeshi) and White British communities, and through the NHS. Children were aged between 4 and 12 years, with a range of asthma severity.

Intervention development

The study had four phases. Phase 1 consisted of an evidence review of barriers and facilitators to asthma management in South Asian children. Phase 2 explored lay understandings of childhood asthma and its management among South Asian community members (n = 63). Phase 3 explored perceptions and experiences of asthma management among South Asian (n = 82) and White British families (n = 31) and HCP perspectives (n = 37). Using a modified intervention mapping approach incorporating psychological theory, phase 4 developed an intervention planning framework addressing the whole asthma pathway leading to the development of an exemplar multifaceted, integrated intervention programme called ‘ACT [Awareness, Context (cultural and organisational) and Training] on Asthma’.

Results

Data on the social patterning of perceptions of asthma and a lack of alignment between the organisation of health services, and the priorities and competencies of British South Asian communities and families were produced. Eleven key problem areas along the asthma pathway were identified. A four-arm multifaceted tailored programme, ‘ACT on Asthma’, was developed, focusing on the theme ‘getting a diagnosis’. This theme was chosen following prioritisation by families during the collaborative workshops, demonstrating the participatory, iterative, phased approach used for the intervention design.

Conclusions

The MIA study demonstrated barriers to optimal asthma management in children at the family, provider and healthcare system levels and across the whole asthma pathway. Interventions need to address each of these levels to be effective. Minority ethnic communities can be successfully engaged in collaborative intervention development with a community-focused and culturally sensitive methodology.

Future work

Further research is required to (1) assess the feasibility and effectiveness of the proposed ‘ACT on Asthma’ programme, (2) develop methods to increase active participation of children in research and service development, (3) develop and test strategies to enhance public understanding of asthma in South Asian communities and (4) identify effective means of engaging the wider family in optimising asthma management.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Sensitization to food and inhalant allergens in relation to age and wheeze among children with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is common in children; however, persistence of AD with or without asthma is less common. Longitudinal studies remain limited in their ability to characterize how IgE antibody responses evolve in AD, and their relationship with asthma.

OBJECTIVE

To use a cross-sectional study design of children with active AD to analyse age-related differences in IgE antibodies and relation to wheeze.

METHODS

IgE antibodies to food and inhalant allergens were measured in children with active AD (5 months to 15 years of age, n = 66), with and without history of wheeze.

RESULTS

Whereas IgE antibodies to foods persisted at a similar prevalence and titre throughout childhood, IgE antibodies to all aeroallergens rose sharply into adolescence. From birth, the chance of sensitization for any aeroallergen increased for each 12-month increment in age (OR ≥ 1.21, P < 0.01), with the largest effect observed for dust mite (OR = 1.56, P < 0.001). A steeper age-related rise in IgE antibody titre to dust mite, but no other allergen was associated with more severe disease. Despite this, sensitization to cat was more strongly associated with wheeze (OR = 4.5, P < 0.01), and linked to Fel d 1 and Fel d 4, but not Fel d 2. Comparison of cat allergic children with AD to those without, revealed higher IgE levels to Fel d 2 and Fel d 4 (P < 0.05), but not Fel d 1.

CONCLUSIONS AND CLINICAL RELEVANCE

Differences in sensitization to cat and dust mite among young children with AD may aid in identifying those at increased risk for disease progression and development of asthma. Early sensitization to cat and risk for wheeze among children with AD may be linked to an increased risk for sensitization to a broader spectrum of allergen components from early life. Collectively, our findings argue for early intervention strategies designed to mitigate skin inflammation in children with AD.

Perceptions of neighborhood safety and asthma among children and adolescents in Los Angeles: a multilevel analysis

Background

Research examining the impact of neighborhoods on asthma has shown an increased interest in the role of the psychosocial environment. We examined the associations between various measures of neighborhood safety, individual and family characteristics, and asthma outcomes among children in Los Angeles.

Methods

Multilevel logistic regression models were used to analyze data on 3,114 children across 65 neighborhoods from Wave 1 of the Los Angeles Family and Neighborhood Survey (2000 to 2002). Primary caregivers reported asthma outcome and all individual covariates; home environmental characteristics were observed by the interviewer.

Results

In fully adjusted models, parents who reported their neighborhood fairly safe or somewhat dangerous had lower odds of reported lifetime asthma compared to those who reported their neighborhood completely safe (OR 0.71; 95% CI 0.52–0.96 and OR 0.60; 95% CI 0.42–0.88 respectively). Conversely, parents who reported they could not trust their neighbors to keep their children safe had a nearly 40% increase in lifetime asthma compared to those who reported they could trust their neighbors to keep their children safe (OR 1.39; 95% CI 1.07–1.81).

Conclusions

The study demonstrates a complex pattern between various measures of neighborhood safety and asthma and suggests that these relationships may operate differently in Los Angeles. As an increasing proportion of children are growing up in newer Western and Southwestern cities, which have different physical layouts and residential segregation patterns compared to Northeast and Midwestern cities, future studies should continue to examine neighborhood psychosocial stressors and asthma in diverse contexts.

Asthma associations in children attending a museum of science

We explored the relative strength of environmental and social factors associated with pediatric asthma in middle class families and considered the efficacy of recruitment for an educational study at a science museum. Eligibility criteria were having a child aged 4-12 and English fluency. Our questionnaire included information on demographics, home environment, medical history, and environmental toxicant exposures. Statistically significant associations were found for: child's age (t = -2.46; p = 0.014), allergies (OR = 11.5; 95%CI = 5.9-22.5), maternal asthma (OR = 2.2; 95%CI = 1.2-3.9), parents' education level (OR = 0.5; 95%CI = 0.3-0.9), family income (OR = 2.4; 95%CI = 1.1-5.5), water damage at home (OR = 2.5; 95%CI = 1.1-5.5), stuffed animals in bedroom (OR = 0.4; 95%CI = 0.2-0.7), hospitalization within a week after birth (OR = 3.2; 95%CI = 1.4-7.0), diagnosis of pneumonia (OR = 2.8; 95%CI = 1.4-5.9), and multiple colds in a year (OR = 2.9; 95%CI = 1.5-5.7). Several other associations approached statistical significance, including African American race (OR = 3.3; 95%CI = 1.0-10.7), vitamin D supplement directive (OR = 0.2; 95%CI = 0.02-1.2), mice in the home (OR = 0.5, 95%CI = 0.2-1.1), and cockroaches in the home (OR = 4.3; CI = 0.8-21.6). In logistic regression, age, parents' education, allergies, mold allergies, hospitalization after birth, stuffed animals in the bedroom, vitamin D supplement directive, and water damage in the home were all significant independent predictors of asthma. The urban science museum was a low-resource approach to address the relative importance of risk factors in this population.

Prospectively assessed early life experiences in relation to cortisol reactivity in adolescents at risk for asthma

Altered cortisol reactivity in individuals with asthma likely increases the risk of inflammation in the face of stress. Understanding antecedents of cortisol reactivity enhances knowledge of factors affecting asthma. Forty-eight subjects genetically predisposed for asthma, recruited from a study that assessed them from birth, completed a laboratory stress procedure and self-report measures at ages 17-19 years. Observation and parent reports from age 0 to 2 years were used to create a parent child relationship risk variable and to define criteria for a cumulative risk variable. In repeated measures analysis of 46 adolescents, those who had experienced early parent child relationship problems, specifically insecure attachment, had an attenuated cortisol stress response, even after controlling for concurrent psychological function and recent stressors (F = 4.6, p < .005). Cortisol stress response was not related to asthma status. This study supports a relationship between the parent child relationship during the first 2 years of life and later cortisol response to stress in youth at genetic risk for asthma.

Human schistosome infection and allergic sensitisation

Several field studies have reported an inverse relationship between the prevalence of helminth infections and that of allergic sensitisation/atopy. Recent studies show that immune responses induced by helminth parasites are, to an extent, comparable to allergic sensitisation. However, helminth products induce regulatory responses capable of inhibiting not only antiparasite immune responses, but also allergic sensitisation. The relative effects of this immunomodulation on the development of protective schistosome-specific responses in humans has yet to be demonstrated at population level, and the clinical significance of immunomodulation of allergic disease is still controversial. Nonetheless, similarities in immune responses against helminths and allergens pose interesting mechanistic and evolutionary questions. This paper examines the epidemiology, biology and immunology of allergic sensitisation/atopy, and schistosome infection in human populations.

Postpartum depression is a family affair: addressing the impact on mothers, fathers, and children

The purpose of this paper is to present research on the effects of postpartum depression (PPD) on mothers, fathers, and children that point to a re-conceptualization of PPD as a mental health condition that affects the whole family. As such, the objectives of this paper are to discuss: (1) the incidence and effects of PPD on mothers and fathers; (2) common predictors of PPD in mothers and fathers, and (3) the effects of PPD on parenting and parent-child relationships, and (4) the effects of PPD on children's health, and their cognitive and social-emotional development. Finally, the implications for screening and intervention if depression is re-conceptualized as a condition of the family are discussed.

Prenatal and passive smoke exposure and incidence of asthma and wheeze: systematic review and meta-analysis

OBJECTIVES

Exposure to passive smoke is a common and avoidable risk factor for wheeze and asthma in children. Substantial growth in the prospective cohort study evidence base provides an opportunity to generate new and more detailed estimates of the magnitude of the effect. A systematic review and meta-analysis was conducted to provide estimates of the prospective effect of smoking by parents or household members on the risk of wheeze and asthma at different stages of childhood.

METHODS

We systematically searched Medline, Embase, and conference abstracts to identify cohort studies of the incidence of asthma or wheeze in relation to exposure to prenatal or postnatal maternal, paternal, or household smoking in subjects aged up to 18 years old. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by using random effects model.

RESULTS

We identified 79 prospective studies. Exposure to pre- or postnatal passive smoke exposure was associated with a 30% to 70% increased risk of incident wheezing (strongest effect from postnatal maternal smoking on wheeze in children aged ≤2 years, OR = 1.70, 95% CI = 1.24-2.35, 4 studies) and a 21% to 85% increase in incident asthma (strongest effect from prenatal maternal smoking on asthma in children aged ≤2 years, OR = 1.85, 95% CI = 1.35-2.53, 5 studies).

CONCLUSIONS

Building upon previous findings, exposure to passive smoking increases the incidence of wheeze and asthma in children and young people by at least 20%. Preventing parental smoking is crucially important to the prevention of asthma.

Levels of household particulate matter and environmental tobacco smoke exposure in the first year of life for a cohort at risk for asthma in urban Syracuse, NY

The Syracuse, NY, AUDIT (Assessment of Urban Dwellings for Indoor Toxics) study was designed to quantify asthma agent levels in the inner-city homes of a birth cohort whose mothers had a diagnosis of asthma. Risk of exposure to particulate matter (PM), particle number and tobacco smoke was assessed in 103 infants' homes. Repeat measurements were made in 44% of the homes. Infants also were examined on a quarterly basis during the first year of life to monitor their respiratory health and urine cotinine levels. Overall geometric mean (GM) values for PM(2.5) of 21.2 μg/m(3) and for PM(10) of 31.8 μg/m(3) were recorded in homes at visit 1. GM values for PM(2.5) and PM(10) in smoking homes were higher at 26.3 and 37.7 μg/m(3), while values in non-smoking homes were 12.7 and 21.2 μg/m(3) respectively. Fifty-four percent of mothers (55/103) smoked at some point in pregnancy (39% smoked throughout pregnancy). Environmental tobacco smoke (ETS) exposure occurred in 68% of homes during the infants' first year. Significant to this study was the size- and time-resolved monitoring of PM at 140 home visits and the classification of PM count data. PM number counts ranged from continuously low levels (little indoor activity) to continuously high counts (constant indoor activity), and recorded apparent instances of prolonged repeated cigarette smoking. Wheezing in the first year of life was recorded for 38% of the infants (39/103). Adjusted logistic regression modeling demonstrated that elevated levels of indoor PM(2.5) (≥ 15 μg/m(3)) were a significant risk factor for infant wheezing after controlling for infant gender, mothers' age and education level, season of home visit and presence of carpeting (OR 4.21; 95% CI 1.36-13.03; p=0.013). An elevated level of the nicotine metabolite cotinine in infant urine also was associated with infant wheezing after adjusting for infant gender, mothers' age and education level (OR 5.10; 95% CI 0.96-27.24; p=0.057). ETS exposure was pervasive in the AUDIT cohort and a risk for developing infants in this urban population.

Familial instability and young children's physical health

This paper uses recent longitudinal data about a cohort of young children born in the United States to mostly unmarried parents to examine the association between increasingly-complex patterns of family instability and physical health in early childhood. The analyses assess whether, and how, the association between family instability and child health varies across a number of family types. We consider several measures of children's health at age five (overweight/obesity, asthma diagnosis and overall health) and examine to what extent the association between family instability and child health varies across outcomes and depends on the number and timing of any familial transitions. We also explore a number of potential mechanisms through which family instability may affect child health. The results suggest that familial instability is related to worse child health, particularly among children born to coresident (married or cohabiting) biological parents and for children who experience high levels of residential instability.

Epidemiology of stress and asthma: from constricting communities and fragile families to epigenetics

Several epidemiologic frameworks, exemplified through extant research examples, provide insight into the role of stress in the expression of asthma and other allergic disorders. Biologic, psychological, and social processes interact throughout the life course to influence disease expression. Studies exploiting a child development framework focus on critical periods of exposure, including the in utero environment, to examine the influence of stress on disease onset. Early stress effects that alter the normal course of morphogenesis and maturation that affect both structure and function of key organ systems (eg, immune, respiratory) may persist into adult life underscoring the importance of a life course perspective. Other evidence suggests that maternal stress influences programming of integrated physiologic systems in their offspring (eg, neuroendocrine, autonomic, immune function) starting in pregnancy; consequently stress effects may be transgenerational. A multilevel approach that includes an ecological perspective may help to explain heterogeneities in asthma expression across socioeconomic and geographic boundaries that to date remain largely unexplained. Evolving studies incorporating psychological, behavioral, and physiologic correlates of stress more specifically inform underlying mechanisms operating in these critical periods of development. The role of genetics, gene by environment interactions, and epigenetic mechanisms of gene expression have been sparsely examined in epidemiologic studies on stress and asthma although overlapping evidence provides proof of concept for such studies in the future.

Psychological characteristics associated with the onset and course of asthma in children and adolescents: a systematic review of longitudinal effects

OBJECTIVE

to systematically review all available studies that investigated the longitudinal relationships between the psychological characteristics of children and adolescents suffering from asthma and those of their caregivers, and the onset and course of the asthma.

METHODS

relevant studies were identified using Medline, PubMed, and PsychINFO between 1970 and September 2009.

RESULTS

twenty studies matching inclusion criteria were reviewed. Six studies focused on child-specific psychological characteristics in relation to the onset and course of asthma. No compelling evidence was found for an association with asthma onset, but there was some evidence that the child's psychological characteristics can contribute to the subsequent course of asthma. Fourteen studies considered the effects of the psychological characteristics of the caregivers. Eleven studies found significant relationships between the psychological problems of caregivers and the subsequent onset and unfavorable course of the asthma in the child.

CONCLUSION

in pediatric asthma both the psychological characteristics of the affected children and their caregivers appear to contribute to the course and possibly also to the onset of the condition.

Stress and the city: housing stressors are associated with respiratory health among low socioeconomic status Chicago children

Asthma disproportionately affects non-whites in urban areas and those of low socioeconomic status, yet asthma's social patterning is not well-explained by known risk factors. We hypothesized that disadvantaged urban populations experience acute and chronic housing stressors which produce psychological stress and impact health through biological and behavioral pathways. We examined eight outcomes: six child respiratory outcomes as well as parent and child general health, using data from 682 low-income, Chicago parents of diagnosed and undiagnosed asthmatic children. We created a continuous exposure, representing material, social and emotional dimensions of housing stressors, weighted by their parent-reported difficulty. We compared the 75th to the 25th quartile of exposure in adjusted binomial and negative binomial regression models. Higher risks and rates of poor health were associated with higher housing stressors for six of eight outcomes. The risk difference (RD) for poor/fair general health was larger for children [RD = 6.28 (95% CI 1.22, 11.35)] than for parents [RD = 3.88 (95% CI -1.87, 9.63)]. The incidence rate difference (IRD) for exercise intolerance was nearly one extra day per 2 weeks for the higher exposure group [IRD = 0.88 (95% CI 0.41, 1.35)]; nearly one-third extra day per 2 weeks for waking at night [IRD = 0.32 (95% CI 0.01, 0.63)]; and nearly one-third extra day per 6 months for unplanned medical visits [IRD = 0.30 (95% CI 0.059, 0.54)]. Results contribute to the conceptualization of urban stress as a "social pollutant" and to the hypothesized role of stress in health disparities. Interventions to improve asthma outcomes must address individuals' reactions to stress while we seek structural solutions to residential stressors and health inequities.

Epidemiology of asthma: risk factors for development

This comprehensive review of the recent literature was undertaken to determine the current state of knowledge of the risk factors involved in the development of asthma in order to focus investigations in a proposed new longitudinal birth cohort study. The origins of asthma appear to lie in the prenatal and early postnatal period, and renewed investigations in this period with long-term close follow-up and objective phenotypic characterization will help to unravel the role of the multiple putative environmental factors in the development of asthma. It is only after understanding these effects that one can hope to design rational prevention studies for asthma.

Parental support and cytokine activity in childhood asthma: the role of glucocorticoid sensitivity

BACKGROUND

Stress is known to worsen the course of asthma, but the underlying mechanisms are poorly understood. This problem is especially difficult because stress elicits secretion of cortisol, a hormone that dampens airway inflammation and ameliorates asthma symptoms.

OBJECTIVE

This article proposes that stress affects asthma by inducing resistance to the anti-inflammatory properties of glucocorticoids. To evaluate this hypothesis, we examine whether a particular kind of stress in children's lives, not feeling supported or understood by parents, is associated with in vitro measures of lymphocyte resistance to glucocorticoids and indices of eosinophil mobilization and activation.

METHODS

Children with asthma (n = 67) and medically healthy children (n = 76) completed standardized questionnaires about support from their parents. PBMCs were collected and incubated with a mitogen cocktail in the presence of physiologic concentrations of hydrocortisone. Production of IL-5, IL-13, and IFN-gamma was measured by means of ELISA. Circulating eosinophils were enumerated with a hematology analyzer, and the extent of their activation was indexed by means of ELISA for eosinophil cationic protein.

RESULTS

To the extent that children with asthma perceived low support from their parents, children were more resistant to hydrocortisone's anti-inflammatory effects on IL-5 and IFN-gamma production and had higher circulating levels of eosinophil cationic protein. These associations were independent of socioeconomic conditions, cigarette exposure, disease severity, and medication use.

CONCLUSIONS

These patterns suggest the hypothesis that strained parent-child relations, and perhaps stress more generally, brings about adverse outcomes in asthma by diminishing cortisol's ability to regulate cytokine activity and subsequent airway inflammation.

Does the social environment contribute to asthma?

The impact of the social environment on asthma has recently begun to receive increasing attention. This article reviews the current literature to investigate the impact of the social environment at three levels-the neighborhood level, the peer level, and the family level-and to explore pathways through which the social environment "gets under the skin" to impact asthma onset and morbidity. Research to date suggests that adverse social conditions at the neighborhood and family levels impact asthma morbidity through direct effects on physiologic systems as well as by altering health behaviors. The impact on asthma of social networks, such as friendships, is less clear and will need to be investigated further. Future research will need to take into account the impact of the social environment to develop more comprehensive models of asthma pathogenesis.

Early identification of atopy in the prediction of persistent asthma in children

The long-term solution to the asthma epidemic is thought to be prevention, and not treatment of established disease. Atopic asthma arises from gene-environment interactions, which mainly take place during a short period in prenatal and postnatal development. These interactions are not completely understood, and hence primary prevention remains an elusive goal. We argue that primary-care physicians, paediatricians, and specialists lack knowledge of the role of atopy in early life in the development of persistent asthma in children. In this review, we discuss how early identification of children at high risk is feasible on the basis of available technology and important for potential benefits to the children. Identification of an asthmatic child's atopic status in early life has practical clinical and prognostic implications, and sets the basis for future preventative strategies.

Parental stress and childhood wheeze in a prospective cohort study

BACKGROUND

Although studies indicate that psychological stress is linked with asthma morbidity, it is unknown whether stress is associated with the incidence of asthma symptoms.

METHOD

In a cohort of 5- to 6-year-old school children participating in the southern California Children's Health Study, we evaluated parent-reported wheeze in the child using a standardized questionnaire and perceived parental stress at study entry. Wheeze in the child was evaluated one year later. Analyses were restricted to children without asthma at study entry (N = 2,888, of whom 286 had wheeze at follow-up).

RESULTS

There was an increase in wheeze across an interquartile range of parent stress (odds ratio [OR] 1.18; 95% confidence interval [CI] 0.99, 1.42). Parent stress was associated with wheeze among children with no parental asthma (OR 1.24; CI 0.99, 1.55) and among boys (OR 1.34; CI 1.04, 1.74), but not among girls or children with parental asthma. Among boys with no parental asthma there was a strong dose-response relationship, and in the top quartile of stress the OR was 2.76 (CI 1.39, 5.51) compared to the bottom quartile.

CONCLUSION

Parental stress increases the risk of childhood wheeze among children with no parental history of asthma, especially among boys. These results suggest that the influence of psychosocial factors on asthma, such as stress and social environment, deserve increased attention.

Family psychological factors in relation to children's asthma status and behavioral adjustment at age 4

The objectives of this study were to determine whether family psychosocial factors influenced asthma development by age 4, and whether family factors and early wheezing illness were associated with behavioral adjustment at age 4. Participants were 98 children enrolled in an intervention study at 9-24 months and followed to age 4. Baseline evaluations assessed infants' respiratory illness severity, family psychosocial characteristics, and parental risk factors for asthma development. Active asthma categorization at age 4 utilized both parent report and objective data. Parents completed the Child Behavior Checklist (CBCL). Caregiver single-parent status, a composite of baseline family stresses, and early wheezing illness severity were associated with active asthma at age 4. The contribution of prenatal smoke exposure and early hospitalization to active asthma varied with racial/ethnic group membership. Maternal mental health and family stresses predicted CBCL scores at age 4, whereas early illness severity and hospitalization were unrelated to CBCL scores. CBCL scores were not elevated for children with active asthma at age 4. Family factors consistent with a negative emotional environment were associated with both active asthma and adjustment problems at age 4, suggesting that both outcomes may be influenced by a common factor.

The potential for reducing asthma disparities through improved family and social function and modified health behaviors

The National Workshop To Reduce Asthma Disparities assembled a multidisciplinary group comprised of scientists, clinicians, and community representatives to examine factors related to asthma disparities. Attention was given to the importance of discerning family, social, and behavioral factors that facilitate or impede the use of health-care services suitable to the medical status of an individual. This review highlights select biopsychosocial factors that contribute to these disparities, the manner in which they may contribute or protect persons affected by asthma, and recommended directions for future research.

A bidirectional relationship between psychosocial factors and atopic disorders: a systematic review and meta-analysis

OBJECTIVE

There is growing epidemiological literature focusing on the bidirectional association between psychosocial factors and atopic disorders, but no efforts to quantify the relationship systematically have been published.

METHODS

We searched Medline, PsycINFO, Web of Science, and PubMed up to June 2007. The studies included were prospective cohort studies investigating the influence of psychosocial factors on atopic disorders and the effect of atopic disorders on mental health. Two investigators independently extracted data and determined study quality.

RESULTS

There were 43 studies (in 22 articles), of which 34 evaluated the effect of psychosocial factors on atopic disorders and 9 evaluated the effect of atopic disorders on mental health. The major atopic disease assessed in these studies was asthma (90.7%) with allergic rhinitis, 4.7%; atopic dermatitis, 2.3%; and food allergies, 2.3%. The overall meta-analysis exhibited a positive association between psychosocial factors and future atopic disorder (correlation coefficient (r) as combined size effect .024; 95% confidence interval, 0.014-0.035; p < .001) as well as between atopic disorders and future poor mental health (r = .044, 95% confidence interval, 0.021-0.067, p < .001). More notably, the subgroup meta-analysis on the healthy and atopic disorder populations showed psychosocial factors had both an etiological and prognostic effect on atopic disorders.

CONCLUSIONS

The current review revealed a robust relationship between psychosocial factors and atopic disorders. This supports the use of psychological in addition to conventional physical and pharmacological interventions, in the successful prevention and management of atopic disorders.

Examining the hygiene hypothesis: the Trial of Infant Probiotic Supplementation

The hygiene hypothesis suggests that the absence of infectious exposure at a critical point in immune system development leads to a greater risk for the later development of atopic disease. As a result, it may be possible to devise strategies that can block the onset of atopic diseases such as asthma. This paper outlines the rationale, background and design for the Trial of Infant Probiotic Supplementation study, which is designed to test the effectiveness of a daily infant probiotic supplement in the first 6 months of life in preventing the development of early markers of asthma.

Continued exposure to maternal distress in early life is associated with an increased risk of childhood asthma

RATIONALE

Evidence is emerging that exposure to maternal distress in early life plays a causal role in the development of childhood asthma.

OBJECTIVES

Because much of the data are from high-risk cohorts, we undertook a birth cohort study in a complete population of children to test this association.

METHODS

Using Manitoba, Canada's, health care and prescription databases, this longitudinal study assessed the association between maternal distress during the first year of life and onward, and asthma at age 7 in a 1995 birth cohort of 13,907 children.

MEASUREMENTS AND MAIN RESULTS

Maternal distress was defined on the basis of health care or prescription medication use for depression or anxiety. Asthma status was derived from health care and prescription records for asthma, using a definition validated by comparison to pediatric allergist diagnosis. Multiple logistic regression was used to determine the likelihood of asthma (odds ratio [OR], 95% confidence interval [95% CI]). Independent of well-known asthma risk factors, our population-based study of a non-high-risk cohort demonstrated an increased risk of childhood asthma (OR, 1.25; 95% CI, 1.01-1.55) among children exposed to continued maternal distress from birth until age 7. Exposure to maternal depression and anxiety limited to the first year of life did not have a demonstrable association with subsequent asthma. Of interest, we observed that the risk of asthma associated with continued maternal distress was increased in children living in high- versus low-income households (OR, 1.44; 95% CI, 1.12-1.85).

CONCLUSIONS

Maternal distress in early life plays a role in the development of childhood asthma, especially if it continues beyond the postpartum period.

The role of the social environment in children and adolescents with asthma

RATIONALE

Biopsychosocial models of asthma have been proposed in the literature, but few empirical tests of social factors at various levels of influence have been conducted.

OBJECTIVES

To test associations of neighborhood, peer, and family factors with asthma outcomes in youth, and to determine the pathways through which these social factors operate.

METHODS

Observational study of youths with asthma (n = 78).

MEASUREMENTS AND MAIN RESULTS

Youths completed questionnaires about neighborhood problems, peer support, and family support. Biological (IgE, eosinophil count, production of IL-4) and behavioral (youth smoking, exposure to smoke, adherence to medications) pathways were measured. Asthma symptoms and pulmonary function were assessed in the laboratory and at home for 2 weeks. Lower levels of family support were associated with greater symptoms (beta coefficients: -0.26 to -0.33, P < 0.05) and poorer pulmonary function (beta: 0.30, P < 0.05) via biological pathways (Z statistics from 1.19 to 1.51, P < 0.05). Higher levels of neighborhood problems were associated with greater symptoms (beta coefficients: 0.27-0.33, P < 0.05) via behavioral pathways related to smoking (Z statistics = 1.40, P < 0.05). Peer support was not associated with symptoms or pulmonary function.

CONCLUSIONS

This study indicates that family factors may affect youths' asthma via physiologic changes, whereas community factors may help shape the health behaviors of youths with asthma.

The Effects of Psychological Intervention on Atopic Dermatitis

BACKGROUND

Psychological interventions may be valuable in atopic dermatitis. We systematically reviewed and carried out a meta-analysis of randomized controlled trials of psychological interventions.

METHODS

Electronic searches and manual journal searches were carried out. Two coders independently coded study designs, participants, treatments and outcome characteristics of the studies meeting the selection criteria.

RESULTS

Eight journal articles published between 1986 and 2006 were included. Eight types of intervention were tested: aromatherapy, autogenic training, brief dynamic psychotherapy, cognitive-behavioral therapy, dermatological education and cognitive-behavioral therapy, habit reversal behavioral therapy, a stress management program, and structured educational programs. Effect sizes were computed as correlation coefficient (r), and random effects models were used in the analysis. For eczema severity, the average effect size for the 8 trials including 8 interventions was -0.367 [chi(2)(1) = 7.452, p = 0.006; 95% CI -0.579 to -0.108]. The average effect sizes on itching intensity (5 trials with 5 interventions) and scratching (5 trials with 4 interventions) were -0.805 [chi(2)(1) = 4.719, p = 0.030; 95% CI -0.971 to -0.108] and -0.620 [chi(2)(1) = 24.24, p < 0.0001; 95% CI -0.767 to -0.410], respectively.

CONCLUSIONS

Although the present meta-analysis revealed that psychological interventions had a significant ameliorating effect on eczema severity, itching intensity and scratching in atopic dermatitis patients, a definite conclusion about their effectiveness seems premature. Accordingly, future studies should involve more sophisticated methodologies, use established measures of outcome variables, adjust for possible confounders between the intervention and control groups, and provide sufficient data to calculate the effect sizes for future meta-analyses.

Family processes in pediatric asthma

PURPOSE OF REVIEW

Family processes are best conceptualized within an integrated, dynamic biopsychosocial model of pediatric asthma. We reviewed the literature on specific family processes proposed to influence asthma outcomes, the mechanisms of influence, and family-focused interventions to improve asthma control.

RECENT FINDINGS

Family characteristics associated with asthma outcomes include caregiver psychological functioning, parenting, and whole-family processes. These characteristics influence asthma outcomes via asthma management behaviors and/or disease-related psychophysiologic pathways. Family-focused interventions designed to promote asthma control include psychoeducation and family therapy, although alternative models have also been proposed.

SUMMARY

Despite the increasing evidence that family processes contribute to asthma outcomes, few theory-based family interventions have been developed for children with asthma. Systemic consultation models and biobehavioral family interventions, in conjunction with pediatric care, appear to hold the most promise for helping families of children with poorly controlled asthma.

In utero and postnatal maternal smoking and asthma in adolescence

BACKGROUND

Asthma in early childhood has been associated with maternal smoking during pregnancy and parental smoking soon after birth. However, less is known about these exposures and the development of asthma symptoms in adolescence.

METHODS

Data were taken from the Mater University Study of Pregnancy, a large birth cohort study of mothers and children enrolled in Brisbane, Australia, beginning in 1981. Smoking was assessed at 2 stages during pregnancy and at the 6-month and 5-year follow-up visits. Asthma was assessed from maternal reports that were provided when the child was age 14 years. We conducted multivariable multinomial logistic regression analyses to assess the effect of maternal smoking on asthma symptoms.

RESULTS

There was a strong sex interaction such that girls whose mothers had smoked heavily (20 or more cigarettes per day) in pregnancy and at the 6-month follow up had increased odds of experiencing asthma symptoms at age 14 (odds ratio = 1.96; 95% confidence interval = 1.25-3.08). The contribution of heavy smoking during pregnancy appeared to be stronger than heavy smoking after the birth. No similar associations were seen for boys.

CONCLUSION

Female adolescents whose mothers smoked heavily during the fetal period and the early months of life have increased risk of asthma symptoms in adolescence. In utero exposure to heavy smoking was found to have a stronger effect than postnatal environmental tobacco exposure.

Issues in design and implementation in an urban birth cohort study: the Syracuse AUDIT project

The Syracuse AUDIT (Assessment of Urban Dwellings for Indoor Toxics) project is a birth cohort study of wheezing in the first year of life in a low-income urban setting. Such studies are important because of the documented serious risks to children's health and the lack of attention and published work on asthma development and intervention in communities of this size. We studied 103 infants of mothers with asthma, living predominantly in inner-city households. Our study combines measurements of a large panel of indoor environmental agents, in-home infant assessments, and review of all prenatal and postnatal medical records through the first year of life. We found multiple environmental pollution sources and potential health risks in study homes including high infant exposure to tobacco smoke. The prevalence of maternal smoking during pregnancy was 54%; postnatal environmental tobacco smoke (ETS) exposure was nearly 90%. The majority (73%) of homes showed signs of dampness. Participants' lives were complicated by poverty, unemployment and single-parenthood. Thirty-three percent of fathers were not involved with their children, and 62% of subjects moved at least once during the study period. These socioeconomic issues had an impact on project implementation and led to modification of study eligibility criteria. Extensive outreach, follow up, and relationship-building were required in order to recruit and retain families and resulted in considerable work overload for study staff. Our experiences implementing the project will inform further studies on this and other similar populations. Future reports on this cohort will address the role of multiple environmental variables and their effects on wheezing outcome during the first year of life.

Breastfeeding does not increase the risk of asthma at 14 years

OBJECTIVES

There are conflicting data regarding the impact of breastfeeding on the development of asthma in late childhood. Our aim with this study was to investigate the relationship between breastfeeding and the prevalence of asthma in children at 14 years.

METHODS

The Mater-University of Queensland Study of Pregnancy is a birth cohort of 7223 women and their infants recruited from a public antenatal clinic in Brisbane, Australia, between 1981 and 1984. Data regarding breastfeeding and the duration of breastfeeding were collected through the use of a questionnaire completed by the mother 6 months postdelivery, and the prevalence of asthma was determined through the use of a questionnaire completed by the mother 14 years postdelivery.

RESULTS

Data regarding both breastfeeding and asthma were available for 4964 children. The prevalence of asthma in children at 14 years was 28.4%. Breastfeeding for > or =4 months was not found to have a significant effect on the prevalence of asthma in 14-year-olds. The unadjusted odds ratio of developing asthma at 14 years if the child was breastfed for > or =4 months was 1.03. The odds ratio of developing asthma did not change appreciably when allowance was made for potential confounding factors.

CONCLUSION

Data from this study indicate that breastfeeding neither increases nor decreases the prevalence of asthma in children at 14 years.

Life stress and diminished expression of genes encoding glucocorticoid receptor and beta2-adrenergic receptor in children with asthma

Despite evidence that stressful experience can exacerbate the symptoms of asthma, little is known about the biological mechanisms through which this occurs. This study examined whether life stress reduces expression of the genes coding for the glucocorticoid receptor and the beta(2)-adrenergic receptor. A total of 77 children were enrolled in the study (59% male; mean age, 13.5 years). Thirty-nine of them were physician-diagnosed with asthma, and 38 were healthy. After an in-depth interview regarding stressful experiences, leukocytes were collected through antecubital venipuncture, and real-time RT-PCR was used to quantify mRNA. Chronic stress was associated with reduced expression of mRNA for the beta(2)-adrenergic receptor among children with asthma. In the sample of healthy children, however, the direction of this effect was reversed. The occurrence of a major life event in the 6 months before the study was not sufficient to influence patterns of gene expression. When such events occurred in the context of a chronic stressor, however, their association with patterns of gene expression was accentuated. Children with asthma who simultaneously experienced acute and chronic stress exhibited a 5.5-fold reduction in glucocorticoid receptor mRNA and a 9.5-fold reduction in beta(2)-adrenergic receptor mRNA relative to children with asthma without comparable stressor exposure. These findings suggest that stressful experience diminishes expression of the glucocorticoid and beta(2)-adrenergic receptor genes in children with asthma. To the extent that it diminishes sensitivity to the antiinflammatory properties of glucocorticoids or the bronchodilatory properties of beta-agonists, this process could explain the increased asthma morbidity associated with stress.

Parental psychopathology and childhood atopic disorders in the community

OBJECTIVE

To examine the association of parental psychopathology and childhood atopic disorders in the general population.

METHODS

In a sample of 9,240 parent-child dyads drawn from the 1999 US National Health Interview Survey, the association of childhood atopic disorders with parental major depression, generalized anxiety disorder, and panic attacks was examined. Parental DSM-IV psychiatric diagnoses were ascertained by the Composite International Diagnostic Interview, Short-Form (CIDI-SF).

RESULTS

Parental major depression and panic attacks were associated with childhood atopic disorders only in biological parent-child dyads (adjusted odds ratios = 1.67 for major depression and 1.46 for panic attacks), and among these more strongly in mother-child dyads. Parental atopic disorders and parental psychopathology had an additive effect on the risk of atopic disorders in the offspring.

CONCLUSION

Findings from this study lend support to the "shared genetic liability" hypothesis for the association of childhood atopic disorders and parental major depression and panic attacks.

The relationship of psychologic stress with childhood asthma

The psychologic influence on childhood asthma has long been a subject of investigation and controversy. This article illustrates the evidence that psychologic stress is related to children with asthma. Individual experience, the impact of family and neighborhood, the effect of caregiver mental status, and the presence of negative psychologic events affect symptoms and management. The pathways through which these factors influence asthma are mediated through cognitive and biologic mechanisms, with evidence indicating changes in behavior and alteration in immune response as underlying mechanisms. Psychologic issues are important in the patient with severe asthma. The mind-body paradigm that links psychologic stress to disease is necessary when considering the global evaluation of childhood asthma.