Lower respiratory tract symptoms in Queensland schoolchildren: risk factors for wheeze, cough and diminished ventilatory function

Recent advances in pediatric asthma treatment

Although wheezing illness is at its most prevalent in infancy and early childhood, its self-limiting nature in the majority poses considerable challenges in offering a long-term prognosis and in initiating long-term prophylaxis. Many of the established treatments in adults have not been adequately assessed in children. Evidence is also emerging for a number of different wheezing syndromes, several of which do not to respond well to currently available medicines. Much research interest is being directed to underlying changes within the airway that appear to be independent of allergic mechanisms and that may lead to novel therapeutic approaches. The aim of this review is to restate and update current best-practice based on evidence, to encourage effective and safe use of asthma medication in children and to point to areas of ongoing research that are likely to influence management decisions in the near future.

[Parental smoking and lung function in healthy children and adolescents]

OBJECTIVE

The debate continues on the effect of passive smoking on nonsmokers. The effect of parental smoking on the lung function of children varies considerably according to geographic area, source of passive smoking, and sex. The objective of this study was to evaluate the effect of parental smoking on the lung function of children.

POPULATION AND METHODS

A cross-sectional study was performed on a sample of the population of healthy children and adolescents between 6 and 18 years of age in Galicia. Subjects were selected by means of 2-stage cluster sampling grouped by sex and age.

RESULTS

Approximately 56% of the children were exposed to the tobacco smoke of one of their parents. Children whose fathers were smokers presented a 40% higher risk of reduced forced expiratory flow at 75% of forced vital capacity (FEF75%) and a 30% higher risk of reduced FEF25%-75%. Children whose mothers were smokers presented a 30% higher risk of reduced forced expiratory volume in the first second and a 40% higher risk of reduced FEF50%. There was a 60% increase in risk of reduced FEF75%. The fact that both parents smoked did not appear to increase the risk of reduced lung function.

CONCLUSIONS

Parental smoking has a considerable effect on the lung function of children and adolescents. Smoking by either the mother or the father has a decisive influence. The fact that this effect is independent of the growth of the child and that the obstructive effect is located principally in the distal airways appears to confirm the hypothesis that this effect is produced after birth.

Association of beta2-adrenoreceptor polymorphisms with nocturnal cough among atopic subjects but not with atopy and nonspecific bronchial hyperresponsiveness

BACKGROUND

The reports from in vitro studies that beta(2)-adre-nergic receptor (B2AR) polymorphisms are associated with agonist-promoted downregulation have evoked considerable research interest for the roles of these polymorphisms to the pathogenesis of asthma.

OBJECTIVE

We sought to evaluate the association between asthma phenotypes and B2AR polymorphisms at 2 sites (Arg16 --> Gly16 and Gln27 --> Glu27) in the general population.

METHODS

Four hundred forty unrelated Korean adults were randomly selected, and asthma phenotypes were determined with a questionnaire, immunoassay, skin prick testing, and methacholine bronchial provocation testing. Genotypes of B2AR polymorphisms were determined with PCR-based methods.

RESULTS

No significant association was found between B2AR alleles and haplotypes and total IgE levels, skin test responses to aeroallergens, and bronchial responsiveness to methacholine. Among the atopic subjects, however, numbers of both Arg16 alleles and Arg16-Gln27 haplotypes were negatively associated with nocturnal cough, and in contrast, Gly16-Gln27 was positively associated with it.

CONCLUSION

B2AR polymorphisms may play an important role in the expression of nocturnal cough in atopic subjects but not in the expression of atopy and bronchial hyperresponsiveness in a general population.

Exposure-response relationship between paternal smoking and children's pulmonary function

We conducted a cross-sectional study to investigate paternal smoking and children's pulmonary function in rural communities of Anqing, China. Our analysis included 1,718 children 8 to 15 yr of age whose mothers were never-smokers. Multiple linear regression models were used to estimate the effect of paternal smoking on children's pulmonary function, with adjustment for children's age, sex, weight, height, square of height, asthma, and father's education. When compared with children of never-smoking fathers, children of smoking fathers had small, but detectable deficits in FEV(1) (-36 ml, SE = 20) and FVC (-37 ml, SE = 22). When children of smoking fathers were subdivided into two subgroups, father smoked < 30 cigarettes/day and >/= 30 cigarettes/day, we found that children whose fathers smoked >/= 30 cigarettes/day had the largest deficits in both FEV(1) (-79 ml, SE = 30) and FVC (-71 ml, SE = 34). This monotonic exposure-response relationship remained in all strata when we further stratified our analysis by children's sex and asthma status. Our data also suggested that the relationship was greatest among nonasthmatic girls, although neither sex nor asthma interaction terms were statistically significant. We conclude that there is a monotonic exposure-response relationship between paternal smoking and decline of pulmonary function in children in this rural Chinese population.

Measuring persistent cough in children in epidemiological studies: development of a questionnaire and assessment of prevalence in two countries

STUDY OBJECTIVE

Cough is a common symptom in children that is frequently encountered in general practice. However, most of the information on the prevalence of persistent cough has come from studies that use different, often ambiguous, definitions for persistent cough. It is therefore important that a validated questionnaire to accurately measure persistent cough is developed and is appropriate for use in different age groups of children and in different cultures. Such a questionnaire is essential for accurately measuring the prevalence of persistent cough and the factors associated with its occurrence.

DESIGN

A parent-administered respiratory questionnaire was developed and administered twice during a 3-week interval pilot study to test repeatability. The questionnaire was then administered to a randomly selected cross-section of Australian children aged 5 to 7 years old and 8 to 11 years old (N = 511 and N = 654, respectively), and to 566 Nigerian children aged 8 to 11 years old.

RESULTS

The new questionnaire was reliable, with most of the questions having a kappa value of above 0.6. The prevalence of persistent cough was similar in younger and older Australian children, but significantly less in Nigerian children (p < 0.001). Also, persistent cough was more prevalent in children of high rather than low socioeconomic status among older Australian children (p = 0.04).

CONCLUSIONS

The newly developed questionnaire will be an important tool in epidemiological studies for measuring the prevalence, morbidity, and risk factors of persistent cough in childhood. Although our findings showed that persistent cough does not occur more frequently in younger than in older Australian children, it is more frequent in Australian than in Nigerian children.

Health effects of passive smoking. 9. Parental smoking and spirometric indices in children

BACKGROUND

A systematic quantitative review was conducted of the evidence relating parental smoking to spirometric indices in children.

METHODS

An electronic search of the Embase and Medline databases was completed in April 1997 and identified 692 articles from which we included four studies in neonates, 42 cross-sectional studies in school aged children (22 were included in a meta-analysis), and six longitudinal studies of lung function development.

RESULTS

In a pooled analyses of 21 surveys of school aged children the percentage reduction in forced expiratory volume in one second (FEV1) in children exposed to parental smoking compared with those not exposed was 1.4% (95% CI 1.0 to 1.9). Effects were greater on mid expiratory flow rates (5.0% reduction, 95% CI 3.3 to 6.6) and end expiratory flow rates (4.3% reduction, 95% CI 3.1 to 5.5). Adjustment for potential confounding variables had little effect on the estimates. A number of studies reported clear evidence of exposure response. Where exposure was explicitly identified it was usually maternal smoking. Two studies in neonates have reported effects of prenatal exposure to maternal smoking. Of five cross sectional studies that compared effects of perinatal exposure (retrospectively assessed) with current exposure to maternal smoking in later childhood, the three largest concluded that the major effect was in utero or neonatal exposure. Longitudinal studies suggest a small effect of current exposure on growth in lung function, but with some heterogeneity between studies.

CONCLUSIONS

Maternal smoking is associated with small but statistically significant deficits in FEV1 and other spirometric indices in school aged children. This is almost certainly a causal relationship. Much of the effect may be due to maternal smoking during pregnancy.

Health effects of passive smoking. 3. Parental smoking and prevalence of respiratory symptoms and asthma in school age children

BACKGROUND

A systematic quantitative review of the evidence relating parental smoking to the prevalence of asthma and respiratory symptoms was conducted amongst school age children.

METHODS

Sixty relevant studies were identified after consideration of 1593 articles selected by electronic search of the Embase and Medline databases using keywords relevant to passive smoking in children. The search was completed in April 1997 and identified 25 studies of asthma, 41 of wheeze, 34 of chronic cough, seven of chronic phlegm and six of breathlessness which were included in a quantitative overview.

RESULTS

The pooled odds ratios for either parent smoking were 1.21 (95% CI 1.10 to 1.34) for asthma, 1.24 (95% CI 1.17 to 1.31) for wheeze, 1.40 (95% CI 1.27 to 1.53) for cough, 1.35 (95% CI 1.13 to 1.62) for phlegm, and 1.31 (95% CI 1.08 to 1.59) for breathlessness. Adjustment for confounding had little effect. Evidence of heterogeneity between studies appeared largely explicable by publication bias with a superfluity of small studies with large odds ratios. However, excluding these had little effect on the pooled odds ratios. The prevalence of all symptoms increased with the number of parents who smoked. While maternal smoking had a greater effect than paternal smoking, the effect of father only was clearly significant.

CONCLUSIONS

The relationship between parental smoking and respiratory symptoms seems very likely to be causal given statistical significance, robustness to adjustment for confounding factors, consistency of the findings in different countries, and evidence of dose response. The raised risk in households where the father, but not the mother, smoked argues for a postnatal effect.

Outcome of children of parents with atopic asthma and transient childhood wheezy bronchitis

BACKGROUND

Childhood asthma and wheeze only in the presence of respiratory infection (wheezy bronchitis) appear to have different prognoses and may differ in their aetiology and heritability. In particular, slight reductions in lung function may be associated with episodes of wheezing associated with intercurrent viral infection.

METHODS

Outcomes for wheezing symptoms and lung function were studied in 133 offspring of three distinct groups of 69 middle aged probands with childhood histories of (1) atopic asthma (n = 18), (2) wheeze associated with upper respiratory tract infection (wheezy bronchitis, n = 24), and (3) no symptoms (n = 27). Probands were selected from a previously studied cohort in which outcomes of wheezy bronchitis and asthma had been shown to differ.

RESULTS

Children of probands with wheezy bronchitis had a lower prevalence of current wheezing symptoms. Forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) in boys of probands with a history of wheezy bronchitis were significantly reduced compared with either of the other two groups (p < 0.0001). In a multivariate analysis, grouping based on parent proband had a significant effect on lung function, independent of factors such as symptoms, atopy or smoking history.

CONCLUSIONS

The different symptomatic and lung function outcome in children of probands with wheezy bronchitis and asthma provides further evidence that wheezy bronchitis and asthma differ in their natural history and heritability, and suggests that there may be familial factors specific to each wheezing syndrome.

Nasal mask continuous positive airway pressure in the treatment of chronic nocturnal cough in a young child

The objective of this case report was to define the effects of nasal mask continuous positive airway pressure (CPAP) on the respiratory and sleep characteristics of a 3 year-old boy with a 2 year history of snoring and 1 year history of chronic nocturnal cough. The method employed was all-night polysomnography before and during treatment with CPAP after the identification of partial upper airway obstruction in association with cough. The results indicated that the child had evidence of mild upper airways obstruction on initial all-night sleep study. Nasal mask CPAP was instituted. On a subsequent sleep study 4 weeks later, this was documented to prevent the upper airway obstruction at a pressure of 5.2 cm of water. In addition, nasal mask CPAP markedly reduced the nocturnal coughing, the total number of coughs decreasing from 92 to one. The rate of cough per h of study (cough disturbance index) decreased from 9.8-0.1. Sleep efficiency (total sleep time as a percentage of study duration) improved on CPAP from 87 to 99%. This study suggests that chronic nocturnal cough can result from upper airway obstruction in sleep in children and is an important initial observation.