Natural history of allergic diseases in children

A systematic review and meta-analysis of the prevalence and phenotype of adult-onset atopic dermatitis

BACKGROUND

Previous studies found conflicting results about whether atopic dermatitis (AD) begins in adulthood.

OBJECTIVE

To determine rates, predictors, and phenotypic differences of adult-onset AD.

METHODS

A systematic review was performed with all published observational studies in Medline, Embase, GREAT (Global Resource of EczemA Trials), LILACS (Latin American and Caribbean Health Sciences Literature), Cochrane Library, and Scopus that analyzed the age of AD onset beyond 10 years of age. At least two reviewers performed study title, abstract review, and data extraction. Pooled meta-analysis of the proportion of adult-onset AD was performed by using random-effects weighting (I² = 99.3%).

RESULTS

Overall, 25 studies met inclusion criteria. Seventeen studies reported age of AD onset as after 16 years of age and had sufficient data for meta-analysis. The pooled proportion (95% confidence interval) of adult-onset AD was 26.1% (16.5%-37.2%). Similar results were found in sensitivity analyses by AD diagnostic method, study region, and sex. Phenotypic differences were observed across studies for adult-onset and child-onset AD, including higher rates of foot dermatitis and personal history of atopy but lower rates of flexural lesions and other signs and symptoms.

LIMITATIONS

Characteristics of adult-onset versus child-onset AD were not commonly reported.

CONCLUSION

AD is not only a disease of childhood; 1 in 4 adults with AD report adult-onset disease, which has distinct clinical characteristics as compared to child-onset AD.

Persistence of atopic dermatitis (AD): A systematic review and meta-analysis

BACKGROUND

Previous studies found conflicting results about whether childhood atopic dermatitis (AD) persists into adulthood.

OBJECTIVE

We sought to determine persistence rates and clinical factors associated with prolonged AD.

METHODS

A systematic review was performed in MEDLINE, EMBASE, Scopus, GREAT, LILACS, Web of Science, Academic Search Complete, and Cochrane Library. Meta-analysis was performed using Kaplan-Meier plots and random-effects proportional hazards regression.

RESULTS

In total, 45 studies including 110,651 subjects spanning 434,992 patient-years from 15 countries were included. In pooled analysis, 80% of childhood AD did not persist by 8 years and less than 5% persisted by 20 years after diagnosis (mean ± SE: 6.1 ± 0.02 years). Children with AD that persisted already for more than 10 years (8.3 ± 0.08 years) had longer persistence than those with 3 (3.2 ± 0.02 years) or 5 (6.8 ± 0.06 years) years of persistence. Children who developed AD by age 2 years had less persistent disease (P < .0001). Persistence was greater in studies using patient-/caregiver-assessed versus physician-assessed outcomes, female versus male patients (P ≤ .0006), but not in those with sensitivity to allergens (P = .90). Three studies found prolonged persistence with more severe AD.

LIMITATIONS

Some studies did not capture recurrences later in life.

CONCLUSIONS

Most childhood AD remitted by adulthood. However, children with already persistent disease, later onset, and/or more severe disease have increased persistence.

A nasally applied cellulose powder in seasonal allergic rhinitis (SAR) in children and adolescents; reduction of symptoms and relation to pollen load

BACKGROUND

A nasally applied cellulose powder is increasingly used in many countries as a remedy for allergic rhinitis. The absence of side effects makes the treatment particularly attractive in children. The efficacy in pollen allergic children, however, is not studied, nor is the relation to various pollen exposures.

METHODS

During the birch pollen season in 2009, a double blind, placebo-controlled study was conducted in 53 subjects, aged 8-18 yr, with allergic rhinitis attributed to birch pollen. All children were on daily oral antihistamine. Reminders and reporting of symptom scores were made by SMS on mobile phones. Pollen was collected in a volumetric trap from which figures of pollen concentrations from 1979 to 2009 were available.

RESULTS

There was a significant reduction in total symptom scores from the nose (Placebo 7.29, Active 6.07, p = 0.033) and specifically for running nose (Placebo 2.56, Active 2.03, p = 0.017). All symptoms from the nose, eyes and lower airways were lower in the active group but reached significance only as earlier. The best effect was seen after days with low or moderate pollen counts (≤100/m(3)), the predominating pollen load over 31 yr in the area. No clinically significant adverse effects were seen.

CONCLUSIONS

The product reduces symptoms of SAR in children and adolescents. Original data on pollen concentrations over 31 yr are presented with levels mainly in the low range favouring the observed efficacy profile. SMS communication on mobile phone for reminders and recording symptom scores was an excellent logistics tool.

[Childhood asthma and risk factors]

INTRODUCTION

This article summarizes the contribution of epidemiology to the understanding of childhood asthma. The first task in epidemiology is to determine prevalence and incidence of any disease.

PREVALENCE

Epidemiological investigations are aimed at evaluating hypotheses about causes of disease by defining demographic characteristics of a certain population as well as by determining possible effects of environmental factors. In spite of some limitations, data obtained by epidemiological investigations have been valuable in confirming both the increasing incidence of asthma and the differences in prevalence in certain population groups. The observance of this phenomenon has led to much speculation and a lot of attempts to identify the reasons behind the rising prevalence.

RISK FACTORS

Epidemiological studies have identified risk factors for the development of childhood asthma and provided insight into natural history of disease and prognosis. Factors ranging from increased numbers of immunizations to increased air pollution have been suggested, but subsequent analysis has failed to provide the supporting evidence to implicate most of these possibilities. The concept known as the hygiene hypothesis has gained some support from epidemiological studies.

CONCLUSION

The development of asthma as well as its severity are affected by numerous factors and their interactions can he explained by the heterogeneous nature of this disease.

Daily versus as-needed inhaled corticosteroid for mild persistent asthma (The Helsinki early intervention childhood asthma study)

OBJECTIVE

To compare the effect of inhaled budesonide given daily or as-needed on mild persistent childhood asthma. Patients, design and

INTERVENTIONS

176 children aged 5-10 years with newly detected asthma were randomly assigned to three treatment groups: (1) continuous budesonide (400 microg twice daily for 1 month, 200 microg twice daily for months 2-6, 100 microg twice daily for months 7-18); (2) budesonide, identical treatment to group 1 during months 1-6, then budesonide for exacerbations as needed for months 7-18; and (3) disodium cromoglycate (DSCG) 10 mg three times daily for months 1-18. Exacerbations were treated with budesonide 400 microg twice daily for 2 weeks.

MAIN OUTCOME MEASURES

Lung function, the number of exacerbations and growth.

RESULTS

Compared with DSCG the initial regular budesonide treatment resulted in a significantly improved lung function, fewer exacerbations and a small but significant decline in growth velocity. After 18 months, however, the lung function improvements did not differ between the groups. During months 7-18, patients receiving continuous budesonide treatment had significantly fewer exacerbations (mean 0.97), compared with 1.69 in group 2 and 1.58 in group 3. The number of asthma-free days did not differ between regular and intermittent budesonide treatment. Growth velocity was normalised during continuous low-dose budesonide and budesonide therapy given as needed. The latter was associated with catch-up growth.

CONCLUSIONS

Regular use of budesonide afforded better asthma control but had a more systemic effect than did use of budesonide as needed. The dose of ICS could be reduced as soon as asthma is controlled. Some children do not seem to need continuous ICS treatment.

The predictive value of early life total immunoglobulin E measurement in identifying atopic children in a population-based birth cohort study

Atopy is common and the prevalence amongst children is rising. Measurements in early childhood that can predict subsequent development of atopy could be clinically useful for targeting preventive measures. We used the Children in Focus (CiF) subgroup of a large population-based birth cohort study (the Avon Longitudinal Study of Parents and Children) to investigate whether total immunoglobulin E (IgE) measured at 12 and 18 months could predict subsequent development of atopy at 5 yr of age. Atopy was determined by positive skin prick test (> or = 3 mm wheal) to one or more of 14 inhalant and food allergens. Prevalence of skin prick positivity to any allergen was 14.5% (104 of 715; 95% CI: 12.0-17.1%). Total IgE levels were significantly higher at 12 months of age (p < 0.0005) but not 18 months of age in those children subsequently atopic. The highest positive predictive value was 41% with an IgE measurement of >51 kU/l, with a sensitivity of 13.5% and a specificity of 95.8%. Although significant differences in early life IgE measurements were seen, the extent of overlap was great, such that the overall performance of IgE at 12 months as a screening test for atopy was poor.

Allergic rhinoconjunctivitis: epidemiology

Allergic rhinoconjunctivitis has been studied much less frequently than asthma using epidemiologic approaches. Population-based studies are difficult to conduct because of misclassification arising from the reliance on self-reported questionnaires that use terms such as allergic rhinitis or hay fever to establish the diagnosis. In addition, many epidemiologic studies focus on diagnostic skin testing or allergen-specific IgE antibodies (RASTs) as an objective outcome to assess for hay fever. These techniques are helpful but not perfect measures for predicting hay fever outcomes in epidemiologic studies. It is generally accepted, however, that allergic rhinoconjunctivitis is one of the most common of chronic diseases and is the most common atopic disorder. This article reviews the definition of allergic rhinoconjunctivitis, the epidemiology of this disorder from infancy into adulthood, and environmental risk factors for development of sensitization to certain allergens.

Current asthma and respiratory symptoms among pupils in relation to dietary factors and allergens in the school environment

The aim was to study asthma and allergy in relation to diet and the school environment. Pupils (5-14 years) in eight schools received a questionnaire, 1014 participated (68%). Settled dust was collected on ALK-filters and analyzed for allergens from cat (Fel d 1), dog (Can f 1), horse (Equ cx), house dust mites (Der p 1, Der f 1), and cockroach (Bla g 1) by ELISA. In total, 6.8% reported cat allergy, 4.8% dog allergy, 7.7% doctor's diagnosed asthma and 5.9% current asthma, and 7.8% reported wheeze. Current asthma was less common among those consuming more fresh milk (P < 0.05) and fish (P < 0.01). Poly-unsaturated fatty acids was associated with more wheeze (P < 0.05), olive oil was associated with less doctors' diagnosed asthma (P < 0.05). Totally, 74% of the classrooms had mean CO(2) <1000 ppm. The median concentration per gram dust was 860 ng/g Fel d 1, 750 ng/g Can f 1 and 954 U/g Equ cx. Horse allergen was associated with more wheeze (P < 0.05), daytime breathlessness (P < 0.05), current asthma (P < 0.05) and atopic sensitization (P < 0.05). Dog allergen was associated with wheeze (P < 0.05) and daytime breathlessness (P < 0.05). The associations between allergens and respiratory symptoms were more pronounced among those consuming margarine, not consuming butter, and with a low intake of milk. In conclusion, cat, dog and horse allergens in schools could be a risk factor for asthma and atopic sensitization, and dietary factors may interact with the allergen exposure.

PRACTICAL IMPLICATIONS

Previous school studies performed by us in mid-Sweden, showed that most classrooms did not fulfill the ventilation standards. In this study, most of the classrooms fulfilled the ventilation standard, but despite that had widespread allergen contamination. Most previous studies have focused on cat allergen, but our study has shown that also dog and horse allergens can be risk factors for asthma and allergy in schools. As allergens are transported from other environments, mainly the home environment, the main prevention should be to minimize transfer of allergens. This could be achieved by reducing contacts with furry pets and horses, or using different clothes at home and at school (e.g. school uniforms). Increased cleaning in the schools may reduce allergen levels, but the efficiency of this measure must be evaluated in further intervention studies. Finally, our study supports the view that dietary habits among pupils should not be neglected and interaction between dietary factors and indoor allergen exposure needs to be further investigated.

How atopic is atopic dermatitis?

BACKGROUND

The extent to which the phenotype of atopic dermatitis (AD) is truly atopic has been the subject of much debate.

OBJECTIVE

We sought to systematically evaluate the evidence for the value of measurement of IgE antibodies in diagnosing AD and whether knowledge of IgE sensitization increases clinical diagnostic and predictive ability.

METHODS

We searched Medline from its inception until September 2003. Only studies that measured atopy as either skin prick test positivity or IgE-antibody sensitization to environmental allergens were included within a descriptive analysis. Because the small number of studies of adequate quality did not allow a formal meta-analysis, we assigned strength of evidence according to predefined quality criteria and ranked studies accordingly.

RESULTS

Inclusion of atopy as part of the diagnostic criteria for AD did not enhance the criteria's sensitivity and specificity in relation to the clinical phenotype of AD. The strength of association between atopy and AD varied significantly between hospital studies (47% to 75%; n=14 studies) and was stronger in hospital than in community populations (7.4% to 78%; n=13 studies). Whereas study quality did not have an effect on atopy prevalence in hospital populations, low atopy prevalences in community surveys were seen in less rigidly conducted studies. AD severity was positively associated with the number of positive skin prick test responses or IgE-antibody levels in 7 of 8 studies that measured both. Only one study suggested that IgE-specific sensitization to hen's egg is associated with subsequent development of AD, and 2 studies found that allergen-specific IgE sensitization in patients with AD is a prognostic marker for allergic airway disease in later life. Atopy-associated AD might also have a worse long-term prognosis than AD that is not associated with atopy.

CONCLUSION

Although atopy is clearly associated with AD, the role of IgE sensitization in AD needs further study. Current evidence suggests that up to two thirds of persons with AD are not atopic, which implies that continued use of the term atopic dermatitis is problematic. Longitudinal studies are needed to compare the treatment response and prognosis of IgE-associated and non-IgE-associated AD.

The prognosis of bronchial asthma in childhood in Hungary: a long-term follow-up

The aim of this study was to determine the prognosis of bronchial asthma in childhood in Hungary. One hundred and forty five adults (96 men and 49 women) with a clinical history of childhood bronchial asthma were examined at the age of 28 years or above (mean age 37.6, SD 5.9 years). The patients completed questionnaires concerning their asthmatic and accompanying allergic symptoms in childhood, at the age of 18 and at present. They were all prick-tested with 12 inhalant allergens. The results showed that 42.8% of the patients had become symptom-free, but 57.2% still had intermittent or persisting asthmatic symptoms in adulthood. More patients had intermittent day-time (59%) and night-time (67%) asthmatic symptoms than persistent symptoms (41% and 33%). Accompanying allergic diseases (rhinitis, conjunctivitis, dermal and gastrointestinal diseases, and drug andfood allergies) in childhood did not definitely affect the prognosis of the bronchial asthma. The proportion of females with allergic diseases increased, and among patients with skin diseases it was significantly higher than the proportion of affected males. At the age of 18, allergic rhinitis was more frequent than in childhood. The frequencies of other allergic disorders did not change significantly. In the patients with asthmatic symptoms, molds and cat-hair allergies were more frequent than in the symptom-free group. The long-term prognosis of bronchial asthma in childhood in Hungary is relatively good, but fewer than half of the patients became symptom-free. The complaints of most of the patients were mild, but one in seven of all the adults suffered from moderate or serious bronchial asthma. Household allergens may contribute to the persistence of asthmatic symptoms.

Polyclonal and allergen-induced cytokine responses in children with elevated immunoglobulin E but no atopic disease

BACKGROUND

Reduced Th1 and elevated Th2 cytokine responses are considered to be a principal mechanism in the generation of the inflammation leading to the manifestations of atopic disease in the skin of atopic dermatitis and in the airways of asthma. If reduced Th1 and elevated Th2 responses are principal determinants of the manifestation of atopic disease it might be expected that subjects with established disease would exhibit differences in their cytokine profiles as compared with atopic patients without clinical disease.

OBJECTIVE

To determine whether asymptomatic atopic children exhibit a cytokine imbalance similar to that seen in patients with established atopic disease or if they behave like non-atopic controls. Cytokine responses in a group of children with elevated IgE but no clinical manifestations of disease, atopic children with established disease and non-atopic controls were compared.

METHODS

We examined allergen-induced (house dust mite, HDM, rye grass pollen and RYE) cytokine responses in parallel with polyclonal (staphylococcal enterotoxin B, SEB) cytokine responses in a group of children with elevated serum IgE levels without current or past evidence of atopic disease (median age 6.6 years) and compared these with a non-atopic control group (median age 6.5 years) and a group of children with atopic disease (median age 6.7 years).

RESULTS

Symptomatic atopic children had reduced SEB-induced IFN-gamma and increased SEB-induced IL-4 and IL-5 as compared with non-atopic controls. In contrast, SEB-induced IFN-gamma, IL-4 and IL-5 production in asymptomatic atopics was not significantly different from the non-atopic control subjects. Allergen-induced Th1 (IFN-gamma) and Th2 (IL-5 and IL-13) cytokine production was increased in both symptomatic atopics and asymptomatic atopics when compared with non-atopic controls.

CONCLUSION

The defect in polyclonally induced IFN-gamma production was associated with the clinical manifestation of atopic disease but not the atopic stateper se. This suggests that the global reduction in IFN-gamma is the key determinant of the development of overt atopic disease. In contrast, elevated allergen-induced Th2 cytokine responses in children related to the atopic state per se irrespective of the presence of clinical atopic disease.

Polyclonal and allergen-induced cytokine responses in adults with asthma: resolution of asthma is associated with normalization of IFN-gamma responses

BACKGROUND

Atopic disease is associated with skewing of immune responses away from a T(H)1 toward a T(H)2 profile. Previous studies have implicated this cytokine imbalance in the development of disease. However, it is not known whether normalization of this imbalance is conversely associated with disease resolution.

OBJECTIVE

To further delineate the role of reduced T(H)1 and increased T(H)2 cytokine production in the pathogenesis of atopic disease and to determine whether disease resolution is associated with alteration of cytokine profiles, we investigated cytokine responses in a cohort of adult patients with asthma followed from childhood.

METHODS

A cohort of wheezy children and control subjects aged 7 to 10 years were recruited from 1964 to 1967. Subjects were reevaluated every 7 years to monitor the outcome of childhood asthma. At the 42-year follow-up, 89 subjects from this cohort were evaluated for mitogen and house dust mite (HDM)-induced T(H)1 (IFN-gamma) and T(H)2 (IL-4, IL-5, and IL-13) cytokine responses. Cytokine responses were compared in patients with ongoing asthma, patients with resolved asthma, and control subjects.

RESULTS

Patients with severe ongoing asthma had significantly reduced HDM-induced IFN-gamma production compared with that of control subjects and patients with resolved asthma. In contrast, HDM-induced IFN-gamma production in patients with resolved asthma was equivalent to that seen in control subjects. Patients with ongoing and resolved asthma produced significantly higher levels of IL-5 in response to HDM compared with that seen in control subjects, with levels being equivalent in patients with active and resolved asthma. HDM-induced IL-13 production was significantly increased in the patients with resolved asthma when compared with that seen in the control subjects. PHA-induced cytokine responses did not parallel HDM-induced responses.

CONCLUSION

Patients with persistent and severe atopic asthma have a reduced HDM-induced T(H)1 response, whereas those with resolved asthma do not. This suggests that reduced HDM-induced IFN-gamma production might be an important factor contributing to ongoing severe asthma and that normalization of allergen-induced T(H)1 responses might be important for disease resolution. The finding that all subjects with a history of asthma displayed increased HDM-induced T(H)2 (IL-5 and IL-13) cytokine responses, irrespective of the presence or absence of asthma, suggests that increased T(H)2 responses reflect the presence of the atopic state per se rather than being specifically linked to asthma.

Allergic rhinoconjunctivitis, eczema, and sensitization in two areas with differing climates

In this 5-year follow-up study we compared the prevalence of allergic rhinoconjunctivitis, eczema, and sensitization, in relation to several background factors, in two Swedish regions (Göteborg and Kiruna). In Göteborg, a city on the southwest coast, the climate is mild and humid. Kiruna is a town north of the Arctic Circle. Questionnaire replies and results of interviews were collected from all 412 7-8-year-old children of a population-based sample (203 in Göteborg and 209 in Kiruna); in addition, 192 children from Göteborg and 205 from Kiruna were skin-prick tested for sensitization to common aero-allergens. After 5 years, at 12-13 years of age, almost all of the initial study cohort were re-investigated. At follow-up the prevalence of allergic rhinoconjunctivitis was 17%, eczema 23%, and sensitization 32%. Allergic rhinoconjunctivitis and eczema were as common in Göteborg as in Kiruna, whereas sensitization was far more common in Kiruna. Children born during the pollen season had allergic rhinoconjunctivitis less often -- and were sensitized to pollen and animal protein less often -- than those born during the rest of the year. Sensitization to birch pollen, cat protein, and horse protein was less common in children living in Göteborg, the region with the highest frequency of cat ownership and horseback riding, and with the longest birch-pollen season. The girls were more commonly horseback riders but the boys were more often sensitized to horses. The results reinforce our previous findings: indoor climate may affect the development of sensitization and allergic diseases, to some extent independently; and if exposure to antigen is unavoidable, high doses might be better than low doses.

Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis

Allergic rhinitis (AR) is a heterogeneous disorder that despite its high prevalence is often undiagnosed. It is characterized by one or more symptoms including sneezing, itching, nasal congestion, and rhinorrhea. Many causative agents have been linked to AR including pollens, molds, dust mites, and animal dander. Seasonal allergic rhinitis (SAR) is fairly easy to identify because of the rapid and reproducible onset and offset of symptoms in association with pollen exposure. Perennial AR is often more difficult to detect than SAR because of the overlap with sinusitis, respiratory infections, and vasomotor rhinitis. SAR can result in hyperresponsiveness to allergens such as cigarette smoke, once pollen season is over. Perennial AR is defined as occurring during approximately 9 months of the year. AR affects an estimated 20 to 40 million people in the United States alone, and the incidence is increasing; an estimated 20% of cases are SAR; 40% of cases are perennial rhinitis; and 40% of cases are mixed. The pathophysiology of SAR is complex. There is a strong genetic component to the allergic response, which is driven through mucosal infiltration and action on plasma cells, mast cells, and eosinophils. The allergic response occurs in two phases, which are considered the "early" and "late" phase responses. Early phase response occurs within minutes of exposure to the allergen and tends to produce sneezing, itching, and clear rhinorrhea; late phase response occurs 4 to 8 hours after allergen exposure and is characterized by congestion, fatigue, malaise, irritability, and possibly neurocognitive deficits. The key to diagnosis of AR is awareness of signs and symptoms. IgE antibody tests to detect specific allergens are the standard method used today; however, in addition, diagnosis must be confirmed with a positive history and demonstration that the symptoms are the result of IgE-mediated inflammation.

Definition of respiratory symptoms and disease in early childhood in large prospective birth cohort studies that predict the development of asthma

We have reviewed the prospective value of early respiratory symptoms for determining the risk of development of asthma later in life by using data from studies based on the general population, hospital population, and general practices. Although "wheezing" in infancy generally has a good prognosis, it is an important risk factor for the development of asthma later in life. The prognostic value of "coughing" and "shortness of breath" in infancy for the later development of asthma is less clear. Despite the fact that no internationally accepted criteria for the definition of asthma in early childhood are available, many studies have been performed on this topic. We also investigated the outcome variables that were used to describe respiratory symptoms and disease in early childhood in the publications of nine large prospective birth cohort studies on the development of asthma. From seven of these studies, we reviewed the original questionnaires. We found that various studies used different outcome variables, but the data actually collected were similar. This is an important observation because it implies that comparisons between studies can be markedly improved by data sharing among investigators.

Risk of childhood asthma and allergic rhinitis in relation to pregnancy complications

BACKGROUND

Events occurring during fetal life may affect the development of the immune and respiratory systems and increase the risk of asthma and allergic diseases.

OBJECTIVES

We sought to elaborate the relations between the occurrence of pregnancy complications and other pregnancy-related conditions and the risk of bronchial obstruction during the first 2 years of life and the occurrence of asthma and allergic rhinitis by the age of 4 years. Pregnancy complications were considered both as predictors of the health outcomes and as possible effects caused by other prenatal factors.

METHODS

A population-based, 4-year, cohort study was carried out involving 2531 children born in Oslo, Norway. We collected information on maternally related (hyperemesis, hypertension, and preeclampsia) and uterus-related complications in pregnancy (antepartum hemorrhage, preterm contractions, insufficient placenta, and restricted growth of the uterus) and the child's health and environmental exposures at birth and at 6, 12, 18, and 24 months and 4 years of age. The outcomes of interest were bronchial obstruction during the first 2 years and asthma and allergic rhinitis at the age of 4 years.

RESULTS

In a logistic regression analysis adjusting for potential confounders, uterus-related, but not other pregnancy-related, complications increased the risk of bronchial obstruction (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.3-3.4), asthma (OR, 3.0; 95% CI, 1.8-5.4), and allergic rhinitis (OR, 2.9; 95% CI, 1.6-5.2). These relations were similar in children of atopic and nonatopic parents.

CONCLUSIONS

Uterus-related complications in pregnancy increase the risk of having asthma and allergic rhinitis in childhood.

Citrus red mite (Panonychus citri) is a common sensitizing allergen among children living around citrus orchards

BACKGROUND

A recent investigation has suggested that Panonychus citri (citrus red mite) is the most common causative allergen in citrus-cultivating farmers with asthma or allergic rhinitis.

OBJECTIVE

A cross-sectional survey was performed to evaluate the prevalence of asthma and sensitization to P. citri among children living around citrus orchards.

METHODS

A total of 1,055 children living around citrus orchards were enrolled. There were 544 boys and 511 girls with a mean age of 12.3 (range 7 to 16) years. They were evaluated by the ISAAC questionnaire, and a skin prick test with 13 common aeroallergens including P. citri and Japanese cedar pollen. Children who recorded ever having experienced wheezing on the questionnaire were evaluated by methacholine bronchial provocation test and determined to have asthma if they showed bronchial hyperresponsiveness to methacholine simultaneously.

RESULTS

The positive skin test response to one or more inhalant allergens except P. citri was 35.5%, but when including P. citri, the positive response increased to 37.7%. The most common sensitizing allergens in the order of decreasing frequency were Dermatophagoides pteronyssinus (26.6%), D. farinae (22.7%), P. citri (14.2%), cockroach (11.3%), and Japanese cedar pollen (9.7%). Among the children without sensitization to house dust mites, the sensitization rate to P. citri was significantly higher in those 13 and over than in those under 12 (5.8% versus 2.5%, P < .05). The prevalence of asthma was not different between the children with sensitization to P. citri and those without it (5.4% versus 4.0%, P > .05), although the prevalence was higher in those with sensitization to D. pteronyssinus or D. farinae than in those without sensitization to these allergens (7.9% versus 2.9%, P < .05; 9.7% versus 2.6%, P < .05).

CONCLUSION

Citrus red mite is a common sensitizing allergen among children living around citrus orchards. The features of sensitization and development of asthma are different between citrus red mite and house dust mites.

Nordic consensus report on asthma management. Nordic Asthma Consensus Group

The work with the Nordic consensus report on asthma management started some years ago. The Nordic countries have common socioeconomic conditions. We acknowledge the international as well as other European guidelines providing valuable recommendations. Nevertheless, we felt the need to combine the common Nordic experiences in order to have a local statement of asthma and asthma care, based upon Nordic clinical science and tradition. The work has been rewarding and we acknowledge many valuable contributions from paediatricians, allergologists and lung physicians in all Nordic countries. The response has so far been positive and we feel that the present material reflects the main opinion of Nordic physicians taking care of asthma patients of all ages. However, the asthma and allergy research field is rapidly developing. Thus, this document should merely be regarded as a time-limited contribution to the continuing scientific discussion of this fascinating field.

Interaction between the growing lung and asthma: role of early intervention

Asthma is a syndrome where an imbalance exists between the forces that maintain airway patency and the forces that act to narrow, or close, airways. The child with asthma is a particular problem because of the rapid growth of the lung during growth that leaves it vulnerable. There is some evidence that asthma leads to impaired lung function in children because those children with untreated asthma show a loss of lung growth velocity. For unclear reasons, asthma is more frequent in boys. What drugs to use to treat childhood asthma is uncertain. Data show that glucocorticoids prevent the structure of the lung from fully developing. In children, the rationale for early intervention seems clear, but the exact means and criteria for initiation of the intervention are uncertain. Finally, childhood asthma raises fundamental issues and questions that are unique to the child with asthma and presents unique and many unresolved treatment dilemmas.

New ventilation systems at select schools in Sweden--effects on asthma and exposure

The air-exchange rate is often low in schools. The authors studied the possible impact of improving school ventilation on health and exposure of pupils. Questionnaire data on allergies, asthma, and asthmatic symptoms were obtained in 1993 and 1995 for 1,476 primary- and secondary-school pupils in 39 randomly selected schools. Various exposure factors were measured in 1993 and 1995 in approximately 100 classrooms. In 12% of the classrooms, new ventilation systems were installed between 1993 and 1995; the subsequent air-exchange rate increased and the relative humidity and concentration of several airborne pollutants were reduced compared with classrooms in nonimproved buildings. The reporting of at least one asthmatic symptom and the reporting of more asthmatic symptoms in 1995 than in 1993 were less common among the 143 pupils who attended schools with new ventilation systems.

Citrus red mite (Panonychus citri) is the most common sensitizing allergen of asthma and rhinitis in citrus farmers

OBJECTIVE

To evaluate type I hypersensitivity to citrus red mite (Panonychus citri), its prevalence, and relationship to respiratory dysfunction, a cross-sectional survey was performed among citrus farmers on Cheju Island, Korea.

MATERIALS AND METHODS

Questionnaires, and skin prick test responses to 11 common inhalant allergens and citrus red mite were performed in 181 citrus farmers, and serum-specific IgE antibodies to citrus red mite were measured by ELISA in sera of 123 subjects. To determine airway hyperresponsiveness, methacholine bronchial provocation tests were performed in 55 subjects who complained of recurrent lower respiratory symptoms.

RESULTS

The prevalence of asthma-based on presence of asthmatic symptoms on the questionnaire and airway hyperresponsiveness to methacholine, and allergic rhinitis based on presence of nasal symptoms on the questionnaire and positive skin-test response were 12.1% and 19.3%, respectively. The positive rate of skin responses to one or more of 11 common inhalant allergens excluding citrus red mite was 17.1%, and if citrus red mite was included, 25.9% of farmers had positive responses. On skin prick tests, citrus red mite (16.5%) was the most common sensitizing allergen, followed by cockroach (11.0%), Dermatophagoides pteronyssinus (9.9%), and D. farinae (9.3%). Among farmers with asthma and allergic rhinitis, the positive skin responses to citrus red mite were noted in 54.5 and 68.5%, respectively. Serum-specific IgE antibodies to citrus red mite were detected in 45 farmers (36. 5%) of the 123 tested, and there was significant correlation between specific IgE level and weal (A/H ratio) to citrus red mite (r = 0.57, P < 0.001). The prevalence of asthma was higher in subjects with positive skin responses or high serum-specific IgE antibodies to citrus red mite than in those without skin response or serum specific IgE (P < 0.05, respectively).

CONCLUSION

Citrus red mite is the most important allergen in citrus farmers with asthma and rhinitis in which causative allergen has not been identified. It should be included in the skin test battery for screening the causative allergen in farmers exposed to citrus red mite.

The natural history of childhood eczema: observations from the British 1958 birth cohort study

The National Child Development Study (NCDS) is a birth cohort study whose longitudinal design makes it suitable for examining the natural history of common diseases in childhood such as atopic eczema. We have analysed the age of onset and clearance rates for examined and/or reported eczema in 6877 children born during the period 3-9 March 1958 for whom linked data were available at birth and at the ages of 7, 11, 16 and 23 years. Of the 870 cases with examined or reported eczema by the age of 16 years, 66% had age of onset by the age of 7 years. Of the 571 children with reported or examined eczema by the age of 7 years, the proportion of children who were clear in terms of examined eczema or reported eczema in the last year at ages 11 and 16 years was 65% and 74%, respectively. These 'apparent' or short-term clearance rates fell to 53% and 65%, respectively, after allowance for subsequent recurrences in adolescence and early adulthood. Age of onset of community-ascertained cases of atopic eczema may be later than that reported in hospital-based studies. The long-term prognosis of childhood eczema may be worse than some previous studies have suggested, especially when subsequent recurrences are taken into account.

Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma, and Immunology

This document contains complete guidelines for diagnosis and management of rhinitis developed by the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology, representing the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology and the Joint Council on Allergy, Asthma and Immunology. The guidelines are comprehensive and begin with statements on clinical characteristics and diagnosis of different forms of rhinitis (allergic, non-allergic, occupational rhinitis, hormonal rhinitis [pregnancy and hypothyroidism], drug-induced rhinitis, rhinitis from food ingestion), and other conditions that may be confused with rhinitis. Recommendations on patient evaluation discuss appropriate use of history, physical examination, and diagnostic testing, as well as unproven or inappropriate techniques that should not be used. Parameters on management include use of environmental control measures, pharmacologic therapy including recently introduced therapies and allergen immunotherapy. Because of the risks to patients and society from sedation and performance impairment caused by first generation antihistamines, second generation antihistamines that reduce or eliminate these side effects should usually be considered before first generation antihistamines for the treatment of allergic rhinitis. The document emphasizes the importance of rhinitis management for comorbid conditions (asthma, sinusitis, otitis media). Guidelines are also presented on special considerations in patients subsets (children, the elderly, pregnancy, athletes and patients with rhinitis medicamentosa); and when consultation with an allergist-immunologist should be considered.

Clinical differences among women with and without self-reported perimenstrual asthma

BACKGROUND

Studies suggesting that 30% to 40% of asthmatic women report significant perimenstrual (late luteal phase) exacerbations of asthma are primarily retrospective, rely on subjective findings and do not demonstrate a consistent association between asthma and the menstrual cycle.

OBJECTIVE

In this exploratory analysis, women with and without self-reported perimenstrual exacerbations of asthma (PMA) were examined prospectively to determine the association between asthma and the menstrual cycle and to characterize associated clinical factors.

METHODS

Thirty-two adult asthmatic women with regular menstrual periods recorded daily asthma symptoms, medication use, and peak expiratory flow rate (PEFR) over six consecutive menstrual cycles, and underwent spirometry and methacholine bronchoprovocation during the luteal and follicular phases of 2 cycles.

RESULTS

Nine of 32 subjects (28.2%) reported PMA. Daily means of rescue medication use and AM peak flow computed for each perimenstrual day demonstrated significant non-parallelism of group profiles; subjects with PMA had increasing inhaled short acting beta 2-agonist use and decreasing AM peak flow rates during the perimenstrual interval. Luteal-follicular phase differences in FEV1 or methacholine bronchoprovocation between the groups were not detected. Subjects with PMA were older (P=.007), had longer duration of asthma (P=.039), and increased baseline asthma severity (P=.076) compared with subjects without PMA.

CONCLUSION

The findings of this study suggest that women with self-reported perimenstrual asthma demonstrate perimenstrual differences in rescue bronchodilator use and AM peak flow and appear to constitute a distinct subset of women with asthma who are older, have longer duration of asthma, and increased severity of asthma compared with women without self-reported perimenstrual asthma. These factors identify women who require close monitoring of their asthma during their menstrual cycles.

Pollen-related allergy in Europe

The increasing mobility of Europeans for business and leisure has led to a need for reliable information about exposure to seasonal airborne allergens during travel abroad. Over the last 10 years or so, aeropalynologic and allergologic studies have progressed to meet this need, and extensive international networks now provide regular pollen and hay-fever forecasts. Europe is a geographically complex continent with a widely diverse climate and a wide spectrum of vegetation. Consequently, pollen calendars differ from one area to another; however, on the whole, pollination starts in spring and ends in autumn. Grass pollen is by far the most frequent cause of pollinosis in Europe. In northern Europe, pollen from species of the family Betulaceae is a major cause of the disorder. In contrast, the mild winters and dry summers of Mediterranean areas favor the production of pollen types that are rarely found in central and northern areas of the continent (e.g., the genera Parietaria, Olea, and Cupressus). Clinical and aerobiologic studies show that the pollen map of Europe is changing also as a result of cultural factors (e.g., importation of plants for urban parklands) and greater international travel (e.g., the expansion of the ragweed genus Ambrosia in France, northern Italy, Austria, and Hungary). Studies on allergen-carrying paucimicronic or submicronic airborne particles, which penetrate deep into the lung, are having a relevant impact on our understanding of pollinosis and its distribution throughout Europe.

No evidence for effects of family environment on asthma. A retrospective study of Norwegian twins

The risk of developing asthma contingent upon the co-twins' history of asthma was analyzed in a population-based study of 5,864 Norwegian twins. A primary aim was to assess the significance of shared environment for the development of asthma from infancy through age 25. Retrospective reports were collected when the twins were 18 to 25 yr of age. The risk of developing asthma, contingent upon the co-twin's history of asthma, was estimated using survival analyses, and genetic and environmental sources of variation in liability for asthma were analyzed with structural equation models. The cumulative incidence of asthma was 6% for males and 5.4% for females. The relative risk of developing asthma among twins whose co-twin had a positive history of asthma compared with those whose co-twin had no history of asthma was 17.9 (95% CI, 10.3 to 31.0) for identical, and 2.3 (95% CI, 1.2 to 4.4) for fraternal twins. Although shared environment encompasses many of the exposures that are putative risk factors for asthma in this age range, there is no evidence of shared environmental influences for asthma. Rather, 75% of the variation in liability for asthma was explained by genetic effects and the remaining variation was due to nonshared environmental influences. These results suggest that the familial risk for asthma is primarily, genetic.

Prognostic factors for the outcome of childhood asthma in adolescence

By the second decade of life asthma symptoms often abate and it may seem that patients with mild asthma have "outgrown" the disease. Unfortunately this is likely to be the exception rather than the rule. Although the severity of asthma symptoms fluctuates with time, the inherited tendency towards respiratory symptoms never disappears and many teenagers who seem to be free of symptoms do, in fact, have persistent asthma. During symptom-free periods subclinical, but nevertheless significant, airways obstruction and/or bronchial hyperresponsiveness may be present. It is not unusual for adults who have been asymptomatic for a number of years to redevelope asthma symptoms. Indeed, much of the so-called adult onset asthma has its roots in childhood. Levison concluded that, in these subjects, it is often not the asthma that is outgrown but the paediatrician. The more severe asthma is in childhood the more likely it is that the disease will persist in adulthood. A complete list of the characteristics of the disease in childhood, and the potential risk factors associated with an unfavourable prognosis, such as pulmonary function and bronchial responsiveness and markers of airway inflammation, is therefore needed. As properly matched and controlled prospective long term studies have not been published it has not been possible to evaluate the effects on prognosis of any single class of antiasthma agent. Such studies are needed to find out if it is possible to alter the natural history of the disease. In theory modern asthma treatments, because they are able to improve symptoms and underlying disease phenomena, are also beneficial in the long term prognosis of childhood asthma. The majority of patients with persistent asthma included in the currently available studies were not receiving adequate treatment. Since compliance with therapeutic regimens in asthma, especially in adolescence, is low, a monitoring system is needed to guarantee adequate follow up and treatment during and beyond puberty.

Breastfeeding as prophylaxis against atopic disease: prospective follow-up study until 17 years old

Atopic diseases constitute a common health problem. For infants at hereditary risk, prophylaxis of atopy has been sought in elimination diets and other preventive measures. We followed up healthy infants during their first year, and then at ages 1, 3, 5, 10, and 17 years to determine the effect on atopic disease of breastfeeding. Of the initial 236 infants, 150 completed the follow-up, which included history taking, physical examination, and laboratory tests for allergy. The subjects were divided into three groups: prolonged (> 6 months), intermediate (1-6 months), and short or no (< 1 month) breastfeeding. The prevalence of manifest atopy throughout follow-up was highest in the group who had little or no breastfeeding (p < 0.05, analysis of variance and covariance with repeated measures [ANOVA]). Prevalence of eczema at ages 1 and 3 years was lowest (p = 0.03, ANOVA) in the prolonged breastfeeding group, prevalence of food allergy was highest in the little or no groups (p = 0.02, ANOVA) at 1-3 years, and respiratory allergy was also most prevalent in the latter group (p = 0.01, ANOVA) having risen to 65% at 17 years of age. Prevalences in the prolonged, intermediate, and little or no groups at age 17 were 42 (95% CI 31-52)%, 36 (28-44)%, and 65 (56-74)% (p = 0.02, trend test) for atopy, respectively, and 8 (6-10)%, 23 (21-25)%, and 54 (52-56)% (p = 0.0001, trend test) for substantial atopy. We conclude that breastfeeding is prophylactic against atopic disease--including atopic eczema, food allergy, and respiratory allergy--throughout childhood and adolescence.

Extrinsic and intrinsic asthma from childhood to adult age: a 10-yr follow-up

BACKGROUND

Asthma constitutes one of the most common chronic diseases in childhood, yet little is known about the factors that determine the outcome in childhood asthma. The purpose of this study was to describe various factors of potential importance for the outcome in children with intrinsic and extrinsic asthma.

METHODS

Of 85 consecutive children, 5-15 years of age with asthma, 70 (82%) participated in a 10-yr follow-up examination. At the time of referral, all children underwent certain tests for asthma (case history, total IgE, skin prick tests, radioallergosorbent (RAST) tests and specific bronchial provocations). On the basis of these tests, 24 children had intrinsic asthma and 46 children had extrinsic asthma.

RESULTS

At the follow-up examination, 60 of the 70 adults (86%, 20 with intrinsic asthma) had current symptoms; 54 of the 60(90%; 18 with intrinsic asthma) were receiving maintenance therapy. Both FEV1 %predicted and FEV1/FVC increased significantly (from 73% +/- 19% to 92% +/- 17% and from 75% +/- 13% to 80% +/- 12% respectively) from childhood to early adulthood (P < 0.0001 and P < 0.001), respectively); a matching amelioration of symptoms was observed (P < 0.0001). Adults with current symptoms had a significantly lower FEV1 %predicted at the time of follow-up (90% +/- 2% vs. 100% +/- 4%, P < 0.02) but not in childhood (73% +/- 20% vs. 71% +/- 10%) than adults who had ceased wheezing.

CONCLUSIONS

In children with intrinsic asthma, the outcome seems to be predicted by a combination of the initial frequency of symptoms (P = 0.04), initial FEV1 (P = 0.002), active smoking (P = 0.001) and age at onset of respiratory symptoms (P = 0.001), whereas the initial FEV1 (P < 0.001) seems to be a strong predictor for the outcome in children with extrinsic asthma. These findings suggest that the pathogenic mechanisms underlying intrinsic and extrinsic asthma in children may differ.

Blood eosinophils, eosinophil-derived proteins, and leukotriene C4 generation in relation to bronchial hyperreactivity in children with atopic dermatitis

To assess the relation among eosinophil-related variables in the peripheral blood, bronchial hyperreactivity, and the presence of atopic dermatitis in children aged 5-14 years, we studied 11 patients with atopic dermatitis alone, six with asthma and atopic dermatitis, 12 with asthma alone, and 12 healthy controls. Eosinophil counts, levels of eosinophil cationic protein, and the capacity of eosinophils to generate leukotriene (LT) C4, as well as bronchial hyperreactivity and a severity score for atopic dermatitis, were determined. Eosinophil variables were significantly higher in both patient groups with atopic dermatitis than in normal controls. In particular, ionophore A 23187 LTC4 generation was higher in patients with atopic dermatitis alone (median 82, range 25-273 ng/10(6) cells) and patients with combined asthma and atopic dermatitis (median 68, range 32-583 ng/10(6) cells) than in normal controls (median 9, range 1-67 ng/10(6) cells). However, there was no difference between the group of atopic dermatitis patients with asthma and without asthma. We conclude that eosinophil variables in the peripheral blood are mainly influenced by the presence of atopic dermatitis, and not the presence and the severity of asthma in patients with both asthma and atopic dermatitis.

Prognosis of asthma in children: a cohort study into adulthood

Fifty-six children with asthma, randomly selected from a hospital clinic, were followed prospectively for 15 years from a median age of 9-24 years of age. Four follow-ups were performed and included scoring of the frequency of wheezing, the need for medication, admissions to hospital, spirometry, skin prick tests and RAST to common inhaled allergens, and evaluation of living conditions. One patient died of asthma. The remaining 55 reported for all follow-ups. After the second follow-up at a median age of 13 years, all parameters of severity of asthma showed improvement, which was significant at the last follow-up when all subjects were more than 20 years of age. Only 16% of the subjects had been free from wheezing and medication the year prior to the last follow-up. Approximately 90% of the children had clinical allergies and positive allergy tests to pollens and danders and the majority of children retained both the allergies and the reactivity into adulthood. Reactivity to moulds and mites was less frequent (40% and 31%, respectively) and seemed to decrease in adulthood. Approximately 10% of the subjects developed neither clinical allergies nor reactivity in allergy tests. Children with atopic eczema usually retained their eczema as adults. Frequent wheezing and abnormal spirometry in childhood and early onset of asthma were associated with poorer outcome. The social prognosis was excellent.

Risk factors for the persistence of respiratory symptoms in childhood asthma

We studied the prognosis of childhood asthma in a cohort of 406 children 8 to 12 yr of age when enrolled. Subjects were followed for a mean of 14.8 yr after their initial evaluation, with a follow-up rate of 86%. The mean age at follow-up was 24.7 yr. We assessed the predictive value of sex and various childhood variables on the outcome of symptoms and medication use in adulthood. Although only 19% of subjects were still under a physician's supervision at the time of follow-up, 76% had respiratory symptoms, 32% used maintenance medication, and 22% used medication intermittently. The incidence of cigarette smoking was disturbingly high (33%). In adulthood, women were more likely than men to have symptoms (85 versus 72%, respectively). The childhood symptom severity and the childhood degree of bronchial responsiveness in combination with a low %FEV1 were also related to the outcome of asthma in adulthood. The high prevalence of symptoms in adults at follow-up coupled with the low rate of physician supervision and medication usage suggest that more aggressive treatment may be indicated in asthmatic children.

Effects of time, sex, ethnic origin, and area of residence on prevalence of asthma in Israeli adolescents

OBJECTIVES

To study effects of time, sex, ethnic origin, and area of residence on prevalence of asthma in Israeli adolescents.

DESIGN

Retrospective survey of asthma from computerised medical draft records of conscripts examined up to the end of 1989.

SETTING

Five regional centres in Israel.

SUBJECTS

443 186 conscripts (262 836 males and 180 350 females) aged 17-18 who were born over a nine year period.

MAIN OUTCOME MEASURES

Asthma determined by medical history, physical examination, and lung function tests at rest and after exercise.

RESULTS

Asthma was more prevalent in males than females (26.5/1000 v 21.4/1000, relative risk 1.25 (95% confidence interval 1.19 to 1.32)). Subjects were split into three groups according to year of birth, and prevalence of asthma increased over time from 18/1000 to 24/1000 to 36/1000 (risk of asthma 0.56 (0.54 to 0.59) for first birth group relative to last birth group and 0.69 (0.66 to 0.72) for second group relative to last group). Risk of asthma was also affected by ethnic origin (highest for Western origin and lowest for north African origin, relative risk 1.63 (1.56 to 1.71)) and area of residence (highest in the central coastal region--risk of 1.24 (1.19 to 1.30) relative to the north coastal region--and lowest in inland areas--risk of 0.67 (0.64 to 0.70) relative to north coastal region).

CONCLUSIONS

Prevalence of asthma in Israel is increasing and is higher in males, in people of Western origin, and in those living in the most industrialised coastal region.

Familial occurrence of atopic disease: genetic versus environmental factors

Cumulative life prevalence of atopic disease (any of reported symptoms of asthma/wheezy bronchitis, allergic rhinitis, eczema and urticaria) was studied by means of a questionnaire in 19814 (7-, 10- and 14-year-old) Swedish school children and their parents. Maternal history was found to be twice as common as paternal history. The children of affected mothers contracted atopic disease in the same proportion as the children of affected fathers yielding twice as many affected children with affected mothers than with affected fathers. The strongest parental influence on childhood disease was seen for multiple symptoms and for congruent symptoms with both parents. The number of children with both parents affected was 1.6 times larger than expected. A possible dose-response effect in polygenic inheritance is discussed as well as assumed impact of environmental factors with a tendency to familial clustering.

Relation between early introduction of solid food to infants and their weight and illnesses during the first two years of life

OBJECTIVE

To assess the relations between early introduction of solid food and infant weight, gastrointestinal illness, and allergic illnesses during the first two years of life.

DESIGN

Prospective observational study of infants followed up for 24 months after birth.

SETTING

Community setting in Dundee.

PATIENTS

671 newborn infants, of whom 455 were still available for study at 2 years of age.

MAIN OUTCOME MEASURES

Infants' diet, weight, and incidence of gastrointestinal illness, respiratory illness, napkin dermatitis, and eczema at 2 weeks and 2, 3, 4, 6, 9, 12, 15, 18, 21, and 24 months of age.

RESULTS

The infants given solid food at an early age (at < 8 weeks or 8-12 weeks) were heavier than those introduced to solids later (after 12 weeks) at 4, 8, 13, and 26 weeks of age (p < 0.01) but not at 52 and 104 weeks. At their first solid feed those given solids early were heavier than infants of similar age who had not yet received solids. The incidence of gastrointestinal illness, wheeze, and nappy dermatitis was not related to early introduction of solids. There was a significant but less than twofold increase in respiratory illness at 14-26 weeks of age and persistent cough at 14-26 and 27-39 weeks of age among the infants given solids early. The incidence of eczema was increased in the infants who received solids at 8-12 weeks of age.

CONCLUSION

Early introduction of solid food to infants is less harmful than was previously reported. Longer follow up is needed, but, meanwhile, a more relaxed approach to early feeding with solids should be considered.