The role of allergy in childhood asthma

A milestone in house dust-mite-allergen immunotherapy: the new sublingual tablet S-524101 (actair)

Subcutaneous allergen-specific immunotherapy has long been used in the treatment of allergic rhinitis and/or asthma and its efficacy has been confirmed. However, due to the discomfort of injections and the risk of severe adverse reactions, alternative routes of allergen administration have emerged. Delivery of allergens through the mucosal route had been proposed and investigated thoroughly, confirming the sublingual route to be the most efficacious. Later, the efficacy and safety of this route have been documented by numerous controlled trials both for house dust mite (HDM) and pollens. Recently, sublingual orodispersable grass pollen allergen tablets were in use followed by the newly developed HDM allergen tablets with satisfactory clinical results: Moreover, very recently 1 year of HDM tablet treatment was demonstrated to exert its clinical efficacy 1 year after discontinuation of tablet IT. The persistence of efficacy after only 1 year of treatment is a new and promising era. Currently, Sublingual Immunotherapy is the most easily administered and safe treatment option until more immunogenic, less allergenic and more efficient allergen extracts are developed.

Severe eczema in infancy can predict asthma development. A prospective study to the age of 10 years

BACKGROUND

Children with atopic eczema in infancy often develop allergic rhinoconjunctivitis and asthma, but the term "atopic march" has been questioned as the relations between atopic disorders seem more complicated than one condition progressing into another.

OBJECTIVE

In this prospective multicenter study we followed children with eczema from infancy to the age of 10 years focusing on sensitization to allergens, severity of eczema and development of allergic airway symptoms at 4.5 and 10 years of age.

METHODS

On inclusion, 123 children were examined. Hanifin-Rajka criteria and SCORAD index were used to describe the eczema. Episodes of wheezing were registered, skin prick tests and IgE tests were conducted and questionnaires were filled out. Procedures were repeated at 4.5 and 10 years of age with additional examinations for ARC and asthma.

RESULTS

94 out of 123 completed the entire study. High SCORAD points on inclusion were correlated with the risk of developing ARC, (B = 9.86, P = 0.01) and asthma, (B = 10.17, P = 0.01). For infants with eczema and wheezing at the first visit, the OR for developing asthma was 4.05(P = 0.01). ARC at 4.5 years of age resulted in an OR of 11.28(P = 0.00) for asthma development at 10 years.

CONCLUSION

This study indicates that infant eczema with high SCORAD points is associated with an increased risk of asthma at 10 years of age. Children with eczema and wheezing episodes during infancy are more likely to develop asthma than are infants with eczema alone. Eczema in infancy combined with early onset of ARC seems to indicate a more severe allergic disease, which often leads to asthma development. The progression from eczema in infancy to ARC at an early age and asthma later in childhood shown in this study supports the relevance of the term "atopic march", at least in more severe allergic disease.

Prevalence of Allergies among University Students: A Study from Ajman, United Arab Emirates

Aim. Urbanization and globalization in the Middle East have resulted in drastic environmental changes and increased allergens present in the environment. This study aimed to assess the prevalence of allergies among undergraduate students from a university. Material and Methods. This cross-sectional survey was carried out among undergraduate students of a University at Ajman, UAE. A self-administered questionnaire was used as research instrument for data collection. The demographic data and the allergy characteristics were collected and analyzed using SPSS version 19. Descriptive and inferential statistics were performed. Results. A total of 255 students (33.3% males; 66.7% females) were included. Commonest allergies among the students were allergic conjunctivitis (104 (40.8%)), allergic dermatitis (89 (34.9%)), and eczema (38 (14.9%)). Family history of allergies was strongly associated with occurrence of allergic conjunctivitis and allergic dermatitis. In about 58 (22%) of the students, dust was the most common triggering factor for allergies. Allergies associated with pollen, food, and drugs were less frequent. The distribution of allergies based on gender revealed female preponderance in all types of allergies. Students with allergies reported interference with their daily activities, and academic, social, and extracurricular activities. Conclusions. Allergic conjunctivitis and allergic dermatitis were the frequent allergies reported. Adequate preventive strategies can crumb the prevalence of allergies.

Relationships between exhaled nitric oxide and atopy profiles in children with asthma

Purpose

We examined whether fractional exhaled nitric oxide (FeNO) levels are associated with atopy profiles in terms of mono-sensitization and poly-sensitization in asthmatic children.

Methods

A total of 119 children underwent an assessment that included FeNO measurements, spirometry, methacholine challenge, and measurement of blood eosinophil count, serum total IgE, and serum eosinophil cationic protein (ECP). We also examined sensitization to five classes of aeroallergens (house dust mites, animal danders, pollens, molds, and cockroach) using skin prick testing. The children were divided into three groups according to their sensitization profiles to these aeroallergens (non-sensitized, mono-sensitized, and poly-sensitized).

Results

The geometric means (range of 1 SD) of FeNO were significantly different between the three groups (non-sensitized, 18.6 ppb [10.0-34.7 ppb]; mono-sensitized, 28.8 ppb [16.6-50.1 ppb]; and poly-sensitized, 44.7 ppb [24.5-81.3 ppb], P=0.001). FeNO levels were correlated with serum total IgE concentrations, peripheral blood eosinophilia, and serum ECP levels to different degrees.

Conclusions

FeNO levels vary according to the profile of atopy, as determined by positive skin prick test results to various classes of aeroallergens. FeNO is also moderately correlated with serum total IgE, blood eosinophilia, and serum ECP. These results suggest that poly-sensitized asthmatic children may have the highest risk of airway inflammation.

Phadiatop Infant(®) detects IgE-mediated diseases among pre-school children: a prospective study

BACKGROUND

IgE-sensitization to food and inhalant allergens may precede and accompany the appearance of clinical symptoms of allergic diseases. The aim was to study the diagnostic capacity of Phadiatop(®) Infant (Phinf) for detecting IgE-sensitization at 5 yr of age and further to evaluate the predictive capacity of Phinf longitudinally with regard to sensitization and allergic symptoms in pre-school children.

METHODS

Two hundred and one children with complete data on sIgE testing for 10 individual allergens, Phinf analyses, and clinical evaluations at 2 and 5 yr of age were evaluated.

RESULTS

The diagnostic performance of Phinf, applied at the age of 5 and compared to specific IgE testing, gave a sensitivity of 84% and a specificity of 98%. The positive and negative predictive values were 97% and 92%, respectively. A positive Phinf test at 2 yr increased the odds 35.6-fold (95% CI 11.8-107) for IgE-sensitization and 14.7-fold (95% CI 4.4-49.7) for any allergic symptom at 5 yr of age. The association (OR) between Phinf and current symptoms was, at 2 and 5 yr of age, 3.6 (95% CI 1.6-7.9) and 18.4 (95% CI 7.4-45.8), respectively.

CONCLUSIONS

Phinf seems to be a reliable tool for predicting future sensitization as well as allergic symptoms in young children.

Pathways and mechanisms in adolescence contribute to adult health inequalities

AIMS

This paper presents a model that encompasses pathways and mechanisms working over adolescence that contribute to adult health inequalities. We review evidence on the four mechanisms: socially differential exposure, tracking, socially differential tracking, and socially differential vulnerability.

METHODS

We conducted literature searches in English-language peer-reviewed journals using PubMed (from 1966 to May 2009) and PsycINFO, and combined these with hand-searches of reference lists, journals, and authors of particular relevance.

RESULTS

Most health indicators are socially patterned in adolescence and track into adulthood, with higher risks of adverse outcomes among individuals from lower socioeconomic positions. Adolescent health behaviours track into adulthood. Smoking, physical activity, and especially fruit and vegetable intake are socially patterned, while evidence for social patterning of alcohol use is less consistent. Relational dimensions like lone parenthood and bullying are socially patterned and track over time, and there are indications of a socially differential vulnerability to the effects of these types of relational strain. Very little research has investigated the social patterning of the above indicators over time or studied social vulnerability of these indicators from adolescence to adulthood. However, all four mechanisms seem to be active in establishing social differences in adult educational attainment.

CONCLUSIONS

We find the Adolescent Pathway Model useful for providing an overview of what elements and mechanisms in adolescence may be of special importance for adult health inequalities. There is a lack of knowledge of how social patterns of health, health behaviours, and social relations in adolescence transfer into adulthood and to what extent they reflect themselves in adult health.

Asthma in children: management issues for family doctors

Asthma is still one of the leading causes of morbidity in children. Despite the improved understanding in the disease pathogenesis and availability of the different classes of drugs, the incidence of emergency visits due to acute exacerbations and admission rates due to frequent and uncontrolled disease is fairly high. Management of bronchial asthma in children is quite different to that of adults. Although there are universal guidelines available for the management of childhood asthma, there is still confusion especially among the family physicians who are largely involved in the management of the children, both in acute exacerbations as well as in long term prevention. This article aims to simplify all the management issues for family physicians in concurrence with the available asthma management guidelines.

Asma infantil y del lactante

El asma es la enfermedad crónica más frecuente de la infancia. El diagnóstico suele ser fácil cuando se producen episodios de disnea espiratoria con sibilancias reversibles de forma espontánea o mediante el uso de broncodilatadores. Las radiografías de tórax, la exploración funcional respiratoria y el estudio alérgico constituyen el aspecto fundamental de las pruebas complementarias necesarias. El tratamiento de la crisis consiste en el uso de β2-adrenérgicos inhalados y, si es necesario, corticoides orales. El tratamiento de fondo tiene como objetivo limitar al máximo los síntomas y restaurar o mantener las funciones pulmonares normales. Se debe adaptar a la gravedad y al control de la enfermedad y los corticoides inhalados tienen un papel de elección.

Clinical importance of identifying immunoglobulin E-mediated disease in patients with asthma

The strong association between allergy and asthma is well documented; however, few practitioners-even asthma specialists-accurately estimate the percentage of patients with asthma who have clinically relevant allergies. Because allergen exposure can prompt airway inflammation, trigger asthma exacerbations, and possibly lead to negative health outcomes for patients with asthma, identifying allergies and immunoglobulin E (IgE)-mediated disease in patients with persistent asthma is crucial. Updated Expert Panel 3 asthma guidelines from the National Asthma Education and Prevention Program reinforce the need for clinicians to identify allergic sensitivities in patients with persistent asthma and determine their clinical relevance. Allergy testing can be useful in educating the patient with IgE-mediated asthma about the need for allergic trigger avoidance and can help determine optimal therapy for patients with concomitant asthma and allergy. Implementing this guideline recommendation, however, requires active clinical engagement. Data from a recent observational study indicate that there may be a substantial gap between guideline recommendations and actual clinical practice. These data also suggest that when clinicians participate in education about the role of IgE in asthma and begin testing their patients for allergy, the recognition of allergies among patients with asthma dramatically increases.

Phadiatop infant in the diagnosis of atopy in children with allergy-like symptoms

Background and Objective. Allergy-like symptoms such as wheezing and eczema are common in young children and an early diagnosis is important to initiate correct management. The objective of this study was to evaluate the diagnostic performance of Phadiatop Infant, an in vitro test for determination of early sensitisation to food and inhalant allergens. Patients and Methods. The study was conducted, retrospectively, using frozen sera from 122 children (median age 2.7 years) admitted to the hospital with suspected allergic symptoms. The doctor's diagnosis atopic/nonatopic was based on routinely used procedures such as clinical evaluation, SPT, total and allergen-specific IgE antibodies. The performance of Phadiatop Infant was evaluated in a blinded manner against this diagnosis. Results. Eighty-four of the 86 children classified as atopic showed a positive Phadiatop Infant test. Thirty-six were classified as nonatopic, 32 of who had a negative test. With a prevalence of atopy of 70% in this population, this gives a sensitivity of 98%, a specificity of 89%, and a positive and negative predictive value of 95% and 94%, respectively. Conclusion. The results from the present study suggest that Phadiatop Infant could be recommended as a complement to the clinical information in the differential diagnosis on IgE-mediated disease in young children with allergy-like symptoms.

Non-atopic asthma in children is related to maternal bronchial hyperreactivity

Data on the pathogenic mechanisms underlying the development of non-atopic asthma in children are scarce. Our aim was to evaluate the association and compare the atopic status, pulmonary functions, bronchial hyperresponsiveness and serum total immunoglobulin E (IgE) levels of parents of atopic and non-atopic asthmatic children by using objective methods. Fifty-one asthmatic children aged 4-16 yr and their parents were included into the study. Initially the American Thoracic Society's Respiratory Disease questionnaire inquiring data on symptoms of asthma, rhinitis and past medical history was filled in. Afterwards, skin prick test with aeroallergens, pulmonary function and methacholine bronchial provocation tests and serum sampling for total IgE level determinations were carried out. Bronchial hyperresponsiveness to methacholine was significantly more common in the mothers of non-atopic children compared to those of atopic ones, although no significant difference was observed in the skin prick test reactivity, pulmonary function test parameters and serum IgE levels. Questionnaire data revealed that the presence of asthmatic symptoms such as wheezing and phlegm and doctor-diagnosed asthma were more common in the mothers of non-atopic children. Meanwhile, asthmatic symptoms were also found to be significantly more common in fathers of non-atopic children. Logistic regression analyses revealed that maternal PC(20) was the only predictive factor for the risk of displaying non-allergic asthma in children. The results demonstrate that among the risk factors studied, maternal bronchial hyperreactivity was associated with the development of asthma in non-atopic children.

Predictors of the persistence of childhood asthma

BACKGROUND

The factors relevant to the prognosis of childhood asthma differ from one population to another.

OBJECTIVES

To characterize the course of childhood asthma in the catchment area of our hospital, and to identify prognostic factors for this population.

METHODS

All children given a diagnosis of asthma in the paediatric pulmonology service of a tertiary hospital were followed up for 5 years.

RESULTS

Satisfactory control of asthma was achieved in 69 % of cases. The factors identified as associated with poor control were allergy to cats and pollen, a large number of crises in the year prior to diagnosis, and younger age at onset.

CONCLUSIONS

In our region, childhood asthma has a relatively favourable prognosis. The subsequent course of the disease appears to be determined in childhood. The persistence of symptoms appears to depend to a significant extent on the degree of atopy.

Assessment of childhood allergy for the primary care practitioner

PURPOSE

To update the primary care practitioner on the assessment of common childhood allergic illnesses.

DATA SOURCES

Relevant scientific literature and published clinical practice guidelines.

CONCLUSIONS

Atopic children often develop symptoms that occur in a predictable progression from atopic dermatitis to gastrointestinal disturbances, chronic serous otitis media, rhinitis, and asthma. Evaluation of allergic symptoms should be based on their chronicity, family history of atopy, and knowledge of how the information will change patient management. Both skin and blood testing are accurate and useful tools in establishing a diagnosis of allergic disease. Management includes avoidance/environmental control, medications, and, when necessary, referral to specialists.

IMPLICATIONS FOR PRACTICE

As the incidence of allergic disease increases, the human and monetary costs associated with allergies place a major burden on our healthcare system. Early identification of allergies and appropriate intervention are important to prevent progression to more significant disease. The use of objective diagnostic testing aids in implementing appropriate evidence-based medical management.

ImmunoCAP Phadiatop Infant--a new blood test for detecting IgE sensitisation in children at 2 years of age

BACKGROUND

Correct diagnosis of immunoglobulin E (IgE)-mediated disease is the prerequisite for secondary allergy prevention during early childhood.

OBJECTIVE

To evaluate the diagnostic efficacy of a new blood test, Phadiatop Infant, in detecting IgE sensitisation to food and inhalant allergens among children at 2 years of age.

METHODS

Children (n = 239) were followed prospectively from birth to 2 years of age for the presence of IgE sensitisation and the development of atopic manifestations. Immunoglobulin E sensitisation was evaluated by skin prick test (SPT) and analysis of allergen-specific IgE antibodies in plasma to food and inhalant allergens. The children were classified into three groups: IgE-sensitised, non-IgE sensitised and inconclusive, depending on SPT and allergen-specific IgE results.

RESULTS

Twenty-six (11%) of the children were classified as IgE-sensitised, 182 (76%) as non-IgE sensitised and 31 (13%) as inconclusive. Phadiatop Infant was positive in 50 (21%) of the children. Ten children (4%) with identified IgE antibodies against the selected food and inhalant allergens showed negative Phadiatop Infant. Three children showed positive Phadiatop Infant but were negative in the other tests performed. These results correspond to positive and negative predictive values for Phadiatop Infant of 89 and 99%, respectively. Children with clinical symptoms of atopic diseases had significantly increased levels for Phadiatop Infant (P < 0.01).

CONCLUSION

Phadiatop Infant appears to be a reliable alternative to SPT and the measurement of allergen-specific IgE antibodies in plasma for detecting clinically important IgE sensitisation among children at 2 years of age.

Diagnosis of allergy syndromes: do symptoms always mean allergy?

Allergic disease has become a major burden in westernized societies because of a recent rise in its prevalence. Approximately one-third of children suffer from an allergic disease, with the prevalence varying from 15 to 20% for atopic dermatitis, 7 to 10% for asthma and 15 to 20% for allergic rhinitis and conjunctivitis. Despite the increase, it is important not to assume a diagnosis of allergy on the basis of symptoms alone, because allergic and nonallergic conditions may present with similar symptoms. An accurate allergy diagnosis is important in order to treat the patient most appropriately and to potentially prevent or delay the development of allergic disease. A good clinical history is the starting point for accurate allergy diagnosis but is not unequivocal. The European Academy of Allergy and Clinical Immunology has recognized the importance of allergy testing and therefore developed evidence-based recommendations on allergy testing in children. Widespread adherence to these recommendations should improve the quality of care for allergy patients. Cooperation between all healthcare professionals involved in the treatment of allergy patients is also a key to improve our response to the allergy epidemic.

T cell and eosinophil activation in mild and moderate atopic and nonatopic children's asthma in remission

BACKGROUND

Inflammation in the pathogenesis of asthma is associated with products of activated T cells and eosinophils. The aim of this study was to determine whether ongoing inflammation persists in children with different phenotypes of asthma despite the disease in remission.

METHODS

Serum samples were collected from 68 children with atopic or nonatopic asthma in remission and from 15 healthy children. Soluble interleukin-2 receptor (sIL-2R), IL-2 and IL-4 were examined by using an enzyme-linked immunosorbent assay. Total and specific immunoglobulin E, and eosinophil cationic protein (ECP) were analysed by fluoroimmunoassay (Pharmacia CAP System).

RESULTS

In patients with moderate persistent atopic asthma, sIL-2R was increased significantly when compared with mild persistent atopic asthma (P < 0.05). No changes of sIL-2R were seen in nonatopic asthmatics compared with atopics and controls. The level of IL-2 was elevated in moderate persistent atopic and nonatopic asthmatic children compared with controls (P < 0.05 and P < 0.05 respectively) and compared with mild persistent atopic asthmatics and mild persistent nonatopic asthmatics (P < 0.05 in both cases). The levels of IL-4 in most patients and controls remained below the sensitivity of the assay. Eosinophil cationic protein levels in moderate persistent atopic and nonatopic asthmatics were significantly higher than in mild persistent asthma severity cases (P < 0.001 and P < 0.01 respectively) and in healthy children (P < 0.01 in both cases).

CONCLUSION

Changes in the concentration of sIL-2R, IL-2 and ECP reflect increased T cell and eosinophil activity in relation to the level of severity of asthma in atopic and nonatopic children, thereby proving the presence of persistent inflammation despite the absence of disease symptoms.

Coincidence of atopy and its profile (monosensitization/polysensitization) between sibling pairs

BACKGROUND

Results of epidemiologic studies have shown that childhood atopy is probably a hereditary disorder. In the atopic population, some individuals are sensitized to only 1 class of allergens (monosensitized), whereas others are sensitized to more than 1 class of allergens (polysensitized).

OBJECTIVE

To investigate whether atopy and its profile (monosensitization/polysensitization) tend to coincide in sibling pairs.

METHODS

We evaluated sensitization to 5 classes of aeroallergens (house dust mites, animal danders, pollens, molds, and cockroach) using skin prick testing in 564 children with symptoms suggestive of allergic diseases (index children) and their paired siblings.

RESULTS

The frequency of sibling atopy was highest (56.8%) for polysensitized index children (n=222), intermediate (45.4%) for monosensitized index children (n=196), and lowest (30.8%) for nonsensitized index children (n=146). The proportion of polysensitization among atopic siblings was significantly higher for polysensitized (47.6%) than for monosensitized (32.6%) index children. Polysensitized index children were found to more frequently have polysensitized siblings (27.0%) than were monosensitized index children (14.8%), with an odds ratio of 2.13 (95% confidence interval, 1.30-3.49), whereas the likelihood of having a monosensitized sibling was similar for monosensitized and polysensitized index children.

CONCLUSION

These data suggest a coincidence of atopy and its profile in terms of monosensitization and polysensitization in sibling pairs, although the relative importance of genetic and environmental influences requires further study.

Frequency of gastroesophageal reflux disease in nonatopic children with asthma-like airway disease

Gastroesophageal reflux disease (GERD) is commonly associated with asthma; however, frequency in nonatopic children with asthmatic symptoms is unknown. The aim of this study was to determine the frequency of gastroesophageal reflux (GER) in nonatopic children with asthma-like airway disease that recur despite conventional asthma treatment and to evaluate the clinical response to lansoprazole treatment. Twenty-five nonatopic children aged between 1 and 16 years who have asthma-like airway disease and 25 healthy children were included in the study. All cases underwent 24 h pH monitoring with dual sensor catheters. Additionally, acid suppressor treatment was administered to patients diagnosed as having GERD and clinical response was evaluated. Major symptoms encountered in the patient group included wheezing and cough (88%, and 32%, respectively). Reflux episodes were more common in distal esophagus during the prone position (reflux index (RI) of 11.5+/-10.3 vs. 16.2+/-9.4 during supine vs. prone). All distal esophageal parameters were significantly higher in the patient group except number of reflux episodes lasting longer than 5 min (RI of 13.3+/-13.1 vs. 3.9+/-2.9 in the patient vs. control groups, respectively). There was a significant improvement in symptoms and requirement for medication with treatment (number of systems decreased from 2.3+/-0.6 to 0.4+/-0.6, P=0.00). In conclusion, GERD is significantly more common in nonatopic children with asthma-like airway disease compared to the controls and clinical improvement is significant after acid suppressor treatment. Thus, we suggest that children followed-up with the diagnosis of nonatopic asthma with recurrent exacerbations despite adequate asthma treatment have a high frequency of GER and that lansoprazole treatment may be considered early in management.

Coincidence of atopy profile in terms of monosensitization and polysensitization in children and their parents

BACKGROUND

Results from epidemiologic studies have shown that childhood atopy is probably a hereditary disorder, because the offspring of affected parents have a higher risk of developing atopy. Among the atopic population, some subjects are sensitized to only one class of allergens (monosensitized), while other subjects are sensitized to more than one class of allergens (polysensitized). The aim of this study was to investigate whether atopy profile (monosensitization/polysensitization) in children is linked to the same conditions in their parents.

METHODS

We evaluated sensitization to five classes of aeroallergens (house dust mites, animal danders, pollens, molds, and cockroach) by skin prick testing in a group of 494 children with suspicious allergic symptoms and in their parents.

RESULTS

The frequency of parental atopy was highest (51.6%) in polysensitized children (n = 189), intermediate (37.1%) in monosensitized children (n = 178), and was lowest (22.4%) in nonsensitized children (n = 127). The proportion of polysensitized subjects among atopic parents was significantly higher for polysensitized children (45.6%) than for monosensitized children (31.1%). Polysensitized children were found to more frequently have one or both parents polysensitized (32.3%, 7.4%) than monosensitized children (18.5%, 2.2%) with odds ratios of 2.09 (95% CI: 1.29-3.40) and 3.48 (1.12-10.78), respectively, whereas the likelihood of having one or two monosensitized parents was not increased for polysensitized children.

CONCLUSION

Our data suggest a familial coincidence of atopy profile in terms of monosensitization and polysensitization, although the relative importance of genetic or environmental influence should be studied further.

Chemokine receptors: understanding their role in asthmatic disease

The incidence, prevalence, and severity of asthma have been increasing steadily in recent years. Prophylactic treatment of this disease and of episodic asthmatic flares is aimed at preventing excessive inflammation in lung tissue and airways. Because chemokines and chemokine receptors are critical mediators of leukocyte trafficking and recruitment, there is the potential to pharmaceutically target these proteins to regulate inflammation. Asthma-associated inflammation is characterized by the infiltration of eosinophils and T helper type 2 cells. Early studies investigated the role of chemokine receptors, which have been shown to predominate on these cell populations.

Dietary prevention of allergic diseases in infants and small children. Part II. Evaluation of methods in allergy prevention studies and sensitization markers. Definitions and diagnostic criteria of allergic diseases

The role of primary prevention of allergic disease has been a matter of debate for the last 40 years. In order to shed some light into this issue a group of experts of the Section of Pediatrics EAACI critically reviewed the existing literature on the subject. The design of observational and interventional studies was evaluated with relevance to the important factors influencing outcome of studies on allergy development/prevention. in this analysis the statements of evidence as defined by WHO were applied. Best evidence of recommendations are those fulfilling the criteria for statements category 1 and 2 and grade of recommendations A and B as proposed by WHO. This survey include target group for dietary prevention and methods and diagnostic criteria of atopic dermatitis, asthma and food allergy for prevention studies.

Epstein-Barr virus infection is not associated with development of allergy in children

BACKGROUND

Differences in concentrations of antibodies to Epstein-Barr virus (EBV) in atopic and nonatopic children have been observed, suggesting that EBV infection may play a role in allergic diseases. AIM To assess the association between EBV infection and atopy in Swedish children at 4 years of age.

MATERIALS AND METHODS

Were studied 2561 children born in 1994 through 1996 in Stockholm, Sweden. The children were enrolled in a prospective birth cohort study focusing on the relation of exposure to various environmental and life style factors during early childhood and development of atopy. Blood samples were obtained when the children were approximately 4 years old, and immunoglobulin G to EBV was determined by indirect immunofluorescence. The relationship between the seroprevalence to EBV and various allergic disorders was assessed, withthe use of logistic regression analysis to account for other risk factors.

RESULTS

Totally 1347 of 2561 (52%) children were EBV-seropositive. Associations between EBV seropositivity and the occurrence of asthma [adjusted odds ratio (OR(adj)), 1.10; 95% confidence interval (95% CI) 0.81 to 1.49] or suspected allergic rhinitis (OR(adj) 0.97; 95% CI 0.76 to 1.25) were not apparent. In children whose mothers were up to 25 years old, a higher EBV seroprevalence was observed than in children of older mothers (OR(adj) 1.34; 95% CI 1.04 to 1.71). Also in children whose mothers smoked, the seroprevalence was higher than in children of nonsmokers (OR(adj) 1.29; 95% CI 1.02 to 1.63).

CONCLUSIONS

The study does not support the hypothesis that EBV infection in early childhood plays an important role in the pathogenesis of allergic diseases in children.

Early sensitisation and development of allergic airway disease - risk factors and predictors

The development and phenotypic expression of allergic airway disease depends on a complex interaction between genetic and several environmental factors, such as exposure to food, inhalant allergens and non-specific adjuvant factors (e.g. tobacco smoke, air pollution and infections). The first months of life seem to be a particularly vulnerable period and there is evidence that sensitisation is related to the level of allergen exposure during early life. At present, the combination of atopic heredity and elevated cord-blood IgE seems to result in the best predictive discrimination as regards development of allergic disease at birth. Early sensitisation, cow's milk allergy and atopic eczema are predictors for later development of allergic airway disease. Exposure to indoor allergens, especially house dust mite allergens, is a risk factor for sensitisation and development of asthma later in childhood in high-risk infants and infants with early atopic manifestations.

Family history as a predictor of asthma risk

Asthma, one of the most important chronic diseases of children, disproportionately affects minority and low-income children. Many environmental risk factors for asthma have been identified, including animal, mite, and other allergens; cigarette smoke; and air pollutants. Genetics also play an important causative role, as indicated by familial aggregation and the identification of candidate genes and chromosomal regions linked to asthma risk. Using a positive family history of asthma to identify children at increased risk could provide a basis for targeted prevention efforts, aimed at reducing exposure to environmental risk factors. To assess the predictive value of family history as an indicator of risk for childhood asthma, we reviewed population-based studies that evaluated family history of asthma and atopic disease in children with asthma. Our search identified 33 studies from all geographic regions of the world for review. The studies varied in definitions of positive family history and asthma phenotype and used study populations with asthma prevalence ranging from 2% to 26%. Nevertheless, family history of asthma in one or more first-degree relatives was consistently identified as a risk factor for asthma. In ten studies, sensitivity and predictive value of a positive family history of asthma could be calculated: sensitivity ranged from 4% to 43%, positive predictive value from 11% to 37%, and negative predictive value from 86% to 97%. Although a positive family history predicts an increased risk of asthma, it identifies a minority of children at risk. Positive family history may have utility in targeting some individual prevention efforts, but the low positive predictive value limits its value as a means to direct environmental remediation efforts.

Effect of mattress and pillow encasings on children with asthma and house dust mite allergy

BACKGROUND

House dust mite (HDM) allergy is a frequent cause of allergic asthma in children. Reduction of exposure seems to be the most logical way to treat these patients.

OBJECTIVE

Our aim was to investigate whether mattress and pillow encasings resulted in an effective long-term control of HDM allergen levels, thereby reducing the need for asthma medication in children with asthma and HDM allergy.

METHODS

In a prospective, double-blind, placebo-controlled study 60 children (age range, 6-15 years) with asthma and HDM allergy were randomized to active (allergy control) or placebo mattress and pillow encasings. After a 2-week baseline period, follow-up was performed every 3 months for 1 year. During the entire study period, the dose of inhaled steroids was tapered off to the lowest effective dose according to well-defined criteria.

RESULTS

Fifty-two patients completed the trial, and 5 were excluded, leaving data from 47 children (26 in the active treatment group and 21 in the placebo group) for analysis. A significant perennial reduction in HDM allergen concentrations was seen only for the active treatment group. Also, a significant decrease in the dose of inhaled steroids (mean, 408 to 227 microg/d; P <.001) was found for the active treatment group only, with significant differences between groups after 9 and 12 months. After 1 year, the dose of inhaled steroids was reduced by at least 50% in significantly more children in the active treatment group than in the placebo group (73% vs 24%, P <.01).

CONCLUSION

Encasing of mattresses and pillows resulted in a significant long-term reduction in HDM allergen concentrations in mattresses and in the need for inhaled steroids in children with asthma and HDM allergy.

Skin-prick test findings in atopic asthmatic children: a follow-up study from childhood to puberty

In a prospective cohort study we investigated the course of allergic sensitization from childhood to puberty in a group of children with atopic asthma. An attempt was made to correlate the findings with the persistence of asthma. A total of 150 children with atopic asthma established at 7 years of age were evaluated when 8-10 years of age. A battery of skin-prick tests (SPTs) to common environmental allergens, a detailed clinical history for asthma severity classification, and spirometric analyses, were performed. In 127 of these children a re-evaluation was performed at puberty. A variety of statistical methods were used to analyze the results regarding changes in skin test reactivity to individual aeroallergens and atopic index (degree of atopy), as well as to determine any correlation between these changes and the persistence of asthma in puberty. A wide spectrum of modification in skin reactivity to common environmental allergens was observed, including the complete loss of sensitization to some allergens or the development of a new one to others. Specifically, 34% of asthmatic children sensitive to Dermatophagoides pteronyssinus and 52.7% sensitive to cat lost their sensitivity in puberty, while only 7.5% and 11.1%, respectively, became sensitized (p = 0.03 and p = 0.001, respectively). In contrast, regarding pollen sensitivity, 30.2% and 24% of asthmatic children became sensitive in puberty to olive pollen and grasses mix, respectively, and only 11.7% and 12.5%, respectively, lost their sensitivity to these allergens (p = 0.04). No correlation was shown between the skin test reactivity changes to individual allergens and the persistence of asthma, but a significant correlation was found between atopic index to indoor allergens in childhood and the persistence of asthma at puberty (p = 0.04). Interestingly, multi-sensitivity to allergens (>/= 4 allergens) in childhood was also found to correlate with the persistence of asthma at puberty [p = 0.05, odds ratio (OR) = 2.65, 95% confidence interval (CI) 1.2-7.2]. Our findings indicate that significant modification of skin reactivity to common environmental allergens in atopic children with asthma in puberty can occur. However, no association between these changes and the persistence of asthma could be demonstrated, although children with indoor allergic sensitization and multi-reactivity were found to have a higher probability of maintaining their asthma in puberty.

High levels of urinary eosinophil protein X in young asthmatic children predict persistent atopic asthma

Levels of urinary eosinophil protein X (U-EPX) and eosinophil counts were measured in 32 children (12-36 months of age) who were hospitalized for acute asthma, and the U-EPX levels were measured in 20 healthy children of the same age. The ability of these parameters to predict persistent asthma (at least one wheezing episode during the last 6 months) and atopic asthma (a positive skin-prick test [SPT]), was evaluated at a follow-up 2 years later. On admission, levels of U-EPX were higher in children with asthma (median: 120 microg/mmol of creatinine; quartiles: 67-123 microg/mmol of creatinine) than in controls (60 microg/mmol of creatinine, 38-74 microg/mmol of creatinine; p< 0.001). The U-EPX level was higher in those with persistent atopic asthma at follow-up (173 microg/mmol of creatinine, 123-196 microg/mmol of creatinine, n = 16), than in those with persistent non-atopic asthma (73 microg/mmol creatinine, 46-105 microg/mmol of creatinine, n = 8; p< 0.05), and higher than in those with transient asthma (no symptoms at follow-up) (106 microg/mmol creatinine; 42-167 microg/mmol of creatinine, n = 8; p< 0.05). By multiple logistic regression analysis, U-EPX was the only parameter able to predict persistent atopic asthma; eosinophil counts, parental atopy, age or gender could not. Parental atopy was the only parameter predictive for persistent asthma, regardless of atopic status. In conclusion, levels of U-EPX, but not eosinophil counts, measured in young children hospitalized with acute asthma can predict the persistence of atopic asthma 2 years later.

Budesonide inhalation suspension: a review of its use in infants, children and adults with inflammatory respiratory disorders

Budesonide, a topically active corticosteroid, has a broad spectrum of clinically significant local anti-inflammatory effects in patients with inflammatory lung diseases including persistent asthma. In infants and young children with persistent asthma, day- and night-time symptom scores, and the number of days in which beta2-agonist bronchodilators were required, were significantly lower during randomised, double-blind treatment with budesonide inhalation suspension 0.5 to 2 mg/day than placebo in 3 multicentre trials. Significantly fewer children discontinued therapy with budesonide inhalation suspension than with placebo because of worsening asthma symptoms in a study that included children who were receiving inhaled corticosteroids at baseline. Recent evidence indicates that budesonide inhalation suspension is significantly more effective than nebulised sodium cromoglycate in improving control of asthma in young children with persistent asthma. At a dosage of 2 mg/day, budesonide inhalation suspension significantly reduced the number of asthma exacerbations and requirements for systemic corticosteroids in preschool children with severe persistent asthma. In children with acute asthma or wheezing, the preparation was as effective as, or more effective than oral prednisolone in improving symptoms. In children with croup, single 2 or 4mg dosages of budesonide inhalation suspension were significantly more effective than placebo and as effective as oral dexamethasone 0.6 mg/kg or nebulised L-epinephrine (adrenaline) 4mg in alleviating croup symptoms and preventing or reducing the duration of hospitalisation. Early initiation of therapy with budesonide inhalation suspension 1 mg/day appears to reduce the need for mechanical ventilation and decrease overall corticosteroid usage in preterm very low birthweight infants at risk for chronic lung disease. In adults with persistent asthma, budesonide inhalation suspension < or =8 mg/day has been compared with inhaled budesonide 1.6 mg/day and fluticasone propionate 2 mg/day administered by metered dose inhaler. Greater improvements in asthma control occurred in patients during treatment with budesonide inhalation suspension than with budesonide via metered dose inhaler, whereas fluticasone propionate produced greater increases in morning peak expiratory flow rates than nebulised budesonide. Several small studies suggest that the preparation has an oral corticosteroid-sparing effect in adults with persistent asthma and that it may be as effective as oral corticosteroids during acute exacerbations of asthma or chronic obstructive pulmonary disease. The frequency of adverse events was similar in children receiving budesonide inhalation suspension 0.25 to 2 mg/day or placebo in 12-week studies. During treatment with budesonide inhalation suspension 0.5 to 1 mg/day in 3 nonblind 52-week studies, growth velocity in children was generally unaffected; however, a small but statistically significant decrease in growth velocity was detected in children who were not using inhaled corticosteroids prior to the introduction of budesonide inhalation suspension. Hypothalamic-pituitary-adrenal axis function was not affected by short (12 weeks) or long (52 weeks) term treatment with nebulised budesonide. In conclusion, budesonide inhalation suspension is the most widely available nebulised corticosteroid, and in the US is the only inhaled corticosteroid indicated in children aged > or =1 year with persistent asthma. The preparation is suitable for use in infants, children and adults with persistent asthma and in infants and children with croup.