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Hu Y, Chen H, Tian Y, Wu D, Vinturache A, Ding G, Yu G. Association of parabens and bisphenols with lung function in children aged 5-12 years from Shanghai, China. Int J Hyg Environ Health 2023; 252:114210. [PMID: 37348164 DOI: 10.1016/j.ijheh.2023.114210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/24/2023] [Accepted: 06/15/2023] [Indexed: 06/24/2023]
Abstract
Epidemiological studies have reported potential effects of individual paraben or bisphenol exposure on lung function, but few studies have estimated their joint effects. We conducted a cross sectional survey to investigate the associations of parabens and bisphenols exposure with lung function in 205 children aged 5-12 years from Shanghai, China. Urinary concentrations of six parabens [methyl-, ethyl-, propyl-, butyl-, benzyl-, and heptyl-paraben (MeP, EtP, PrP, BuP, BzP, and HeP)] and seven bisphenols [bisphenol A (BPA), bisphenol AF (BPAF), bisphenol AP (BPAP), bisphenol B (BPB), bisphenol P (BPP), bisphenol S (BPS), and bisphenol Z (BPZ)] were assessed by the high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). Lung function, including forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC, peak expiratory flow (PEF), and forced expiratory flow between 25% and 75% of forced vital capacity (FEF25-75%), was further measured. Linear regression, bayesian kernel machine regression (BKMR), and weighted quantile sum regression (WQS) evaluated the individual and joint relationships of the parabens and bisphenols with the lung function parameters. Further, the analysis was stratified by child sex. Parabens (MeP, EtP, PrP, and BuP) and bisphenols (BPA, BPAP, BPB, and BPS) with detection rates >75% were included for analyses. In linear regressions, parabens (MeP, PrP, and BuP) were generally negatively associated with FEV1, FVC, PEF, and FEF25-75%, but no associations for bisphenols were found. The association of parabens with lung function was more pronounced in girls. The aforementioned negative associations between parabens and lung function were confirmed by both the BKMR and WQS, with MeP being considered most heavily weighing chemical. Our findings suggested that exposure to parabens, either individuals or as a mixture, were associated with decreased lung function in children aged 5-12 years, and these associations were stronger among girls. Considering the cross-sectional study design, large longitudinal studies are warranted to confirm our findings.
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Affiliation(s)
- Yi Hu
- Center for Medical Bioinformatics, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hao Chen
- Department of Neonatology, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuan Tian
- Department of Child Health Management, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dan Wu
- Center for Medical Bioinformatics, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Angela Vinturache
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada; Department of Neuroscience, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Guodong Ding
- Department of Pediatric Respiratory Medicine, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Guangjun Yu
- Center for Medical Bioinformatics, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Gaylord A, Barrett ES, Sathyanarayana S, Swan SH, Nguyen RHN, Bush NR, Carroll K, Day DB, Kannan K, Trasande L. Prenatal bisphenol A and S exposure and atopic disease phenotypes at age 6. ENVIRONMENTAL RESEARCH 2023; 226:115630. [PMID: 36889565 PMCID: PMC10101912 DOI: 10.1016/j.envres.2023.115630] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 03/03/2023] [Accepted: 03/04/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Atopic disease may be influenced by prenatal and early life exposure to endocrine disrupting chemicals, including bisphenols, but results from epidemiological studies have been mixed. This study aimed to extend the epidemiological literature, hypothesizing that children with higher prenatal bisphenol exposure are more likely to have childhood atopic disease. METHODS Urinary bisphenol A (BPA) and S (BPS) concentrations were measured in each trimester from 501 pregnant women in a multi-center, prospective pregnancy cohort. Ever asthma, current asthma, wheeze, and food allergy) were assessed at age six via standardized ISAAC questionnaire. We constructed generalized estimating equations to examine BPA and BPS exposure jointly at each trimester for each atopy phenotype. BPA was modeled as a log-transformed continuous variable, whereas BPS was modeled as detected versus not detected. We also modeled pregnancy-averaged BPA values and a categorical indicator for number of detectable BPS values over pregnancy (0-3) in logistic regression models. RESULTS First trimester BPA was associated with inverse odds of food allergy among the entire study sample (OR = 0.78, 95% CI = 0.64-0.95, p = 0.01) and females only (OR = 0.69, 95% CI = 0.52-0.90, p = 0.006). The inverse relationship persisted in pregnancy-averaged models of BPA among females (OR = 0.56, 95% CI = 0.35-0.90, p = 0.006). Second trimester BPA was associated with greater odds of food allergy in the entire sample (OR = 1.27, 95% CI = 1.02-1.58, p = 0.03) and among males only (OR = 1.48, 95% CI = 1.02-2.14, p = 0.04). Odds of current asthma increased among males in the pregnancy-averaged BPS models (OR = 1.65, 95% CI = 1.01-2.69, p = 0.045). CONCLUSION We saw opposite effects of BPA on food allergy that were trimester- and sex-specific. These divergent associations warrant further investigation. There is some evidence to suggest that prenatal BPS is associated with asthma among males, but further research is required in cohorts with a greater proportion of prenatal urine samples with detectable BPS to validate these results.
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Affiliation(s)
- Abigail Gaylord
- Department of Environmental Health Sciences, Columbia Mailman School of Public Health, New York, NY, USA.
| | - Emily S Barrett
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, NJ, USA
| | - Sheela Sathyanarayana
- Department of Pediatrics, Department of Environmental and Occupational Health Sciences, Department of Epidemiology, University of Washington, Seattle, WA, USA; Seattle Children's Research Institute, University of Washington, Seattle, WA, USA
| | - Shanna H Swan
- Department of Preventive Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruby H N Nguyen
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Nicole R Bush
- Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA; Department of Pediatrics, University of California-San Francisco, San Francisco, CA, USA
| | - Kecia Carroll
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, NY, USA
| | - Drew B Day
- Seattle Children's Research Institute, University of Washington, Seattle, WA, USA
| | - Kurunthachalam Kannan
- Department of Pediatrics, New York University School of Medicine, New York, NY, USA; Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA
| | - Leonardo Trasande
- Department of Population Health, New York University School of Medicine, New York, NY, USA; Department of Pediatrics, New York University School of Medicine, New York, NY, USA; Department of Environmental Medicine, New York University School of Medicine, New York, NY, USA; New York University Wagner School of Public Service, New York, NY, USA; New York University School of Global Public Health, New York, NY, USA
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Kimber I, Woeffen N, Sondenheimer K. Bisphenol A, T H17 cells, and allergy: a commentary. J Immunotoxicol 2022; 19:93-99. [PMID: 36070621 DOI: 10.1080/1547691x.2022.2113842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
There is a continuing interest in whether Bisphenol A (BPA) is able to cause adverse health effects through interaction with elements of the immune system. That interest has been fuelled further by the recent publication of a draft opinion on BPA prepared by the European Food Safety Authority (EFSA) Panel on Food Contact Materials, Enzymes and Processing Aids (CEP). This draft opinion judged effects on the immune system to be the most sensitive health outcome, and identified BPA-induced changes in the frequency of T-helper (TH)-17 cells in the spleens of mice as being the critical effect based on an association of these cells with inflammation. Based on these evaluations the CEP Panel recommended that a revised Tolerable Daily Intake (TDI) for BPA of 0.04 ng/kg bw/day should be adopted; representing a very substantial reduction (100,000-fold) compared with the existing TDI. The purpose of this commentary is to summarize briefly the role of TH17 cells in immune responses, and to review relevant literature regarding the influence of BPA on these cells, and on inflammatory responses in the lung and respiratory allergy. The conclusion drawn is that based on uncertainties about the effects of BPA on TH17 cells and lung inflammation in mice, the absence of consistent or persuasive evidence from human studies that exposure of BPA is associated with inflammation or allergy, and unresolved questions regarding the species selectivity of immune effects induced by BPA, it is inappropriate to adopt the revised TDI. Additional research is required to explore further the influence of BPA on the immune system and immune responses.
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Affiliation(s)
- Ian Kimber
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Li XN, Wu D, Liu Y, Zhang SS, Tian FL, Sun Q, Wei W, Cao X, Jia LH. Prenatal exposure to bisphenols, immune responses in cord blood and infantile eczema: A nested prospective cohort study in China. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2021; 228:112987. [PMID: 34781129 DOI: 10.1016/j.ecoenv.2021.112987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 06/13/2023]
Abstract
Increasing evidence shows that human exposure to bisphenols can increase the risk of allergic disease, such as child asthma. However, the mechanism by which exposure to bisphenols causes allergic disease is unclear. In addition, the effects of exposure to bisphenols during pregnancy on infantile eczema have been poorly studied. The aim of our study was to investigate the effect of bisphenols (BPA, BPF and BPS) exposure during pregnancy on immune cells in cord blood, and on the occurrence of infantile eczema. 111 mother-child pairs with urine samples from pregnant women and cord blood were recruited from a birth cohort established in February 2019 in Shenyang, China. The levels of urinary bisphenols and Th1-, Th2-, Treg- and Th17-related genes, and cytokines in cord blood, as well as the incidence of infantile eczema at 6 and 12 months follow up were determined. Our results show that BPA, BPF and BPS were detected in 100%, 63.1% and 46.8% of the urine samples, respectively. The median concentration of urine specific gravity adjusted BPA (SG-BPA) was 7.46 ng/mL. High SG-BPA levels during pregnancy was independently associated with increased risk of infantile eczema (adjusted OR = 2.731, 95%CI: 1.064-7.012, P = 0.037). Higher levels of FOXP3 gene in cord blood had a significantly lower risk of developing eczema in infants (adjusted OR=0.430, 95%CI: 0.190-0.972, P = 0.042). However, BPS and BPF levels were not associated with infantile eczema. FOXP3 gene levels in cord blood mediated the relationship between SG-BPA levels during pregnancy and infantile eczema (indirect effect: β = 0.350 [CI:0.011,1.077]). Our findings indicate that high levels of BPA exposure during pregnancy increase the risk of infantile eczema, which may be associated with down-regulation of FOXP3 gene expression in cord blood.
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Affiliation(s)
- Xue-Ning Li
- Department of Child and Adolescent Health, School of Public Health, China Medical University, Shenyang 110122, China; Department of Pediatrics, The Fourth Affiliated Hospital of China Medical University, Shenyang 110032, China
| | - Dan Wu
- Department of Child and Adolescent Health, School of Public Health, China Medical University, Shenyang 110122, China
| | - Ying Liu
- Department of Pediatrics, The Fourth Affiliated Hospital of China Medical University, Shenyang 110032, China
| | - Shuang-Shuang Zhang
- Department of Pediatrics, The Fourth Affiliated Hospital of China Medical University, Shenyang 110032, China
| | - Fu-Lin Tian
- Center for Public Health Safety Risk Assessment, School of Public Health, China Medical University, Shenyang 110122, China
| | - Qi Sun
- Department of Child and Adolescent Health, School of Public Health, China Medical University, Shenyang 110122, China
| | - Wei Wei
- Department of Child and Adolescent Health, School of Public Health, China Medical University, Shenyang 110122, China
| | - Xia Cao
- Department of obstetrics, The Fourth Affiliated Hospital of China Medical University, Shenyang 110032, China
| | - Li-Hong Jia
- Department of Child and Adolescent Health, School of Public Health, China Medical University, Shenyang 110122, China; Liaoning Key Laboratory of Obesity and Glucose/Lipid Associated Metabolic Diseases, Shenyang 110122, China.
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Kiook B, Jong-Tae P, Kyeongmin K. Association of Urinary Bisphenols Concentration with Asthma in Korean Adolescents: Data from the Third Korean National Environmental Health Survey. TOXICS 2021; 9:toxics9110291. [PMID: 34822682 PMCID: PMC8621547 DOI: 10.3390/toxics9110291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/17/2021] [Accepted: 10/29/2021] [Indexed: 11/28/2022]
Abstract
The effects of bisphenol A (BPA) on asthma have been reported in various in vitro, animal, and human epidemiologic studies. However, epidemiological studies on the effects of bisphenol S (BPS) and bisphenol F (BPF), which are substitutes of BPA, on asthma are lacking. The purpose of this study was to identify the association between BPA, BPS, and BPF and asthma. An asthma-related questionnaire; urinary BPA, BPS, BPF; and the possible confounders were analyzed among 922 adolescents aged 12–17 years who participated in the Korean National Environmental Health Survey 2016. In males, urinary BPA, BPS, and BPF did not show a significant relationship with the lifetime prevalence of asthma. In females, urinary BPS was higher in the asthma group (p < 0.01). High urinary BPS showed a significant relationship with a high odds ratio (OR) of lifetime asthma prevalence in the model adjusted for possible confounders (p < 0.05). High urinary BPS was particularly associated with an increase in the OR of asthma diagnosed after the age of 60 months (p < 0.01). Urinary BPS was significantly associated with asthma diagnosis, especially after the age of 60 months, among Korean adolescent females.
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Lee S, Park SK, Park H, Lee W, Lee JH, Hong YC, Ha M, Kim Y, Lee BE, Ha E. Joint association of prenatal bisphenol-A and phthalates exposure with risk of atopic dermatitis in 6-month-old infants. THE SCIENCE OF THE TOTAL ENVIRONMENT 2021; 789:147953. [PMID: 34323845 DOI: 10.1016/j.scitotenv.2021.147953] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 05/16/2023]
Abstract
BACKGROUND Prenatal exposure to bisphenol A (BPA) and phthalates could trigger immune response. Few studies have investigated the association between prenatal BPA and phthalate exposure and atopic dermatitis (AD) in infants. OBJECTIVE We aimed to clarify the joint association of prenatal exposure to BPA and phthalate metabolites with AD incidence in 6-month-old infants. METHODS We included 413 mother-child pairs from the Mothers and Children's Environmental Health (MOCEH) in a prospective birth cohort study. Maternal urinary BPA, mono-2-ethyl-5-hydroxyhexyl phthalate (MEHHP), mono-2-ethyl-5-oxohexyl phthalate (MEOHP), and mono-n-butyl phthalate (MnBP) concentrations were measured during early and late pregnancy. We applied the Bayesian kernel machine regression (BKMR) with probit regression to estimate the association of BPA and phthalate metabolites with AD incidence after adjusting for potential confounders. Individual association was estimated by differences in predicted probabilities comparing each individual chemical concentration at 75th versus 25th percentiles, while other chemicals were set at their median. Overall joint effect was estimated by differences in predicted probabilities comparing all chemical concentrations at 75th versus 25th percentiles. RESULTS Individual effect of MEHHP in late pregnancy was strongly associated with incident AD [Difference: 0.244 (95% credible interval: -0.066, 0.554)] in the model including both early and late exposures. Furthermore, we confirmed overall joint association of urinary BPA and phthalate metabolites during pregnancy with a higher risk of AD [0.347 (0.168, 0.526) for late pregnancy exposure, and 0.307 (0.094, 0.521) for both early and late pregnancy]. Additionally, the joint association was more prominent among girls than that in boys. CONCLUSIONS The joint association of prenatal exposure to BPA and phthalates could be associated with the incident AD in 6-month-old infants. Further studies are needed to confirm the synergistic effect of BPA and phthalate exposures on AD in children.
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Affiliation(s)
- Seulbi Lee
- Department of Occupational and Environmental Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea; Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States; Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Hyesook Park
- Department of Preventive Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea; Graduate Program in System Health Science and Engineering, Ewha Womans University, Seoul, Republic of Korea
| | - Woojoo Lee
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Ji Hyen Lee
- Department of Pediatrics, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Yun-Chul Hong
- Department of Preventive Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Mina Ha
- Department of Preventive Medicine, College of Medicine, Dankook University, Cheonan, Republic of Korea
| | - Yangho Kim
- Department of Occupational and Environmental Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Bo-Eun Lee
- Environmental Health Research Division, National Institute of Environmental Research, Incheon, Republic of Korea
| | - Eunhee Ha
- Department of Occupational and Environmental Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea; Graduate Program in System Health Science and Engineering, Ewha Womans University, Seoul, Republic of Korea; Ewha Medical Research Institute, College of Medicine, Ewha Womans University, Seoul, Republic of Korea.
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Su KW, Chiu CY, Tsai MH, Liao SL, Chen LC, Hua MC, Yao TC, Huang JL, Yeh KW. Cord blood soluble Fas ligand linked to allergic rhinitis and lung function in seven-year-old children. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 55:300-306. [PMID: 33879403 DOI: 10.1016/j.jmii.2021.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 03/01/2021] [Accepted: 03/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Serum or cord blood soluble Fas ligand (FasL) has been related to asthma, allergic rhinitis, and atopic dermatitis in cross-sectional and short-term follow-up studies. However, the association of cord blood soluble FasL with long-term allergic outcomes has seldom been investigated. METHODS The Prediction of Allergies in Taiwanese Children birth cohort study recruited healthy newborns upon delivery. At birth, blood was collected from the umbilical cords of these children, and the cord blood soluble Fas ligand levels were measured. At the age of seven years, the allergic outcome of each child was diagnosed by pediatric allergists and pulmonologists. Tests were conducted to measure the specific immunoglobulin E, fractional exhaled nitric oxide (FeNO), and pulmonary function levels of each child. RESULTS Cord blood soluble FasL levels were higher in seven-year-old children with allergic rhinitis (Odds ratio [OR] = 2.41, p = 0.012) and expiratory airway obstruction (the highest forced expiratory volume in 1 second/forced vital capacity < 90%, OR = 2.11, p = 0.022). The FeNO and Dermatophagoides pteronyssinus-specific immunoglobulin E levels of seven-year-old children were positively correlated with cord blood soluble FasL levels (p = 0.006 and 0.02, respectively). CONCLUSION In this birth cohort, the cord blood soluble FasL levels were associated with allergic rhinitis, obstructive-type lung function, FeNO, and house dust mite sensitization in 7-year-old children. The cord blood soluble FasL level might be used as a predictor for allergic diseases in children who are 7 years old.
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Affiliation(s)
- Kuan-Wen Su
- Department of Pediatrics, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Graduate Institute of Clinical Medical Science, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chih-Yung Chiu
- Department of Pediatrics, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Division of Pediatric Pulmonology, College of Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Han Tsai
- Department of Pediatrics, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Sui-Lin Liao
- Department of Pediatrics, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Li-Chen Chen
- Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Department of Pediatrics, New Taipei Municipal TuCheng Hospital, Chang Gung Memorial Hospital and Chang Gung University, Taiwan
| | - Man-Chin Hua
- Department of Pediatrics, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Tsung-Chieh Yao
- Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jing-Long Huang
- Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Department of Pediatrics, New Taipei Municipal TuCheng Hospital, Chang Gung Memorial Hospital and Chang Gung University, Taiwan
| | - Kuo-Wei Yeh
- Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan; Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, and College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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