Prevalence of attention-deficit/hyperactivity disorder in patients with pediatric allergic disorders: a nationwide, population-based study

Omalizumab in combination with subcutaneous immunotherapy for the treatment of multiple allergies associated with attention-deficit/hyperactivity disorder: a case report and a literature review

We describe the case of a 10-year-old boy with asthma (AS), accompanied by allergic rhinitis (AR), food allergy (FA), and combined attention-deficit/hyperactivity disorder (ADHD), who was treated at Shanghai Renji Hospital on 11 July 2020. The efficiency of the previous treatment with salmeterol/ticlosone was poor. Treatment with montelukast sodium resulted in development of neurological symptoms. Treatment with omalizumab in combination with subcutaneous immunotherapy (SCIT) was then initiated in our department based on anti-asthmatic therapy. Symptoms of asthma were completely controlled, and FA and AR symptoms improved. The treatment regimen led to a significant improvement in ADHD symptoms and the overall quality of life of the patient. The literature search was done in the PubMed database using "attention deficit/hyperactivity disorder/ADHD" and "asthma" as keywords, and we identified 47 relevant articles. In conclusion, our results show that treating asthma with omalizumab in combination with salmeterol/ticlosone and SCIT is efficient in controlling symptoms of multiple allergies and may lead to the improvement in ADHD symptoms and the overall quality of life of pediatric patients with ADHD. While current studies suggest that allergic diseases are closely related to ADHD, there is still a lack of studies or case reports of complete treatment protocols to provide clinical clues for management of the disease.

Investigating causal relationships between genetically determined increased risk of attention-deficit/hyperactivity disorder (ADHD) and atopic dermatitis (AD): A Mendelian randomization analysis

Atopic dermatitis (AD) is a chronic, inflammatory skin condition with a huge disease burden. Attention-deficit/hyperactivity disorder (ADHD) is often diagnosed in children, and is associated with symptoms of inattention, hyperactivity and impulsive behaviour. Observational studies have demonstrated associations between AD and ADHD. However, to date, there has been no formal assessment of causal relationship between the two. We aim to evaluate causal relationships between genetically increased risk of AD and ADHD using Mendelian randomization (MR) approach. Two-sample bi-directional MR was conducted to elucidate potential causal relationships between genetically increased risk of AD and ADHD, using the largest and most recent genome-wide association study datasets for AD and ADHD-EArly Genetics & Lifecourse Epidemiology AD consortium (21 399 cases and 95 464 controls) and Psychiatric Genomics Consortium (20 183 cases and 35 191 controls). Genetically determined increased risk of AD is not associated with ADHD based on genetic information: odds ratio (OR) of 1.02 (95% CI -0.93 to 1.11; p = 0.705). Similarly, genetic determined increased risk of ADHD is not associated with an increased risk of AD: OR of 0.90 (95% CI -0.76 to 1.07; p = 0.236). Horizontal pleiotropy was not observed from the MR-Egger intercept test (p = 0.328) Current MR analysis showed no causal relationship between genetically increased risk of AD and ADHD in either direction in individuals of European descent. Any observed associations between AD and ADHD in previous population studies could possibly be due to confounding lifestyle factors such as psychosocial stress and sleeping habits.

Impact of the Allergic Therapeutic Adherence in Children with Allergic Rhinitis and ADHD: A Pilot Study

BACKGROUND

Allergic rhinitis (AR) is the most common chronic allergic disease in children. Several studies have shown an association between attention deficit hyperactivity disorder (ADHD) and allergies, especially AR. Patients with ADHD usually have poor therapeutic adherence, and untreated AR symptoms may worsen the quality of life of patients.

METHODS

The aim of our study was to analyse therapeutic adherence in patients with ADHD and AR and estimate the impact of the adherence on ADHD symptoms. Total Nasal Symptoms Score (TNSS), Paediatric or Adolescent Rhinoconjunctivitis Quality of Life Questionnaire (PRQLQ 6-12 years; ARQLQ 13-17 years), Swanson, Nolan, and Pelham version IV scale (SNAP-IV), and Medication Assessment Questionnaire (MGL MAQ) were recorded.

RESULTS

In the AR-ADHD group, a positive correlation between TNSS and SNAP-IV subscales was found: worse AR symptoms were related to a negative effect on ADHD scores. AR-ADHD patients with better ADHD therapeutic adherence showed higher AR symptoms and higher oppositional defiant disorder scores in the SNAP-IV questionnaire.

CONCLUSIONS

Our results suggest that better adherence to AR therapy (oral antihistamines and/or intranasal corticosteroids, INCS) is associated with a reduction in inattention symptoms in children with ADHD. This data could prove to be fundamental for the psychic outcome of these patients.

Atopic dermatitis and risk of major neuropsychiatric disorders in children: A population-based cohort study

BACKGROUND

Paediatric atopic dermatitis (AD) has been linked to neuropsychiatric comorbidities such as depression, anxiety and attention-deficit/hyperactivity disorder (ADHD). However, longitudinal data are limited, and the effect of AD severity on neuropsychiatric outcomes requires further characterization.

OBJECTIVES

To determine the risk of several major neuropsychiatric conditions in children with AD.

METHODS

We analysed UK health records data in a population-based cohort study. Each patient <18 years old with AD was matched to up to five unaffected patients on age, practice and index date. Treatments served as proxies for AD severity, which was analysed in a time-updated manner. Outcomes were incident anxiety, depression, bipolar disorder, schizophrenia, ADHD, autism, obsessive-compulsive disorder (OCD), suicidal ideation or attempt, and completed suicide.

RESULTS

A total of 409,431 children with AD (93.2% mild, 5.5% moderate, 1.3% severe) were compared to 1,809,029 children without AD. In Cox regression models adjusted for age, sex, socioeconomic status and other atopic comorbidities, no statistically significant relationships were observed between AD and incident anxiety (HR 1.01, 95% CI 0.99-1.03), ADHD (1.02, 0.97-1.06), autism (1.02, 0.98-1.06), bipolar disorder (1.08, 0.85-1.36), suicidal ideation/attempt (0.98, 0.95-1.01) or completed suicide (0.85, 0.64-1.14). Children with AD were less likely to develop depression (0.93, 0.91-0.95) or schizophrenia (0.72, 0.54-0.95) but more likely to develop OCD (1.26, 1.16-1.37). However, there was substantial variation by AD severity and age in both the direction and magnitude of effect for many of the neuropsychiatric conditions examined.

CONCLUSIONS

The was no substantial impact of AD on the overall risk of many neuropsychiatric conditions in children, but disease severity and age may be important modifying factors. Additional research is needed to further dissect the complex relationship between paediatric AD and neuropsychiatric comorbidities.

Living proximity to petrochemical industries and the risk of attention-deficit/hyperactivity disorder in children

Evidence regarding the negative neurodevelopmental effects of compound exposure to petrochemicals remains limited. We aimed to evaluate the association between exposure to petrochemical facilities and generated emissions during early life and the risk of attention-deficit/hyperactivity disorder (ADHD) development in children. We conducted a population-based birth cohort study using the 2004 to 2014 Taiwanese Birth Certificate Database and verified diagnoses of ADHD using the National Health Insurance Database. The level of petrochemical exposure in each participant's residential township was evaluated using the following 3 measurements: distance to the nearest petrochemical industrial plant (PIP), petrochemical exposure probability (accounting for monthly prevailing wind measurements), and monthly benzene concentrations estimated using kriging-based land-use regression models. We applied Cox proportional hazard models to evaluate the association. During the study period, 48,854 out of 1,863,963 children were diagnosed as having ADHD. The results revealed that residents of townships in close proximity to PIPs (hazard ratio [HR] = 1.20, 95% confidence interval [CI]: 1.16-1.23, <3 vs. ≥10 km), highly affected by petrochemical-containing prevailing winds (HR = 1.12, 95% CI: 1.08-1.16, ≥40% vs. <10%), and with high benzene concentrations (HR = 1.26, 95% CI: 1.23-1.29, ≥0.75 vs. <0.55 ppb) were consistently associated with the increased risk of ADHD development in children. The findings of the sensitivity analysis remained robust, particularly for the 2004 to 2009 birth cohort and for models accounting for a longer duration of postnatal exposure. This work provided clear evidence that living near petrochemical plants increases the risk of ADHD development in children. Further studies are warranted to confirm our findings.

Association of Atopic Dermatitis with Depression and Suicide: A Two-Sample Mendelian Randomization Study

Background

Atopic dermatitis (AD) has long been hypothesized to be associated with risk of depression and suicide, but the causal relationship between them is still unclear.

Objective

To evaluate the causality between AD, depression, and suicide using a Mendelian randomization (MR) approach.

Method

We extracted summary-level data for AD, major depression, and suicidal ideation or attempt from published, nonoverlapping genome-wide association studies (GWAS). Inverse variance-weighted (IVW) analysis was used as the primary analysis. Alternate methods, including weighted median, MR Egger, MR pleiotropy residual sum and outlier, weighted mode, and leave-out analysis, were performed to assess pleiotropy.

Results

13 SNPs (13,287 cases and 41,345 controls) were selected as instrumental variables (IVs). The IVW analysis indicated a statistically significant but small causal effect of AD on major depression (OR = 1.027, 95% CI 1.004-1.050; p = 0.020). No significant evidence was observed for a causal effect of AD on suicide. No significant effect of pleiotropy was found.

Conclusion

AD has a significant but small effect on major depression, but not on suicide.

Do allergic clinical manifestations increase the risk of behavioral problems in children? A cross-sectional study

BACKGROUND

Children with allergic clinical manifestations tend to have behavioral or emotional problems such as hyperactivity or worse mental health. However, previous studies on this association did not adequately adjust for confounders like parenting stress, demographic characteristics, or allergy presentation. This study aimed to investigate the relationship between childhood allergic clinical manifestations and behavioral problems, adjusting for confounders such as demographic characteristics, parenting stress, and allergy-related variables.

METHODS

We conducted an online cross-sectional survey among caregivers of children aged 2-6 years (n = 633). The Strengths and Difficulties Questionnaire (SDQ) was used to determine children's behavioral characteristics as the primary outcome. Allergic clinical manifestations, wheeze, rash, and nose symptoms were the exposure variables. Associations were estimated using logistic regression analyses with propensity scores to adjust for confounders.

RESULTS

We analyzed 633 caregivers of children aged 2-6 years (valid rate, 61.5%). Univariate analyses showed that wheezing was associated with conduct problems (odds ratio [OR] = 1.48, 95% confidence interval [CI]:1.01-2.16), a behavioral component of the SDQ. Rash was also associated with hyperactivity (OR = 1.62, 95% CI: 1.02-2.57). Furthermore, nose symptoms were associated with conduct problems (OR = 1.65, 95% CI:1.16-2.33) and emotional symptoms (OR=1.62, 95% CI:1.06-2.45). After adjusting for potential confounders, wheezing (adjusted OR = 1.69, 95% CI:1.04-2.75) and nose symptoms (adjusted OR = 1.56, 95% CI: 1.05-2.34) remained associated with conduct problems.

CONCLUSIONS

This study revealed that a history of wheezing and nose symptoms in children is associated with an increased risk of behavioral problems, in particular, conduct problems.

Psychiatric Morbidity and Behavioral Problems in Children and Adolescents with Bronchial Asthma

OBJECTIVES

Psychiatric morbidity and behavioral problems are quite common in children and adolescents with bronchial asthma, yet they remain underexplored and often ignored in clinical settings. This can impact the child's overall quality of life. There seems to be a dearth of Indian literature and so the current study was planned to assess psychological impact of asthma on the pediatric population.

METHODS

Thirty children and adolescents, attending the Pediatric Chest Clinic at a tertiary care hospital in North India in the age group of 8-15 y having moderate to severe asthma formed the study group and matched healthy controls formed the other group. Sociodemographic and clinical details were obtained. Mini International Neuropsychiatric Interview (M.I.N.I. KID) and Child Behavior Checklist (CBCL) were applied.

RESULTS

Irregular attendance at school was reported by 23.33% of the participants with asthma. About 17% of the thirty study-participants were diagnosed with specific phobia, 10% with conduct disorder, and 7% with attention deficit hyperactivity disorder (ADHD). Participants in the study group had significantly more behavioral problems in the syndrome domain anxious/depressed and attention problems. Total CBCL scores were significantly higher in the study group as compared to the control group (t = 3.816, p = 0.0003), indicating the presence of more behavioral problems in pediatric population with bronchial asthma.

CONCLUSION

Children and adolescents with bronchial asthma have co-morbid psychiatric morbidities and behavioral problems.

Childhood atopic dermatitis as a precursor for developing attention deficit/hyperactivity disorder

Atopic dermatitis (AD) is a skin disease characterized by chronic inflammatory condition that shows hallmark presentations in terms of sleep disturbances, pruritus, and psychological stress, and an association with increased attention deficit/hyperactivity disorder (ADHD) risk. A number of studies have suggested for the co-occurrence of the two diseased conditions. In terms of global prevalence, AD and ADHD almost exhibit a parallel increment according to epidemiological data. In addition, recent reports indicate AD to show a temporal association with later onset of ADHD. Although several studies suggest for the potential link between AD and ADHD, currently there is no definitive answer to this regard. Furthermore, epidemiological evidence of co-occurrence does not ascertain a pathophysiological link between the two conditions. The pathophysiological basis behind the association of AD and ADHD also remain poorly elucidated. The objective of this review is to present an extensive account of AD and associated comorbidities with a special attention toward ADHD as well as to elaborate on the mechanisms underlying their association. The review can provide healthcare providers with the recent updates on AD-ADHD association and help them while dealing with such patients. In general, AD and ADHD show a positive association in majority of the cross-sectional studies. However, large longitudinal studies are required to draw any conclusion on the temporal nature of such association.

Montelukast does not increase the risk of attention-deficit/hyperactivity disorder in pediatric asthma patients: A nationwide population-based matched cohort study

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) has been linked to pediatric asthma patients treated with montelukast. This study is the first to use a nationwide health insurance research database (NHIRD) to study whether asthmatic children using montelukast are at an increased risk of ADHD.

METHODS

We used data from the Taiwan NHIRD, which is a longitudinal database of one million randomly selected subjects. The enrolled patients were followed up until 2013. Patients younger than and equal to 12 years old with new-onset asthma (ICD-9 CM code 493.X) diagnosed between 1997 and 2013 were enrolled. A multivariate Cox regression analysis was conducted to evaluate the association between montelukast treatment and the risk of ADHD (ICD-9-CM code 314.X).

RESULTS

We enrolled a total of 54,487 asthmatic children younger than and equal to 12 years old who had at least one claim of inpatient admission or at least three claims of an ambulatory visit. Montelukast users and match controls were identified by matching age, gender, residence, the comorbidities including allergic rhinitis and atopic dermatitis, admission or emergency department visits due to asthma attack, and index date of starting montelukast in a 1:1 ratio, with 12,806 in the montelukast group and 12,806 in the non-montelukast group. The montelukast group had a similar risk of ADHD (n = 632, 4.94%) as the non-montelukast group (n = 610, 4.76%) [adjusted hazard ratio 1.04; 95% confidence interval, 0.93 to 1.17]. In children treated with montelukast, high cumulative days of montelukast use did not increase the risk of ADHD.

CONCLUSION

This nationwide population-based cohort study reveals that asthma children treated with montelukast were not at an increased risk of developing ADHD. Nevertheless, validation of our retrospective survey requires further prospective study.

Type 1 Diabetes Mellitus (Juvenile Diabetes) - A Review for the Pediatric Oral Health Provider

Objective: To describe the significance of type 1 diabetes mellitus (juvenile diabetes) to the pediatric oral health provider. Relevance: The oral health provider must be aware of type 1 diabetes mellitus (T1DM) characteristics, influence of on oral health, each patient pre-operative diabetic management, symptoms and treatment of hypo and hyper-glycemia, and the clinical implications before, during and after treatment of children with T1DM. Study design: A review of the scientific literature about the T1DM influence on dental development, caries prevalence, gingival and periodontal diseases, wound healing, salivary and taste dysfunction, oral infections, and the factors that must be taken in consideration before, during and after oral treatment of children with T1DM is presented. Conclusion: The increasing prevalence of T1DB in children strongly emphasizes the need for oral health providers to be aware of the complicacy of the treatment aimed to obtain and maintain acceptable blood glucose levels in diabetic children, the effect of diabetes on the oral cavity, the possible serious complications due to hypo- or hyper glycemia before, during and after oral treatments, the effect of stress on blood glucose levels, and the special behavioral interaction between the diabetic child, his/her family and the oral health providers.

Risk of Mental Disorders in Children and Adolescents With Atopic Dermatitis: A Systematic Review and Meta-Analysis

Assessing the psychological effects on children and adolescents of suffering atopic dermatitis (AD) is essential, when planning successful management. This study aimed to systematically review the literature regarding risk of mental disorders in children and adolescents with, or without, AD; and to explore confounders. We identified potentially relevant studies from EMBASE, MEDLINE, PsycINFO, ERIC, the British Nursing Index, the Family and Society Studies Worldwide, the Social Work Abstracts, and the Sociological Abstracts from inception to Sep 30, 2018. Investigators independently screened titles and abstracts, and then full-texts. Investigators independently extracted data from included studies. Meta-analyses using random-effects models were performed, reporting odds ratios (ORs; 95% CIs). Thirty-seven studies (n = 2,068,911 children/ adolescents) were included. Meta-analysis of 35 studies found that children and adolescents with AD had significantly higher risk of total mental disorders than those without AD (OR = 1.652; 95% CI, 1.463-1.864). There was no significant difference in risks for ADHD (OR = 1.563; 95% CI, 1.382-1.769); sleep disorders (OR = 2.100; 95% CI, 1.322-3.336); anxiety (OR = 1.339; 95% CI, 1.062-1.687); depression (OR = 1.402 95% CI, 1.256-1.565); conduct disorder (OR = 1.494 95% CI, 1.230-1.815); or ASD (OR = 2.574; 95% CI, 1.469-4.510; Q b = 8.344, p = 0.138). Race/ethnicity of child, target of comparison, type of studies, representativeness of the sample, measures of AD and mental disorders were significant moderators for total mental disorders. Integrated, holistic, multidisciplinary management of pediatric AD is significantly important, which emphasizes the well-being of the whole person.

Psychiatric Disorders After Attention-Deficit/Hyperactivity Disorder: A Nationwide Population-Based Study in Taiwan

PURPOSE

To investigate the risk for psychiatric disorders in patients newly diagnosed with attention deficit hyperactive disorder (ADHD) from two longitudinal groups of children with and without ADHD.

STUDY DESIGN

In total, 1,745 children newly diagnosed with ADHD and 6,980 participants without ADHD were identified from Taiwan's National Health Insurance Research Database in 2005 and followed until 2010. Risks for psychiatric disorders in the ADHD and non-ADHD groups were compared.

RESULTS

The ADHD group was 3.82 times more likely to develop psychiatric disorders than their counterparts. The ADHD group showed the highest risk for oppositional defiant disorder, followed by adult ADHD and autism spectrum disorder. Moreover, the time effects of psychiatric disorders in the ADHD group were significant. Patients with ADHD subtypes had a significant risk for psychiatric disorders compared to their counterparts.

CONCLUSIONS

A high risk for psychiatric disorders was revealed in this study among children with ADHD. Childhood ADHD, the duration after the ADHD diagnosis, and the ADHD subtype were associated with psychiatric disorders.

CLINICAL RELEVANCE

Various psychiatric disorders were observed in children after they had been newly diagnosed with ADHD, indicating a need for integrated care that includes medical practitioners, family members, social workers, and early intervention workers for patients newly diagnosed with ADHD to decrease the risk for comprehensive psychiatric disorders.

Major Comorbidities of Atopic Dermatitis: Beyond Allergic Disorders

The consequences of atopic dermatitis reach beyond the skin and past childhood. Patients with atopic dermatitis are at risk of developing allergic comorbidities, but less is known about the associations between atopic dermatitis and non-allergic conditions. Understanding these non-allergic comorbidities has the potential to improve patient outcomes and to help mitigate the cost and burdens associated with these conditions. Atopic dermatitis is associated with cutaneous bacterial infections, more severe forms/courses of cutaneous viral infections, and extra-cutaneous infections. Atopic dermatitis is also associated with several mental health comorbidities particularly attention-deficit hyperactivity disorder, anxiety, and depression. Data are largely inconsistent for specific cancers, but atopic dermatitis appears to protect against malignancy overall; severe long-term atopic dermatitis is associated with adult lymphomas. Atopic dermatitis may also be associated with obesity, cardiovascular disease, and autoimmune disease, particularly alopecia areata and gastrointestinal immune-mediated disorders. Although the causative mechanisms underlying these associations are poorly understood, treating physicians should be aware of associations in seeking to alleviate the burden for patients with atopic dermatitis.

Keloid risk in patients with atopic dermatitis: a nationwide retrospective cohort study in Taiwan

OBJECTIVE

The pathogenesis of keloid is largely unknown. Because keloid and atopic dermatitis have overlapping pathophysiological mechanisms, we aimed to evaluate keloid risk in patients with atopic dermatitis.

STUDY DESIGN

Population-based retrospective cohort study.

SETTING

The Taiwan National Health Insurance Research Database was used to analyse data for people who had been diagnosed with atopic dermatitis.

PARTICIPANTS

We identified 8371 patients with newly diagnosed atopic dermatitis during 1996-2010. An additional 33 484 controls without atopic dermatitis were randomly identified and frequency matched at a one-to-four ratio.

PRIMARY AND SECONDARY OUTCOME MEASURE

The association between atopic dermatitis and keloid risk was estimated using Cox proportional hazard regression models.

RESULTS

After adjustment for covariates, the atopic dermatitis patients have a 3.19-fold greater risk of developing keloid compared with the non-atopic dermatitis group (3.19vs1.07 per 1000 person-years, respectively). During the study period, 163 patients with atopic dermatitis and 532 patients without atopic dermatitis developed keloid. Notably, keloid risk increased with severity of atopic dermatitis, particularly in patients with moderate to severe atopic dermatitis.

CONCLUSIONS

Our results indicate that patients with atopic dermatitis had a higher than normal risk of developing keloid and suggest that atopic dermatitis may be an independent risk factor for keloid.

Systemic Inflammation during the First Postnatal Month and the Risk of Attention Deficit Hyperactivity Disorder Characteristics among 10 year-old Children Born Extremely Preterm

Although multiple sources link inflammation with attention difficulties, the only human study that evaluated the relationship between systemic inflammation and attention problems assessed attention at age 2 years. Parent and/or teacher completion of the Childhood Symptom Inventory-4 (CSI-4) provided information about characteristics that screen for attention deficit hyperactive disorder (ADHD) among 793 10-year-old children born before the 28th week of gestation who had an IQ ≥ 70. The concentrations of 27 proteins in blood spots obtained during the first postnatal month were measured. 151 children with ADHD behaviors were identified by parent report, while 128 children were identified by teacher report. Top-quartile concentrations of IL-6R, TNF-α, IL-8, VEGF, VEFG-R1, and VEGF-R2 on multiple days were associated with increased risk of ADHD symptoms as assessed by a teacher. Some of this increased risk was modulated by top-quartile concentrations of IL-6R, RANTES, EPO, NT-4, BDNF, bFGF, IGF-1, PIGF, Ang-1, and Ang-2. Systemic inflammation during the first postnatal month among children born extremely preterm appears to increase the risk of teacher-identified ADHD characteristics, and high concentrations of proteins with neurotrophic properties appear capable of modulating this increased risk.

Association of Pediatric Allergic Rhinitis with the Ratings of Attention-Deficit/Hyperactivity Disorder

Background

Allergic rhinitis (AR) is currently the most prevalent allergic disease in children and adolescents.

Objective

Surveys conducted by population-based studies of East Asia revealed an increased prevalence of behavioral disorders in patients with AR. Thus, in this study, we explored the prevalence of attention-deficit/hyperactivity disorder (ADHD) in pediatric patients with AR.

Methods

A total of 333 children (6–12 years of age) with AR and a total of 322 age-matched controls were included in this study. An otorhinolaryngologist diagnosed all AR cases and evaluated the severity of the disease. Skin-prick test results for 18 major allergens, Paediatric Rhinoconjunctivitis Quality of Life Questionnaire (PRQLQ), Child Behavior Checklist (CBCL), and Swanson, Nolan, and Pelham version IV (SNAP-IV) scores were recorded.

Results

In total, 320 age-matched controls and 323 children with AR completed the study. With respect to the Total Nasal Symptom Score and the PRQLQ, the condition of the experimental group was more serious than that of the controls. The scores on the hyperactivity/impulsivity and inattention subscales, which evaluate ADHD symptoms, and those on the CBCL subscales were significantly higher in patients with AR than in the controls (all p values were <0.01). From the results of the Pearson correlation, we deduced that there were significant positive correlations between the AR-related data and each subscale of the CBCL and SNAP-IV in the AR group. Moreover, two basic characteristics (males and environmental exposure to tobacco smoke) present significant positive and age showed a significant negative correlations affect ADHD symptom in both the AR group and the control group. Also, in the “pure AR” group, hierarchical regression analyses were performed to determine the subtests of the PRQLQ, which are significant predictors of SNAP-IV and CBCL.

Conclusions

Apart from AR per se, the possible comorbidities of impulsivity and inattention are important when managing children with AR. It is essential to evaluate the symptoms of ADHD in children and adolescents with AR.

Association of atopic diseases and attention-deficit/hyperactivity disorder: A systematic review and meta-analyses

Over the last decades, the hypothesis has been raised that an atopic response could lead to the development of attention-deficit/hyperactivity disorder (ADHD). This study systematically reviews the observational cross-sectional and longitudinal studies that assessed the association between atopic disorders including asthma, atopic eczema, allergic rhinitis, and ADHD in children and adolescents. For longitudinal studies, a weighted Mantel-Haenszel odds ratio of these associations was estimated. The majority of cross-sectional and longitudinal studies reported a statistically significant positive association. The meta-analysis of longitudinal studies revealed an overall weighted odds ratio for asthma of 1.34 (95% confidence interval [CI] 1.24-1.44), 1.32 (95% CI 1.20-1.45) for atopic eczema, and 1.52 (95% CI 1.43-1.63) for allergic rhinitis. Heterogeneity of study data was low (I²: 0%, p=0.46 and p=0.64, respectively) for both studies examining asthma and eczema but substantial for rhinitis studies (I²: 82%, p=0.004). This current systematic review provides strong evidence that ADHD is associated with atopic diseases and that individuals have a 30% to 50% greater chance of developing ADHD compared to controls.

Risk factors for the existence of attention deficit hyperactivity disorder symptoms in children with autism spectrum disorders

Over the years, several authors have reported symptoms of attention deficit hyperactivity disorder (ADHD) in patients with autism spectrum disorders (ASD); however, studies on the risk factors of ADHD symptoms in children with ASD are lacking. The aim of this cross-sectional study was to identify the risk factors for the development of ADHD symptoms in children with ASD. The sample consisted of 67 children with ASD who were assessed with Conner's Parent Rating Scale-Revised (CPRS-R), and with a semi-structured detailed interview administered to parents, to collect a series of clinical data such as coexisting somatic and neuropsychiatric problems and familial and pre/peri/postpartum risk factors. We found that 55% of ASD children exceeded the cut-off of CPRS-R Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), total scale. The univariate analyses showed that children's age (P=0.048), motor delay (P=0.039), enuresis (P=0.014), allergies (P<0.01), comorbid oppositional defiant disorder (P=0.026) and intellectual disabilities comorbidities (P=0.034) were associated to the CPRS-R DSM-IV total score. Some familial predictors such as neuropsychiatric family history of intellectual disabilities (P=0.003) and psychosis (P=0.039) were related to the CPRS-R DSM-IV total score. In particular, a model including allergies (P=0.000) and family history of psychosis (P=0.03) explained 25% (corrected R²=0.25) of the variance of the DSM-IV ADHD score. In conclusion, we identified some risk factors associated with the development of ADHD symptoms in ASD children that need to be studied further.

Medical comorbidities in children and adolescents with autism spectrum disorders and attention deficit hyperactivity disorders: a systematic review

Somatic disorders occur more often in adult psychiatric patients than in the general adult population. However, in child and adolescent psychiatry this association is unclear, mainly due to a lack of integration of existing data. To address this issue, we here present a systematic review on medical comorbidity in the two major developmental disorders autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) and formulate clinical recommendations. The literature was searched using the PubMed and PsycINFO databases (2000-1 May 2016) with the keywords "[((child and adolescent) AND (Autism OR Attention Deficit Hyperactivity Disorder* OR ADHD)) AND ("Cardiovascular Diseases" [Mesh] OR "Endocrine System Diseases" [Mesh] OR "Immune System Diseases" [Mesh] OR "Neurobehavioral Manifestations" [Mesh] OR "Gastrointestinal Disorders" [Mesh] OR Somatic OR Autoimmune disease OR Nervous system disease OR Infection OR Infectious disease)]. Two raters independently assessed the quality of the eligible studies. The initial search identified 5278 articles. Based on inclusion and exclusion criteria 104 papers were selected and subsequently subjected to a quality control. This quality was assessed according to a standardized and validated set of criteria and yielded 29 studies for inclusion. This thorough literature search provides an overview of relevant articles on medical comorbidity in ADHD and/or ASD, and shows that medical disorders in these children and adolescents appear to be widespread. Those who work with children with ASD and/or ADHD should be well aware of this and actively promote routine medical assessment. Additionally, case-control studies and population-based studies are needed to provide reliable prevalence estimates. Future studies should furthermore focus on a broader evaluation of medical disorders in children and adolescents with ADHD and/or ASD to improve treatment algorithm in this vulnerable group.

Psychiatric disorders and symptoms severity in pre-school children with cow's milk allergy

BACKGROUND

Psychiatric disorders are seen frequently in atopic diseases. The present study aims to evaluate the frequency of psychiatric disorders and the severity of psychiatric symptoms in pre-school children with cow's milk allergy.

METHODS

The parents of the pre-school children with cow's milk allergy were interviewed in person and asked to fill out the Early Childhood Inventory-4 form.

RESULTS

The cow's milk allergy group included 40 children (27 male, 13 female) with mean age, 44.5±14.7 months, and the control group included 41 children (25 male, 16 female) with mean age, 47.6±15.2 months. It was established that 65% of the group with cow's milk allergy received at least one psychiatric diagnosis, while 36.6% of the control group received at least one psychiatric diagnosis, with a statistically significant difference (p=0.02). Within the psychiatric disorders, attention deficit hyperactivity disorders (odds ratio: 4.9, 95% CI: 1.472-16.856, p=0.006), oppositional defiant disorder (odds ratio: 5.6, 95% CI: 1.139-28.128, p=0.026), and attachment disorder (odds ratio: 4.8, 95% CI: 1.747-13.506, p=0.004) were found significantly higher compared with the healthy control group. When the groups were compared in terms of psychiatric symptom severity scores, calculated by using the Early Childhood Inventory-4 form, attention deficit hyperactivity disorders severity (p=0.006) and oppositional defiant disorder severity (p=0.037) were found to be higher in the cow's milk allergy group.

CONCLUSION

Psychiatric disorders are frequent and severe in pre-school children with cow's milk allergy.

Longitudinal association between early atopic dermatitis and subsequent attention-deficit or autistic disorder: A population-based case-control study

Atopic dermatitis (AD) is one of the common allergic diseases in children. The presence of allergic diseases was found to have association with the risk of developing attention-deficit hyperactivity disorder (ADHD) or autistic spectrum disorder (ASD) in children, but it is still inconclusive. This study was to investigate the longitudinal relationship between AD developed during toddlerhood and subsequent development of ADHD or ASD in later childhood. Toddlers born between 1998 and 2008 and diagnosed with AD at the age younger than 3 years and older than 1 month were retrieved from Taiwan's National Health Insurance Research Database. Age- and gender-matched toddlers with no lifetime AD were enrolled as the control group. All enrolled toddlers were followed until 2011 to identify the development of ADHD or ASD. Multivariate Cox regression analysis was performed to analyze the hazard ratios (HRs). The risks associated with allergic comorbidities were analyzed. A total of 18,473 toddlers were enrolled into the AD group. The presence of AD significantly increased the risk of developing ADHD (HR = 2.92, 95% confidence interval [CI] = 2.48-3.45) or ASD (HR = 8.90, 95% CI = 4.98-15.92) when aged 3 years or older. Children from the AD group with 3 comorbidities together, namely, allergic rhinitis, allergic conjunctivitis, and asthma, had the greatest risk of developing ADHD and ASD (ADHD: HR = 4.67, 95% CI = 3.81-5.43; ASD: HR = 16.65, 95% CI = 8.63-30.60). In conclusion, toddlers who suffer from AD at the age younger than 3 years are at a higher risk of developing ADHD and ASD during later childhood. Pediatricians taking care of toddlers with AD should have knowledge of this increased risk of developing ADHD and ASD later in life, especially when children have certain comorbidities such as allergic rhinitis, allergic conjunctivitis, and asthma.

Association of traumatic brain injury in childhood and attention-deficit/hyperactivity disorder: a population-based study

BACKGROUND

We evaluated the risk of attention-deficit hyperactivity disorder (ADHD) following childhood traumatic brain injury (TBI).

METHODS

Using Taiwan's National Health Insurance Research Database, we included 10,416 newly diagnosed TBI children (aged ≤12 y) between 2001 and 2002 and 41,664 children without TBI, who were frequency matched by sex, age, and year of the index medical service with each TBI child, as controls. Children who had been diagnosed with ADHD prior to their medical service index were excluded. Each individual was followed for 9 y to identify ADHD diagnosis. We also compared the ADHD risk in children who were treated for fractures but not TBI as sensitivity analysis.

RESULTS

During the 9-y follow-up period, children with TBI had a higher ADHD risk (adjusted hazard ratio (AHR) = 1.32, 95% confidence interval (CI) = 1.19, 1.45) than did those without TBI. Furthermore, children with mild and severe TBI had higher AHRs for ADHD than did those without TBI (AHR = 1.30; 95% CI = 1.10, 1.53; and AHR = 1.37; 95% CI = 1.22, 1.55). However, no significant association was observed between fractures and ADHD.

CONCLUSION

TBI in childhood is associated with a greater likelihood of developing ADHD.

Utilization Pattern and Drug Use of Traditional Chinese Medicine, Western Medicine, and Integrated Chinese-Western Medicine Treatments for Allergic Rhinitis Under the National Health Insurance Program in Taiwan

OBJECTIVES

Patients in Taiwan with allergic rhinitis seek not only Western medicine treatment but also Traditional Chinese Medicine treatment or integrated Chinese-Western medicine treatment. Various studies have conducted pairwise comparison on Traditional Chinese Medicine, Western medicine, and integrated Chinese-Western medicine treatments. However, none conducted simultaneous analysis of the three treatments. This study analyzed patients with allergic rhinitis receiving the three treatments to identify differences in demographic characteristic and medical use and thereby to determine drug use patterns of different treatments.

MATERIALS AND METHODS

The National Health Insurance Research Database was the data source, and included patients were those diagnosed with allergic rhinitis (International Classification of Diseases, Ninth Revision, Clinical Modification codes 470-478). Chi-square test and Tukey studentized range (honest significant difference) test were conducted to investigate the differences among the three treatments.

RESULTS

Visit frequency for allergic rhinitis treatment was higher in female than male patients, regardless of treatment with Traditional Chinese Medicine, Western medicine, or integrated Chinese-Western medicine. Persons aged 0-19 years ranked the highest in proportion of visits for allergic rhinitis. Traditional Chinese Medicine treatment had more medical items per person-time and daily drug cost per person-time and had the lowest total expenditure per person-time. In contrast, Western medicine had the lowest daily drug cost per person-time and the highest total expenditure per person-time. The total expenditure per person-time, daily drug cost per person-time, and medical items per person-time of integrated Chinese-Western medicine treatment lay between those seen with Traditional Chinese Medicine and Western medicine treatments.

CONCLUSIONS

Although only 6.82 % of patients with allergic rhinitis chose integrated Chinese-Western medicine treatment, the visit frequency per person-year of integrated Chinese-Western medicine ranked highest. In addition, multiple-composition medicines were used more frequently than single-composition medicines, and mar huang (Ephedra sinica Stapf) was seldom used to decrease the risk of combining medications.

Association between medication prescription for atopic diseases and attention-deficit/hyperactivity disorder

BACKGROUND

Data on the association between atopic diseases and attention-deficit/hyperactivity disorder (ADHD) have been inconclusive.

OBJECTIVE

To assess whether children with drug-treated ADHD are more likely to receive treatment for asthma, allergic rhinitis, or eczema before the start of ADHD medication use compared with controls and to examine the effect of parents receiving medication for ADHD and atopic diseases on ADHD medication use in their offspring.

METHODS

We conducted a retrospective nested case-control study among children (6-12 years of age) using the Groningen University prescription database. Cases were defined as children with at least 2 prescriptions of methylphenidate within 12 months. For each case, 4 controls were matched on age, sex, and regional area code. Parental prescription data were linked to cases and controls to assess the influence of parents receiving medication for ADHD and atopic diseases on ADHD medication use in their offspring.

RESULTS

We identified 4257 cases and 17,028 matched controls. Drug treatment for asthma, allergic rhinitis, and eczema was more common in cases than controls (adjusted odds ratios [aORs], 1.4 [95% confidence interval (CI), 1.3-1.6], 1.4 [95% CI, 1.1-1.8], and 1.3 [95% CI, 1.1-1.5], respectively). Medication for allergic rhinitis and asthma among parents was associated with ADHD treatment in their children (aORs, 1.3 [95% CI, 1.1-1.5] and 1.2 [95% CI, 1.1-1.3], respectively).

CONCLUSION

This study provides further evidence to support the hypothesis that atopic diseases are associated with ADHD. The parental-offspring association suggests a possible genetic and/or environmental component.

Effects of montelukast on M2-related cytokine and chemokine in M2 macrophages

BACKGROUND/PURPOSE

Asthma is a chronic airway inflammatory disease mediated by T-helper (Th)2 cells. Montelukast (trade name Singulair) is a cysteinyl leukotriene receptor antagonist used for asthma treatment. Mirroring Th1-Th2 polarization, two distinct states of macrophages have been recognized: the classically activated (M1) macrophages and the alternatively activated (M2) macrophages. M2 polarization is known to be a response to the Th2 cytokines; however, the effects of montelukast on M2 macrophages have not been well characterized. The aim of the present study was to investigate the effects of montelukast on the expression of cytokines and chemokines in M2-like macrophages, and to explore possible intracellular signaling pathways.

METHODS

The human monocytic leukemia cell line THP-1 and human monocytes from healthy donors were cultured with interleukin-4 for M2 polarization, and then the cells were pretreated with or without montelukast before lipopolysaccharide (LPS) stimulation. Supernatants were collected to determine interleukin-10, I-309/CCL1, and MDC/CCL22 levels by enzyme-linked immunosorbent assay. Intracellular signaling was investigated using nuclear factor (NF)-κB inhibitors, mitogen-activated protein kinase (MAPK) inhibitors, and western blot analysis.

RESULTS

LPS-induced interleukin-10 and I-309/CCL1 expression was significantly suppressed by montelukast in THP-1-derived and human monocyte-derived M2 macrophages after LPS stimulation. MDC/CCL22 expression was only significantly suppressed by montelukast in THP-1-derived M2 macrophages after 48 hours of incubation. In western blot analysis, montelukast was able to suppress LPS-induced MAPK-phospho-p38 and NF-κB-phospho-p65 expression.

CONCLUSION

Montelukast suppressed LPS-induced M2-related cytokines and chemokines in alternatively activated macrophages, and the effects might be mediated through the MAPK-p38 and NF-κB-p65 pathways.

Marked improvement of neuropsychiatric symptoms following control of allergy symptoms with the use of humanized murine anti-IgE antibody (omalizumab) in 2 patients with severely limited expressive language

Flare-up of allergic rhinitis has been implicated in worsening neuropsychiatric symptoms such as hyperactivity and anxiety in the general population, mostly supported by epidemiological data. However, it is unknown how such respiratory allergy symptoms affect behavioral symptoms in patients with intellectual disability and limited expressive language. These patients may express more severe behavioral symptoms partly due to frustration and anxiety, being under-diagnosed and undertreated secondary to a lack of proper communication means. Herein, we present two cases of patients with severely limited expressive language , in whom we observed marked improvement in behavioral symptoms and even cognitive activity following control of their symptoms of allergic rhinitis with the use of omalizmab, a humanized anti-IgE antibody. The presented cases indicate that clinicians need to be aware of profound effects of allergy rhinitis on neuropsychiatric symptoms in individuals with limited expressive language.

Oxidative Stress and ADHD: A Meta-Analysis

OBJECTIVE

To clarify the role of oxidative stress and antioxidant activity in ADHD.

METHOD

We examined the association of ADHD and oxidative stress by applying random effects meta-analysis to studies of oxidative stress and antioxidant status in medication naive patients with ADHD and controls.

RESULTS

Six studies of a total of 231 ADHD patients and 207 controls met our selection criteria. The association between ADHD and antioxidant status was not significant. We found a significant association between ADHD and oxidative stress that could not be accounted for by publication bias. The significant association lost significance after correcting for intrastudy clustering. No one observation accounted for the positive result.

CONCLUSION

These results are preliminary given the small number of studies. They suggest that patients with ADHD have normal levels of antioxidant production, but that their response to oxidative stress is insufficient, leading to oxidative damage.

Child Allergic Symptoms and Well-Being at School: Findings from ALSPAC, a UK Cohort Study

Background

Eczema and asthma are common conditions in childhood that can influence children’s mental health. Despite this, little is known about how these conditions affect the well-being of children in school. This study examines whether symptoms of eczema or asthma are associated with poorer social and mental well-being in school as reported by children and their teachers at age 8 years.

Methods

Participants were from the Avon Longitudinal Study of Parents and Children. Measures of child well-being in school were child-reported (n = 6626) and teacher reported (n = 4366): children reported on their enjoyment of school and relationships with peers via a self-complete questionnaire; teachers reported child mental well-being using the Strengths and Difficulties Questionnaire [binary outcomes were high ‘internalizing’ (anxious/depressive) and ‘externalizing’ (oppositional/hyperactive) problems (high was >90th percentile)]. Child rash and wheeze status were maternally reported and symptoms categorised as: ‘none’; ‘early onset transient’ (infancy/preschool only); ‘persistent’ (infancy/preschool and at school age); and ‘late onset’ (school age only).

Results

Children with persistent (OR 1.29, 95% CI 1.02 to 1.63) and late onset (OR 1.48, 95% CI 1.02 to 2.14) rash were more likely to report being bullied, and children with persistent wheeze to feel left out (OR 1.42, 95% CI 1.10 to 1.84). Late onset rash was associated with high teacher-reported internalising behaviours (OR 1.61, 95% CI 1.02 to 2.54), and persistent rash with high externalising behaviours (OR 1.37, 95% CI 1.02 to 1.84). Child sleep and maternal mental health explained some of the associations with teacher-reported mental well-being.

Conclusion

Symptoms of eczema or asthma can adversely affect a child’s social and mental well-being at primary school. This suggests interventions, such as additional support or education of peers, should begin at early stages in schooling.

Treatment of allergic rhinitis is associated with improved attention performance in children: the Allergic Rhinitis Cohort Study for Kids (ARCO-Kids)

Background

It has been well known that pediatric allergic rhinitis was associated with poor performance at school due to attention deficit. However, there were no cohort studies for the effect of treatment of allergic rhinitis on attention performance in pediatric population. Thus, the aim of this study was to investigate whether attention performance was improved after treatment in children with allergic rhinitis.

Methods

In this ARCO-Kids (Allergic Rhinitis Cohort Study for Kids), consecutive pediatric patients with rhinitis symptoms underwent a skin prick test and computerized comprehensive attention test. According to the skin prick test results, the children were diagnosed as allergic rhinitis or non- allergic rhinitis. All of the patients were regularly followed up and treated with oral medication or intranasal corticosteroid sprays. The comprehensive attention tests consisted of sustained and divided attention tasks. Each of the tasks was assessed by the attention score which was calculated by the number of omission and commission errors. The comprehension attention test was repeated after 1 year.

Results

A total of 797 children with allergic rhinitis and 239 children with non-allergic rhinitis were included. Initially, the attention scores of omission and commission errors on divided attention task were significantly lower in children with allergic rhinitis than in children with non-allergic rhinitis. After 1 year of treatment, children with allergic rhinitis showed improvement in attention: commission error of sustained (95.6±17.0 vs 97.0±16.6) and divided attention task (99.1±15.8 vs 91.8±23.5). Meanwhile, there was no significant difference of attention scores in children with non-allergic rhinitis.

Conclusions

Our study showed that management of allergic rhinitis might be associated with improvement of attention.

Child allergic symptoms and mental well-being: the role of maternal anxiety and depression

OBJECTIVE

To determine whether maternal mental health mediates the relationship between eczema or asthma symptoms and mental well-being in children.

STUDY DESIGN

Analysis of 7250 children from the Avon Longitudinal Study of Parents and Children. Child mental well-being at 8 years was measured by the Strengths and Difficulties Questionnaire. Binary outcomes were high 'internalizing' (anxious/depressive) and 'externalizing' (oppositional/hyperactive) problems (high was >90th percentile). Child rash and wheeze categories were 'none'; 'early onset transient' (infancy/preschool only); 'persistent' (infancy/preschool and at school age); and 'late onset' (school age only). Maternal anxiety and depression were reported during pregnancy and when child was 8 years old.

RESULTS

Persistent wheezing symptoms were associated with high externalizing (OR 1.74, 95% CI, 1.41-2.15) and internalizing (1.67, 1.35-2.06) problems compared with never wheeze. Maternal anxiety and depression, and disrupted child sleep, attenuated these associations. Persistent rash (externalizing: 1.74, 1.40-2.15; internalizing: 1.42, 1.16-1.74) and late onset rash (externalizing: 1.62, 1.17-2.25; internalizing: 1.46, 1.07-1.99) symptoms were associated with poorer mental well-being compared with no rash at any age. Maternal anxiety and depression, particularly when child was aged 8 years rather than during pregnancy, accounted for the association with internalizing symptoms and partly for externalizing symptoms. Sleep disruption did not mediate the association.

CONCLUSIONS

Maternal anxiety and depression may mediate the association between child rash and wheeze and child mental well-being.

Nutrition, immunological mechanisms and dietary immunomodulation in ADHD

Attention-deficit hyperactivity disorder (ADHD) etiology is not completely understood, but common comorbid dysfunction of the gastrointestinal and immune system suggests that these systems may be affected by a common genetic background and molecular mechanisms. For example, increased levels of specific cytokines were observed in ADHD. Moreover, ADHD has a high comorbidity with both Th1- and Th2-mediated disorders like ear infections, eczema and asthma. A common pathophysiological mechanism was suggested to underlie both asthma and ADHD, while several genes that are linked to ADHD have immune functions. Furthermore, immunological recognition of food provoking ADHD-like behavior was suggested. An immune imbalance, probably requiring a predisposing genetic background, is therefore suggested to contribute to ADHD etiology, with immune dysregulation being more likely than a single subcellular defect. However, next to allergic mechanisms, also pharmacological mechanisms (especially in case of food additives) might be involved. In addition, though cellular (cytokine-related) rather than antibody-mediated immune mechanisms seem involved, specific immune-inflammatory markers other than antibodies have not been systematically studied in ADHD. Substantial alterations implicated in ADHD apparently occur in the immune system and epigenetic regulation of gene expression. As a result, chronic inflammation and oxidative stress could develop, which can lead to ADHD symptoms, for example by chronic T-cell-mediated neuroinflammation. If immune pathways contribute to ADHD, both its diagnosis and treatment should be reconsidered. Modulation of immune system activity might have potential in ADHD treatment, for example by nutritional approaches providing safe and low-cost ADHD therapy, but further research in these fields is implicated.

Hyperactivity and impulsivity in children with untreated allergic rhinitis: corroborated by rating scale and continuous performance test

BACKGROUND

Allergic rhinitis (AR) is the most common chronic allergic disease in school-age children. An increased prevalence of attention deficit hyperactivity disorder (ADHD) in AR patients has been reported; however, inattention and hyperactivity in AR children have not been investigated using objective and scientific measurements.

METHODS

We used AR symptom score, ADHD symptom scale, and computerized continuous performance test (CPT) to study the attention and impulsivity in AR children, age-matched controls, and ADHD children (aged 6-15 years). Univariate and multivariate linear regression analyses were applied to identify risk factors for impulsivity and inattention in AR children.

RESULTS

Twenty-nine controls, 10 ADHD, and 105 AR children were enrolled. There were no differences in age and sex among the three groups. The scores of Hyperactivity/Impulsivity subscales of ADHD symptoms from both parents and teachers were significantly higher in the AR children. The CPT in AR children revealed higher commission errors, shorter reaction times, and more perseveration. Risk factors for inattention and impulsivity in AR children included younger age, male sex, higher AR symptom scores, persistent AR, moderate/severe AR, multiple atopic diseases, family history of atopy, and possible comorbidity with ADHD.

CONCLUSION

Care for AR children should not only involve treating their allergy, but also monitoring the possible comorbidities of impulsivity and inattention. In children with impulsivity, AR should be considered in addition to ADHD.

Food allergy and food-based therapies in neurodevelopmental disorders

Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) are neurodevelopmental disorders which occur in childhood and may persist into adulthood. Although the etiology of these disorders is largely unknown, genetic and environmental factors are thought to play a role in the development of ASD and ADHD. Allergic immune reactions, in prenatal and postnatal phases, are examples of these environmental factors, and adverse reactions to foods are reported in these children. In this review, we address the clinical and preclinical findings of (food) allergy in ASD and ADHD and suggest possible underlying mechanisms. Furthermore, opportunities for nutritional interventions in neurodevelopmental disorders are provided.

Risk of subsequent attention deficit-hyperactivity disorder in children with febrile seizures

OBJECTIVE

In this study, we obtained relevant data from a nationwide cohort database to investigate the risk of attention deficit-hyperactivity disorder (ADHD) in children with a history of febrile seizures (FS).

METHODS

We identified 1081 children with FS as the case cohort, and the date of diagnosis was used as an index date. Four controls were matched randomly with each case based on age, sex, urbanisation level, parents' occupation, and index date. We applied Cox's proportional hazards regression to estimate the HR and CI of FS-associated ADHD.

RESULTS

After 11 years of follow-up, the incidence of ADHD for the FS and control cohorts is 7.83 and 4.72 per 1000 person-years, respectively. The FS cohort was 1.66 times more at risk of ADHD occurrence (95% CI 1.27 to 2.18) than the control cohort. The risk of developing ADHD increased in conjunction with the frequency of FS-related visits.

CONCLUSIONS

FS may increase the risk of subsequent ADHD occurrence in children. Children who visited physicians for FS more than twice had a significantly higher cumulative incidence of ADHD.

Infant atopic eczema and subsequent attention-deficit/hyperactivity disorder--a prospective birth cohort study

BACKGROUND

Comorbidity between childhood atopic eczema (AE) and attention-deficit/hyperactivity disorder (ADHD) has been observed, but temporal relationships remain unclear.

METHODS

We analyzed data of a population-based, prospective birth cohort study among 770 children included at baseline in 2000/2001 with follow-up up to age 11. Information on age at diagnosis of AE, rhinoconjunctivitis, and ADHD was obtained by questionnaires administered to parents and for AE also to caring physicians. Adjusted relative risks (aRR) with 95% confidence intervals (95% CI) were modeled with a modified Poisson regression.

RESULTS

Early AE up to age 4 yr was reported for 14.8% of the children by the parents and for 26.0% by the physicians with only fair agreement between these reports (kappa = 0.36). Based on parental reports, the association of early AE with early ADHD was strong (aRR: 5.17, 95% CI: 2.18; 12.28), but absent for late ADHD [aRR: 0.50 (0.13; 2.02)]. The association of late AE with late ADHD [aRR: 3.03 (0.75; 12.29)] was not statistically significant. This pattern was independent of the presence of rhinoconjunctivitis.

CONCLUSIONS

The observed comorbidity between AE and ADHD may indicate vulnerability to develop ADHD symptoms in response to AE symptoms or through a common underlying mechanism. This vulnerability seems to decrease with time since AE onset and may be greater in early life. These temporal relationships should be considered in future research investigating mechanisms linking both diseases and in clinical efforts to screen for and prevent ADHD symptoms in children with AE.

Early life exposure to antibiotics and the risk of childhood allergic diseases: an update from the perspective of the hygiene hypothesis

The prevalence of allergic diseases has been growing rapidly in industrial countries during recent decades. It is postulated that growing up with less microbial exposure may render the immune system susceptible to a T helper type 2 (Th2)-predominant allergic response-also known as the hygiene hypothesis. This review delineates recent epidemiological and experimental evidence for the hygiene hypothesis, and integrates this hypothesis into the association between early life exposure to antibiotics and the development of allergic diseases and asthma. Several retrospective or prospective epidemiological studies reveal that early exposure to antibiotics may be positively associated with the development of allergic diseases and asthma. However, the conclusion is inconsistent. Experimental studies show that antibiotics may induce the Th2-skewed response by suppressing the T helper type 1 (Th1) response through inhibition of Th1 cytokines and disruption of the natural course of infection, or by disturbing the microflora of the gastrointestinal (GI) tract and therefore jeopardizing the establishment of oral tolerance and regulatory T cell immune responses. The hygiene hypothesis may not be the only explanation for the rapid increase in the prevalence of allergic diseases and asthma. Further epidemiological and experimental studies addressing the issue of the impact of environmental factors on the development of allergic diseases and the underlying mechanisms may unveil novel strategies for the prevention and treatment of allergic diseases in the future.

Altered serum mono- and polyunsaturated fatty acid levels in adults with ADHD

Other than in children diagnosed with attention deficit hyperactivity disorder (ADHD), the connection between ADHD and lipids has not been sufficiently investigated so far in adults. Blood serum lipoproteins and fatty acids (FA) composition were measured and analyzed by colorimetry and gaschromatography in eight male and seven female adults diagnosed with ADHD as well as in 15 age- and gender-matched healthy control subjects. In ADHD patients, polyunsaturated FAs [docosahexaenoic, arachidonic and dihomogammalinolenic acid (p = 0.048; 0.003; 0.012)] showed lower concentrations, while monounsaturated acids (palmitoleic and oleic acid) as well as total and LDL cholesterol showed higher concentrations (p = 0.011; 0.005). ADHD scores positively correlated with palmitoleic (R = -0.56; p = 0.032), stearic (R = 0.53; p = 0.044), eicosapentaenoic (R = 0.62; p = 0.014), docosahexaenoic (R = 0.51; p = 0.050), gammalinolenic (R = 0.62; p = 0.018) and alphalinolenic acid (R = 0.56; p = 0.031) concentration. Even though the total and LDL cholesterol concentrations in blood serum were significantly higher among the ADHD patients than in controls, none of the ADHD symptom scores were significantly associated with any of the lipoproteine measures. We could demonstrate that a lack of polyunsaturated FAs in blood serum of subjects with ADHD persists into adulthood. Furthermore, we could show that adult ADHD symptomatology positively correlates with elevated levels of saturated stearic and monounsaturated FAs.

Atopic dermatitis in children: management of pruritus

Children with chronic atopic dermatitis (AD)-related itch require a comprehensive treatment approach that addresses the underlying cause of pruritus, as well as symptoms and complications that extend beyond the physical domain. In small children and infants, the short-term complications of quality of life disturbance and sleep dysfunction are closely associated with the course of adolescent development. In addition, the physical damage that results from uncontrolled pruritus and scratching can lead to disease chronification. Therefore, the rapid relief of acute pruritic flares, followed by the long-term maintenance of symptom-free skin, should be prioritized in AD treatment, in an effort to avoid the emotional, social and physical chronic manifestations described above. Alleviation of AD symptoms with fourth-generation topical anti-inflammatory agents like methylprednisolone aceponate is an appropriate choice of therapy for children and infants, due to its optimized therapeutic index and versatility in formulation. Especially in AD, supplemental disease management education should be considered, to address the psycho-social needs of children (and their families) suffering from pruritus.