Infant wheeze, comorbidities and school age asthma

Predictive characteristics to discriminate the longitudinal outcomes of childhood asthma: a retrospective program-based study

BACKGROUND

Childhood asthma is an inflammatory disease with heterogeneous outcomes. We sought to determine the impact of total IgE, blood eosinophil, allergen sensitization, and inhaled corticosteroid (ICS) on longitudinal outcomes and to identify characteristics for discriminating different outcomes.

METHODS

We conducted a retrospective study in 383 childhood asthma patients and another 313 patients with blood eosinophil data only receiving regular program-based visits from September 1, 2004, to December 31, 2018. Peak expiratory flow (PEF) variability, PEF predicted %, asthma severity, and asthma control at each visit were assessed as clinical outcomes.

RESULTS

Our data show that the percentage of blood eosinophils was significantly associated with increased asthma severity (OR: 1.043, 95% CI: 1.002-1.086, P = 0.0392). Mold sensitization was significantly associated with asthma severity (OR: 2.2485, 95% CI: 1.3253-3.8150, P = 0.0027). Characteristics including sensitization status plus ICS dosage had the best area under the receiver operating characteristic curve (AUC) value for predicting longitudinal PEF predicted % (0.6609), PEF variability (0.6885), asthma severity (0.5918), and asthma control (0.6441), respectively.

CONCLUSIONS

We showed that the risk for adverse clinical outcomes at follow-up differed between serum IgE, blood eosinophil, and allergen sensitization identified at baseline. Sensitization and ICS dosage were predictive characteristics of long-term clinical outcomes.

IMPACT

The unique aspects of the study are its longitudinal assessment of patients receiving guideline-based asthma management program to help characterize the stability of the clinical outcomes over time. Characteristics including allergen sensitization and ICS dosage demonstrated an improved capability for distinguishing between better and worse clinical outcomes. Through longitudinal serial assessment, this study indicates the risk for adverse clinical outcomes differed between children with serum IgE/blood eosinophil/allergen sensitization characterized at baseline.

Wheeze trajectories: Determinants and outcomes in the CHILD Cohort Study

BACKGROUND

Wheezing in early life is associated with asthma in adulthood; however, the determinants of wheezing trajectories and their associations with asthma and lung function in childhood remain poorly understood.

OBJECTIVE

In the CHILD Cohort Study, we aimed to identify wheezing trajectories and examine the associations between these trajectories, risk factors, and clinical outcomes at age 5 years.

METHODS

Wheeze data were collected at 8 time points from 3 months to 5 years of age. We used group-based trajectory models to derive wheeze trajectories among 3154 children. Associations with risk factors and clinical outcomes were analyzed by weighted regression models.

RESULTS

We identified 4 trajectories: a never/infrequent trajectory, transient wheeze, intermediate-onset (preschool) wheeze, and persistent wheeze. Higher body mass index was a common risk factor for all wheeze trajectories compared with that in the never/infrequent group. The unique predictors for specific wheeze trajectories included male sex, lower respiratory tract infections, and day care attendance for transient wheeze; paternal history of asthma, atopic sensitization, and child genetic risk score of asthma for intermediate wheeze; and maternal asthma for persistent wheeze. Blood eosinophil counts were higher in children with the intermediate wheeze trajectory than in those children with the other trajectories at the ages of 1 and 5 years. All wheeze trajectories were associated with decreased lung function and increased risk of asthma at age 5 years.

CONCLUSIONS

We identified 4 distinct trajectories in children from 3 months to 5 years of age, reflecting different phenotypes of early childhood wheeze. These trajectories were characterized by different biologic and physiologic traits and risk factors.

The effect of recombinant human interferon α1b treatment of infants hospitalized with lower respiratory tract infection on subsequent wheezing

OBJECTIVE

To investigate the impact of recombinant human interferon α1b (rhIFNα1b) treatment in infants hospitalized with lower respiratory tract infections on subsequent wheezing.

METHODS

The clinical data of infants (n=540) with viral pneumonia, wheezy bronchitis, or bronchiolitis hospitalized in 19 Chinese hospitals from June 2009 to June 2015 were retrospectively analyzed. The parameters relevant to wheezing episodes within the last year were collected by telephone and questionnaires. The rhIFNα1b treatment group (n=253) and control group (n=287) were compared in terms of wheezing episodes within the last year. Moreover, the wheezing group (95 cases) and non-wheezing group (445 cases) were compared.

RESULTS

Out of 540 cases, 95 (17.6%) experienced wheezing episodes, 13.8% (35/253) cases treated with rhIFNα1b, and 20.9% (60/287) cases without rhIFNα1b experienced wheezing episodes within the last year. The rhIFNα1b treatment significantly improved wheezing episodes within the last year, compared with the control peers (p=0.031). Single-factor regression showed statistically significant differences between the wheezing and non-wheezing groups in terms of age, rhIFNα1b use, childhood and family history of allergy, housing situation, and feeding history (p<0.05). Binary logistic regression showed a childhood history of allergy (OR=2.14, p=0.004), no rhIFNα1b use (OR=1.70, p=0.028), and living in a crowded house (OR=1.92, p=0.012) might be risk factors of subsequent wheezing. Accordingly, breastfeeding (OR=0.44, p=0.008) and hospitalization age of ≤1-year-old (OR=0.58, p=0.024) were protective factors.

CONCLUSIONS

Early use of rhIFNα1b in infants hospitalized with lower respiratory tract infections and breastfeeding could prevent subsequent wheezing. Living in a crowded house could promote subsequent wheezing.

Phenotypes of atopic dermatitis and the risk for subsequent asthma: a systematic review and meta-analysis

BACKGROUND

Various atopic dermatitis (AD) phenotypes showed an enormously heterogenic risk for subsequent asthma development.

OBJECTIVE

We aimed to investigate the association between AD phenotypes and the risk for progression to asthma.

METHODS

We searched PubMed, Embase, and Web of Science databases for relevant publications. Pooled relative risks (RR) with 95% confidence intervals (CI) were calculated using the CMA-3.0 software. This study has been registered with PROSPERO (CRD42019129273).

RESULTS

We analyzed 39 publications with 458,810 participants. The RR for asthma in AD was 2.16 (95% CI, 1.88-2.48). The risk in persistent AD (RR, 3.36; 95% CI, 2.83-3.99) was higher than in transient AD (RR, 1.52; 95% CI, 1.34-1.73), and in severe AD (RR, 2.40; 95% CI, 1.96-2.94) was higher than mild (RR, 1.82; 95% CI, 1.03-3.23) or moderate (RR, 1.51; 95% CI, 1.30-1.75) AD. The risk for asthma in early-onset AD was slightly higher than in late-onset AD and in boys higher than girls.

LIMITATIONS

The AD and asthma definitions differed across the included studies.

CONCLUSION

Patients with persistent or severe AD were at a higher risk for developing asthma. These findings further elucidate the atopic march and identify target populations for asthma prevention.

Operational definitions of paediatric asthma used in epidemiological studies: A systematic review

Background

Researchers use different definitions to identify children with asthma in epidemiological surveys. We conducted a systematic review to describe the definitions used in epidemiologic studies for wheeze and asthma in the paediatric population, aimed to inform the development of a uniform definition of paediatric asthma for future epidemiological research.

Methods

We systematically searched terms to identify asthma and/or wheeze among children aged <13 years and published between 1995-2020 across seven databases (MEDLINE, EMBASE, PsycINFO, Global Health, AMED, LILACS and CINAHL). PRISMA guidelines were followed for this review.

Results

We extracted a total of 11 886 records, where 190 met our eligibility criteria and included in the analysis. Among the included studies, 62.1% (n = 118/190) used the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaires, predominantly in developing countries (80%, n = 64/80). ‘Wheeze’ was reported in five categories, subdivided by 14 different definitions. “Current wheeze”, defined as caregivers report of wheezing sounds from the chest of the child in the past 12 months and “Wheeze ever”, defined as caregivers’ report of wheezing or whistling in the chest of the child at any previous time, were the most common wheeze category reported in 129 and 95 studies, respectively. Asthma was reported in nine categories using 53 definitions. The most common asthma category was “Asthma ever”, which was reported in 89 studies, based on caregiver statement that the child had asthma in the past.

Conclusion

Definitions of wheeze and asthma for children used in surveys are primarily based on parent-reported clinical features. Studies from developing countries more frequently used the ISAAC definitions to report childhood asthma and wheeze compared to the studies from developed counties. The use of a uniform asthma definition will aid the interpretation of research findings globally.

Effect of prenatal and postnatal exposure to tobacco in the development of acute bronchiolitis in the first two years of life

INTRODUCTION

Environmental exposure to tobacco increases the risk of respiratory disease in infants. However, the impact of maternal smoking on the development of acute bronchiolitis has hardly been assessed. The aim of this study was to determine the incidence of acute bronchiolitis and to analyse the effect of prenatal and postnatal maternal smoking on the development of this disease.

PATIENTS AND METHODS

A prospective, observational study was performed on healthy newborns from a third level hospital born between October 2015 and February 2016. Questionnaires were completed by the mothers at discharge from maternity and followed-up for two years. These collected information about prenatal and postnatal smoking, lifestyle, family and personal history, and the development of bronchiolitis. A bivariate and multivariate logistic regression analysis was performed.

RESULTS

A total of 223 newborns were included, of whom 13.9% were exposed to tobacco smoking during gestation, 21.4% in the postnatal period, and 12.4% in both times. The incidence of bronchiolitis was 28.7% at one year of life, and 34.5% at two years. The multivariate analysis demonstrated that the prenatal and postnatal exposure to tobacco is an independent risk factor for the development of bronchiolitis (OR 4.38; 95% CI; 1.63-11.76), while prolonged breastfeeding is a protective factor (OR 0.13; 95% CI; 0.04-0.48). Other factors that were statistically significant were: atopic dermatitis (OR 2.91; 95% CI; 1.26-6.73), and gestational age (OR 1.42; 95% CI; 1.08-1.88).

CONCLUSIONS

Children exposed to prenatal and postnatal maternal smoking have a higher risk of suffering bronchiolitis. Reducing the smoking habit in women that intend to become pregnant must be a priority in preventive medicine.

The course of asthma: A population-based 10-year study examining asthma remission in children diagnosed with asthma in preschool

BACKGROUND

The natural course of asthma may differ depending on the age of onset.

OBJECTIVE

To investigate predictors of asthma remission with a focus on the age of asthma onset.

METHODS

The study was a retrospective birth cohort of children with asthma in Saskatchewan, Canada. Using the Saskatchewan Ministry of Health databases, we identified children with a diagnosis of asthma in the first 6 years of life and who had at least 10 years of follow-up after diagnosis (n = 22 563). Of these, we included 6393 children either with persistent asthma (≥1 physician visit or hospitalization for asthma [PVHA] during each year of follow-up) and those who had remission (had PVHA in the first year after diagnosis but at some point during the follow-up no longer received PVHA until end of the study). We used survival analysis to examine associations between remission and age of asthma onset.

RESULTS

Of the study participants, 87.2% had early-onset (≤3 years) and 12.8% had late-onset (4-6 years) asthma. Over the 10-years of follow-up, the rate of asthma remission was 37 per 100 person-years. Early-onset asthma (hazard ratio [HR] = 1.10; 95%confidence interval [CI]: 1.01-1.20), being female (HR = 1.12; 95%CI: 1.07-1.18), living in a rural (HR = 1.20; 95%CI: 1.14-1.27) and medium urban (HR = 1.16; 95%CI: 1.08-1.26) location were positively associated with remission while history of atopy decreased likelihood of remission (HR = 0.73; 95%CI: 0.54-0.97).

CONCLUSION

Most children with asthma experienced remission, especially those with the onset of symptoms within the first 3 years of life.

Asthma prevalence and risk factors in school children: The RESPIR longitudinal study

OBJECTIVES

To analyze the incidence of wheezing in the first six years of life; the prevalence of asthma at six years of age; and the associated risk factors, in a population from Valencia, Spain.

METHODS

A prospective longitudinal study was made of a cohort of 636 newborn infants, with follow-up of the clinical records and the completion of questionnaires up to the age of six years.

RESULTS

The prevalence of asthma at six years of age was 12.8%. Up until that age, 63% of the study population had experienced at least one episode of wheezing, and 35% had suffered recurrent wheezing (three or more episodes). Admission due to wheezing was associated to school asthma. The following risk factors were identified: atopic dermatitis (OR: 2.1; 95%CI: 1.2-3.5), the presence of at least one episode of wheezing in the first year (OR: 1.8; 95%CI: 1.1-2.9), prematurity (OR: 2.5; 95%CI: 1.2-5.1), and a family history of asthma (OR: 2.2; 95%CI: 1.2-4.1).

CONCLUSIONS

The prevalence of asthma at six years of age in our population is similar to that described in other longitudinal studies. An important increase is observed in the cumulative incidence of wheezing and of recurrent wheezing up to three years of age, followed by stabilization. The most relevant risk factors for developing asthma at six years were atopic dermatitis, wheezing during the first year, prematurity, and a family history of asthma. Full-term pregnancy and the minimization of respiratory infections at an early age could reduce the prevalence of asthma at six years of age in our population.

Persistent Wheeze in Infants: A Guide for General Pediatricians

Infants with persistent wheeze is a common diagnostic challenge for the general pediatrician because of the broad differential diagnoses. The initial diagnostic approach should include a comprehensive history, physical examination, and chest radiography. Additional testing may be warranted. Involvement of a pediatric pulmonary subspecialist may also be indicated. [Pediatr Ann. 2019;48(3):e110-e114.].

Factors predicting persistence of early wheezing through childhood and adolescence: a systematic review of the literature

Background

For the early identification of persistent asthma symptoms among young children with recurrent wheezing, it would be helpful to identify all available studies that have identified at least one factor for predicting the persistence of early wheezing. The objective of the present study was to perform a systematic review of all studies that have identified factors that predict the persistence of symptoms among young patients with recurring wheezing.

Methods

A systematic review of relevant studies was conducted through searching in MEDLINE, EMBASE, CINHAL, and SCOPUS databases up to June 2016. Studies that identified predictors of persistence of wheezing illness among young children with recurrent wheezing were retrieved. Two independent reviewers screened the literature and extracted relevant data.

Results

The literature search returned 649 references, 619 of which were excluded due to their irrelevance. Five additional studies were identified from reference lists, and 35 studies were finally included in the review. Among all the identified predictors, the most frequently identified ones were the following: family asthma or atopy; personal history of atopic diseases; allergic sensitization early in life; and frequency, clinical pattern, or severity of wheezing/symptoms.

Conclusion

Parental asthma (especially maternal), parental allergy, eczema, allergic rhinitis, persistent wheezing, wheeze without colds, exercise-induced wheeze, severe wheezing episodes, allergic sensitization (especially polysensitization), eosinophils (blood or eosinophil cationic protein in nasal sample), and fraction of exhaled nitric oxide were risk factors predicting persistence of early wheezing through school age. All of them are included in conventional algorithms, for example, Asthma Predictive Index and its modifications, for predicting future asthma.

Asthma and allergic rhinitis in childhood: what's new

Novel approaches are currently offered for the diagnostic workup and therapeutic management of allergic rhinitis and asthma. New predictive biomarkers of allergy and asthma are available. Primary and secondary prevention, earlier intervention, and modification of the natural history of allergic rhinitis and asthma are being intensively investigated. This review highlights advances in the understanding of the etiology, diagnosis, and management of atopic airway diseases in childhood, as well as prenatal and early-life risk factors and strategies for prevention.

Pre-birth cohort study of atopic dermatitis and severe bronchiolitis during infancy

BACKGROUND

Infants hospitalized for bronchiolitis (i.e. severe bronchiolitis) are at increased risk of childhood asthma. There are many known risk factors for severe bronchiolitis, including cardiac and pulmonary diseases. Less is known about the association between atopic diseases and risk of severe bronchiolitis. We sought to further examine risk factors for severe bronchiolitis, focusing on atopic dermatitis (AD).

METHODS

We conducted a nested cohort study within the Massachusetts General Hospital Obstetric Maternal Study (MOMS), a prospective cohort of pregnant women enrolled during 1998-2006. Children of mothers enrolled in MOMS were included in the analysis if they received care within our health system (n = 5407). Potential risk factors for bronchiolitis and hospitalization data were extracted from the children's electronic health records; we also examined pregnancy and perinatal risk factors collected from the underlying MOMS data.

RESULTS

During the first year of life, 125 infants (2.3%) had severe bronchiolitis. Eighteen of these patients had AD; 11 (61%) were diagnosed with AD prior to bronchiolitis hospitalization. In unadjusted analyses, AD was associated with severe bronchiolitis (χ(2) 14.6; p < 0.001). In multivariable analyses adjusting for nine known risk factors for severe bronchiolitis, including demographics, birth season, disposition at birth, cardiac disease, maternal parity, and delivery mode, AD was associated with increased odds of severe bronchiolitis (odds ratio 2.72, 95% confidence interval 1.60-4.63).

CONCLUSIONS

Atopic dermatitis is significantly associated with severe bronchiolitis in infancy. The mechanism of the AD-bronchiolitis association is unclear and merits further study; this research may shed light on the pathogenesis of asthma.

Predicting asthma outcomes

This review addresses predictors of remission or persistence of wheezing and asthma from early childhood through adulthood. Early childhood wheezing is common, but predicting who will remit or have persistent childhood asthma remains difficult. By adding parental history of asthma and selected infant biomarkers to the history of recurrent wheezing, the Asthma Predictive Index and its subsequent modifications provide better predictions of persistence than simply the observation of recurrent wheeze. Sensitization, especially to multiple allergens, increases the likelihood of development of classic childhood asthma. Remission is more likely in male subjects and those with milder disease (less frequent and less severe symptoms), less atopic sensitization, a lesser degree of airway hyperresponsiveness, and no concomitant allergic disease. Conversely, persistence is linked strongly to allergic sensitization, greater frequency and severity of symptoms, abnormal lung function, and a greater degree of airway hyperresponsiveness. A genetic risk score might predict persistence more accurately than family history. Remission of established adult asthma is substantially less common than remission during childhood and adolescence. Loss of lung function can begin early in life and tracks through childhood and adolescence. Despite therapy which controls symptoms and exacerbations, the outcomes of asthma appear largely resistant to pharmacologic therapy.

Clinical phenotype and allergen sensitization in the first 2 years as predictors of atopic disorders at age 5 years

Introduction

From a birth cohort of at-risk Asian infants, we prospectively investigated the role of early onset allergen sensitization and clinical phenotypes as risk factors for atopic disorders at the age of 5 years.

Methods and materials

The study recruited 253 families with a history of allergic disease in a first degree relative from an antenatal clinic in Singapore. The children were followed prospectively to assess clinical outcomes and skin prick test was performed at 2 and 5 years of age.

Results

Allergen sensitization (food and/or house dust mites) alone at 2 years of age was not associated with increased risk of wheeze and eczema at 5 years. However, the clinical phenotype (eczema and wheeze) with or without the presence of concomitant allergen sensitization at 2 years increased this risk. For eczema, eczema alone at year 2 increased the risk of eczema at year 5 (adjOR = 7.1; 95 % CI: 1.8–27.8) and this was further increased by the presence of allergen sensitization (adjOR = 25.4; 95 % CI: 4.7–138.5) and the concomitant presence of both wheeze and allergen sensitization (adjOR = 64.9; 95 % CI: 4.7–900.0). For wheeze, wheeze alone at 2 years (adjOR = 4.5; 95 % CI: 1.4 -14.8), and wheeze with concomitant allergen sensitization and eczema (adjOR = 13.9; 95 % CI: 1.2–168.5) increased the risk of wheeze at 5 years. The exception was rhinitis, where allergen sensitization alone at 2 years (adjOR = 5.6; 95 % CI: 1.1–29.2) increased the risk of rhinitis at 5 years. Early onset of eczema at 2 years also increased the risk of rhinitis (adjOR = 6.8; 95 % CI: 2.0–23.1).

Conclusion

In this Asian birth cohort, the clinical phenotype (eczema and wheeze) with or without concomitant allergen sensitization in the first 2 years of life were strong predictors of atopic disorders at 5 years.

Early risk factors for pubertal asthma

BACKGROUND

Early life risk factors are previously described for childhood asthma, but less is known related to asthma in adolescence. We aimed to investigate early risk factors (before 2 years) for pubertal asthma and secondarily for pubertal asthma phenotypes based upon allergic comorbidities.

METHODS

Based on data from 550 adolescents in the prospective birth cohort 'Environment and Childhood Asthma' study, subjects were categorized by recurrent bronchial obstruction (rBO) 0-2 years, asthma 2-10 years, and pubertal asthma from 10 to 16 years including incident asthma in puberty and asthma in remission from 10 to 16 years or as never rBO/asthma 0-16 years. Asthma in puberty was further classified based on the comorbidities atopic dermatitis and allergic rhinitis (AR) from 10 to 16 years. Twenty-three common asthma risk factors identified by 2 years of age, including frequency and persistence of bronchial obstruction (severity score), were analysed by weighted logistic regression for each phenotype.

RESULTS

In adjusted models, the risk of pubertal asthma increased significantly with higher severity score, parental rhinitis, being the firstborn child, and familial stress around birth. Pubertal asthma in remission was significantly associated with severity score and number of lower respiratory tract infections and inversely associated with breastfeeding beyond 4 months. Pubertal incident asthma was more common among firstborn children. All asthma phenotypes with allergic diseases were significantly associated with severity score, whereas familial perinatal stress increased the risk of asthma only. Asthma combined with AR was associated with parental asthma and being firstborn, whereas the risk of asthma with both atopic dermatitis and AR increased with higher paternal education, atopic dermatitis, being firstborn, and familial perinatal stress.

CONCLUSION AND CLINICAL RELEVANCE

Important early risk factors for pubertal asthma were early airways obstruction, parental rhinitis, being the firstborn child, and perinatal familial stress.

Integrated Allergy and Asthma Prevention and Care: Report of the MeDALL/AIRWAYS ICPs Meeting at the Ministry of Health and Care Services, Oslo, Norway

Allergic diseases and asthma are increasing in prevalence globally. They can start early in life and many persist. It is important to prevent, detect and control these diseases early on and throughout life, so as to promote active and healthy ageing. The translational activities of MeDALL (Mechanisms of the Development of Allergy; EU FP7) are of great importance and include the deployment of successful allergy programmes. The Finnish Allergy Plan is a prototype for the prevention and control of severe allergic diseases. It has been considered for deployment to Norway by the Ministry of Health and Care Services in the frame of AIRWAYS ICPs (Integrated Care Pathways for Airway Diseases), a programme of Action Plan B3 of the EIP on AHA (European Innovation Partnership on Active and Healthy Ageing). Deployment of the Finnish and Norwegian Plans will make use of the scaling-up strategy of the EIP on AHA in regions in the European Union, and the WHO GARD (Global Alliance against Chronic Respiratory Diseases) globally. The regional deployment in Norway serves as a model of a national plan for the use of the EIP on AHA scaling-up strategy in other regions.