Advances in pediatric asthma in 2008: where do we go now?

Comparison of the effect of fluticasone combined with salmeterol and fluticasone alone in the treatment of pediatric asthma: review and meta-analysis

BACKGROUND

A systematic review and meta-analysis was performed to investigate the effect of fluticasone + salmeterol and fluticasone alone in the treatment of pediatric asthma.

METHODS

Studies meeting specific selection criteria were selected from online databases, including Pubmed, Embase, and the Cochrane Library. The quality of randomized controlled trials was assessed using the Cochrane Library. Weighted mean difference (WMD) and 95% CI were used to evaluate the effect size of continuous variables, while rate ratio (RR) and 95% CI were used for dichotomous variables.

RESULTS

A total of 11 studies, including 8,272 pediatric asthma patients, were included in this meta-analysis. Among these, 4,133 patients were in the salmeterol + fluticasone group. The changes in forced expiratory volume in 1 second in children with asthma in the salmeterol + fluticasone and fluticasone alone groups were significantly different (fixed effects model, WMD = 3.26, 95% CI: 1.52-5.00, P = 0.0002). Asthma exacerbation between two groups were significantly different (fixed effects model, RR = 0.85, 95% CI: 0.73-0.98, Z = 2.18, P = 0.03). There was no difference in the incidence of adverse events between salmeterol + fluticasone and fluticasone alone in the treatment of pediatric asthma (P > 0.05). When the control group was treated with double dose fluticasone, the difference of changes in FEV1 and asthma exacerbation in children with asthma between the two groups were not significant.

CONCLUSIONS

The efficacy of salmeterol + fluticasone is better than fluticasone alone, and the efficacy of salmeterol + fluticasone is equal to doubling the dose of fluticasone in the treatment of pediatric asthma.

Risk factors for wheezing in infants born in Cuba

BACKGROUND

Cuba is a unique country, and despite limited economic development, has an excellent health system. However, the prevalence of asthma symptoms in children in Havana, Cuba, is unusually high.

AIM

As early life exposures are critical to the aetiology of asthma, we have studied environmental influences on the risk of wheezing in Cuban infants.

DESIGN

Cross-sectional study.

METHODS

A random sample of 2032 children aged 12-15 months living in Havana was selected for inclusion in the cohort. Data were collected using questionnaires administered by researchers.

RESULTS

Of 2032 infants invited to participate, 1956 (96%) infants provided data. The prevalence of any wheeze was 45%, severe wheeze requiring use of emergency services was 30% and recurrent wheeze on three or more occasions was 20%. The largest adjusted risk factors for any wheeze were presence of eczema [odds ratio (OR) 2.09; 95% confidence interval (CI) 1.48-2.94], family history of asthma (OR 2.05; 95% CI 1.60-2.62), poor ventilation in the house (OR 1.99; 95% CI 1.48-2.67), attendance at nursery (OR 1.78; 95% CI 1.24-2.57), male sex (OR1.52; 95% CI 1.19-1.96) and the number of smokers in the house (P < 0.03 for trend), OR 1.64 (95% CI 1.17-2.31) for three or more smokers in the house compared to no smokers in the household.

CONCLUSION

We have identified several risk factors for any wheeze in young infants living in modern day Cuba. As the prevalence of smoking in the house is high (51%), intervention studies are required to determine effective strategies to improve infant health.

Exhaled nitric oxide in pediatrics: what is new for practice purposes and clinical research in children?

Fractional exhaled NO (FeNO) is universally considered an indirect marker of eosinophilic airways inflammation, playing an important role in the physiopathology of childhood asthma. Advances in technology and standardization have allowed a wider use of FeNO in clinical practice in children from the age of four years. FeNO measurements add a new dimension to the traditional clinical tools (symptoms scores, lung function tests) in the assessment of asthma. To date a number of studies have suggested a possible use of FeNO in early identification of exacerbation risk and in inhaled corticosteroids titration. The aim of this paper is to address practical issues of interest to paediatric clinicians who are attempting to use FeNO measurements as an adjunctive tool in the diagnosis and management of childhood airway diseases.

A medical nutrition therapy primer for childhood asthma: current and emerging perspectives

Asthma is the most common chronic disease in children. Prevalence has increased in the past 2 decades and has reached a plateau of approximately 9% of children in the United States, affecting about 6.7 million children. The increased prevalence of childhood asthma has paralleled the increased prevalence in childhood obesity. Changes in diet have also been implicated in the increased prevalence of asthma, among other risk factors. The main symptoms of asthma (ie, wheezing, coughing, and chest tightness) require medical evaluation and monitoring. The cornerstone of asthma management is medication therapy, frequently consisting of inhaled bronchodilators and corticosteroids and, when needed, therapy of corticosteroids by mouth. As part of the multidisciplinary management of this chronic disease, nutrition assessment and follow-up in childhood asthma is necessary to identify and address relevant nutrition-related problems. These problems can involve food-medication interactions, obesity, gastroesophageal reflux disease, food allergies, and other issues; therefore, individualized medical nutrition therapy is warranted. Finally, counseling to achieve a healthy balanced diet is recommended for overall health and weight management. A recent but small number of descriptive investigations agree that adherence to a Mediterranean dietary pattern can be associated with a decreased risk of current asthma symptoms in children. Although this evidence is promising, food interventions are required to substantiate an evidence-based foundation for medical nutrition therapy in childhood asthma. At this time, there is no known health risk if a Mediterranean diet is adopted.

Fluctuation phenotyping based on daily fraction of exhaled nitric oxide values in asthmatic children

BACKGROUND

Fraction of exhaled nitric oxide (Feno), a marker of airway inflammation, has been proposed to be useful for asthma management, but conclusions are inconsistent. This might be due to the failure of mean statistics to characterize individual variability in Feno values, which is possibly a better indicator of asthma control than single measurements.

OBJECTIVE

We characterized fractal fluctuations in daily Feno values over time and the relationship between Feno values and symptom scores. We investigated whether these are associated with asthma severity, control, and exacerbation risk.

METHODS

Daily Feno values and symptom scores over 192 days in 41 atopic asthmatic children from the Childhood Asthma Respiratory Inflammatory Status Monitoring study were analyzed. Two methods of time-series analysis were used: detrended fluctuation analysis to quantify fractal patterns in fluctuations in daily Feno values (α value) and cross-correlation to quantify the strength of the relationship between daily Feno values and symptom scores. The associations of α values and cross-correlation with markers of asthma severity and control were assessed by means of regression analysis.

RESULTS

Daily fluctuations in Feno values exhibited fractal-type long-range correlations. Those subjects receiving higher doses of inhaled corticosteroids at study entry had a significantly lower α value, corresponding to more random fluctuations in Feno values in those with greater inhaled corticosteroid need. The cross-correlation between Feno values and symptom scores was significantly higher in those subjects who had exacerbations.

CONCLUSIONS

Fluctuation in Feno values and their cross-correlation to symptom scores contains information on asthma severity and control. Methods that quantify the complexity of asthma over time might assist in identifying asthmatic subjects with concordance between eosinophilic inflammation and symptoms and thus increased exacerbation risk.

Advances in pediatric asthma in 2009: gaining control of childhood asthma

This year's summary will focus on recent advances in pediatric asthma as reported in Journal of Allergy and Clinical Immunology publications in 2009. New National Asthma Education and Prevention Program asthma guidelines were released in 2007, with a particular emphasis on asthma control. Now that we have worked with the principals of the guidelines for 2 years, new insights are reported on how to implement the guidelines into clinical practice. This year's report will focus on gaps in management that need to be addressed, including health disparities, methods to improve asthma management through opportunities available in school-based asthma programs, and more information on the development of asthma in childhood. This information brings us closer to the point of managing children with controllable asthma and understanding reasons why asthma is not controlled in the remaining children. If we can close these gaps through better communication, improvements in the health care system, and new insights into treatment, we will move closer to better methods to intervene early in the course of the disease and induce clinical remission as quickly as possible in most children.

Exercise-induced asthma: critical analysis of the protective role of montelukast

Exercise-induced asthma/exercise-induced bronchospasm (EIA/EIB) is a prevalent and clinically important disease affecting young children through older adulthood. These terms are often used interchangeably and the differences are not clearly defined in the literature. The pathogenesis of EIA/EIB may be different in those with persistent asthma compared to those with exercise-induced symptoms only. The natural history of EIA is unclear and may be different for elite athletes. Leukotriene biology has helped the understanding of EIB. The type and intensity of exercise are important factors for EIB. Exercise participation is necessary for proper development and control of EIA is recommended. Symptoms of EIB should be confirmed by proper testing. Biologic markers may also be helpful in diagnosis. Not all exercise symptoms are from EIB. Many medication and nonpharmacologic treatments are available. Asthma education is an important component of managing EIA. Many medications have been tested and the comparisons are complicated. Montelukast is a US Food and Drug Administration-approved asthma and EIB controller and has a number of potential advantages to other asthma medications including short onset of action, ease of use, and lack of tolerance. Not all patients improve with montelukast and rescue medication should be available.