Fluticasone improves pulmonary function in children under 2 years old with risk factors for asthma

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Effectiveness and tolerability of dual and triple combination inhaler therapies compared with each other and varying doses of inhaled corticosteroids in adolescents and adults with asthma: a systematic review and network meta-analysis

BACKGROUND

Current guidelines recommend a higher-dose inhaled corticosteroids (ICS) or adding a long-acting muscarinic antagonist (LAMA) when asthma is not controlled with medium-dose (MD) ICS/long-acting beta2-agonist (LABA) combination therapy.

OBJECTIVES

To assess the effectiveness and safety of dual (ICS/LABA) and triple therapies (ICS/LABA/LAMA) compared with each other and with varying doses of ICS in adolescents and adults with uncontrolled asthma.

SEARCH METHODS

We searched multiple databases for pre-registered randomised controlled trials (RCTs) of at least 12 weeks of study duration from 2008 to 18 February 2022.

SELECTION CRITERIA

We searched studies, including adolescents and adults with uncontrolled asthma who had been treated with, or were eligible for, MD-ICS/LABA, comparing dual and triple therapies. We excluded cluster- and cross-over RCTs.

DATA COLLECTION AND ANALYSIS

We conducted a systematic review and network meta-analysis according to the previously published protocol. We used Cochrane's Screen4ME workflow to assess search results and Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess the certainty of evidence. The primary outcome was steroid-requiring asthma exacerbations and asthma-related hospitalisations (moderate to severe and severe exacerbations).

MAIN RESULTS

We included 17,161 patients with uncontrolled asthma from 17 studies (median duration 26 weeks; mean age 49.1 years; male 40%; white 81%; mean forced expiratory volume in 1 second (MEF 1)1.9 litres and 61% predicted). The quality of included studies was generally good except for some outcomes in a few studies due to high attrition rates. Medium-dose (MD) and high-dose (HD) triple therapies reduce steroid-requiring asthma exacerbations (hazard ratio (HR) 0.84 [95% credible interval (CrI) 0.71 to 0.99] and 0.69 [0.58 to 0.82], respectively) (high-certainty evidence), but not asthma-related hospitalisations, compared to MD-ICS/LABA. High-dose triple therapy likely reduces steroid-requiring asthma exacerbations compared to MD triple therapy (HR 0.83 [95% CrI 0.69 to 0.996], [moderate certainty]). Subgroup analyses suggest the reduction in steroid-requiring exacerbations associated with triple therapies may be only for those with a history of asthma exacerbations in the previous year but not for those without. High-dose triple therapy, but not MD triple, results in a reduction in all-cause adverse events (AEs) and likely reduces dropouts due to AEs compared to MD-ICS/LABA (odds ratio (OR) 0.79 [95% CrI 0.69 to 0.90], [high certainty] and 0.50 [95% CrI 0.30 to 0.84], [moderate certainty], respectively). Triple therapy results in little to no difference in all-cause or asthma-related serious adverse events (SAEs) compared to dual therapy (high certainty). The evidence suggests triple therapy results in little or no clinically important difference in symptoms or quality of life compared to dual therapy considering the minimal clinically important differences (MCIDs) and HD-ICS/LABA is unlikely to result in any significant benefit or harm compared to MD-ICS/LABA.

AUTHORS' CONCLUSIONS

Medium-dose and HD triple therapies reduce steroid-requiring asthma exacerbations, but not asthma-related hospitalisations, compared to MD-ICS/LABA especially in those with a history of asthma exacerbations in the previous year. High-dose triple therapy is likely superior to MD triple therapy in reducing steroid-requiring asthma exacerbations. Triple therapy is unlikely to result in clinically meaningful improvement in symptoms or quality of life compared to dual therapy considering the MCIDs. High-dose triple therapy, but not MD triple, results in a reduction in all-cause AEs and likely reduces dropouts due to AEs compared to MD-ICS/LABA. Triple therapy results in little to no difference in all-cause or asthma-related SAEs compared to dual therapy. HD-ICS/LABA is unlikely to result in any significant benefit or harm compared to MD-ICS/LABA, although long-term safety of higher rather than MD- ICS remains to be demonstrated given the median duration of included studies was six months. The above findings may assist deciding on a treatment option when asthma is not controlled with MD-ICS/LABA.

Nebulized step-down budesonide vs. fluticasone in infantile asthma: A retrospective cohort study

The United States Food and Drug Administration has approved budesonide in infantile asthma but nebulization of infants under budesonide has the risk of relapse of asthma. The objective of the present study was to compare the effectiveness and safety of fluticasone step-down treatment with budesonide step-down treatment in infantile asthma. The data of 778 infants with confirmed asthma were included in the analysis. Infants who had received nebulized 500 µg budesonide twice daily for 6 weeks followed by 250 µg budesonide twice daily for 6 weeks were included in the BS group (n=389), while infants who had received nebulized 250 µg fluticasone twice daily for 6 weeks followed by 125 µg fluticasone twice daily for 6 weeks were included in the FC group (n=389). The data of lung function tests and a safety study were collected and analyzed. Budesonide treatment achieved a reduced specific airway resistance (sRaw; 1.28±0.11 vs. 1.21±0.10 kPa/sec; P<0.0001, q=13.45) and improved forced expiratory volume in 1 sec (FEV1; 0.977±0.068 vs. 0.997±0.085 l/sec; P<0.0001, q=5.54). In addition, fluticasone treatment achieved a reduced sRaw (1.27±0.1 vs. 1.23±0.11 kPa/sec, P<0.0001, q=7.39) and improved FEV1 (0.971±0.069 vs. 0.992±0.085 l/sec; P=0.0003, q=5.46). Of note, the efficacy of budesonide to reduce sRaw (P=0.008, q=3.69) and improve FEV1 (P<0.0001, q=6.93) was greater than that of fluticasone. The budesonide treatment group had more post-treatment symptom-free days than the fluticasone treatment group (165.56±23.15 vs. 112.21±9.45 days; P<0.0001). The step-down approach of budesonide nebulization may better support the functional and clinical outcomes with an increased number of post-treatment symptom-free days compared with fluticasone in infantile asthma (level of evidence, 3).

Usefulness of Nonvalved Spacers for Administration of Inhaled Steroids in Young Children with Recurrent Wheezing and Risk Factors for Asthma

Background

In vitro and scintigraphic studies have suggested that effectiveness of metered-dose inhalers (MDI) with nonvalved spacers (NVS) is similar to that of MDI with valved holding chambers (VHC). Nevertheless, there are no clinical studies that compare these techniques in long-term treatment with inhaled steroids in young children with recurrent wheezing and risk factors for asthma.

Objective

To compare the efficacy of a long-term treatment with Fluticasone Propionate administered by an MDI through both type of spacers, with and without valves, in young children with recurrent wheezing and risk factors for asthma.

Patients and Methods

Outpatient children (6 to 20 months old) with recurrent wheezing and risk factors for asthma were randomized to receive a 6-month treatment with metered-dose inhaler (MDI) of Fluticasone Propionate 125 mcg BID through an NVS or through a VHC. Parents recorded daily their child's respiratory symptoms and rescue medication use.

Results

46 patients of 13.4 ± 5 months old were studied. During the study period, the NVS group (n=25) experienced 3.9 ± 2.4 obstructive exacerbations, and the VHC group (n=21) had 2.6 ± 1.6 (p=0.031). The NVS group had 17.4 ± 14% of days with respiratory symptoms, and the VHC group had 9.7 ± 7% (p=0.019). The NVS group spent 29.8 ± 22 days on albuterol while the VHC group spent 17.9 ± 11 days (p=0.022).

Conclusion

Long-term treatment with inhaled steroids administered by MDI and NVS is less effective than such treatment by MDI and VHC in infants with recurrent wheezing and risk factors for asthma.

Changes in the prevalence and severity of recurrent wheezing in infants: The results of two surveys administered 7 years apart

OBJECTIVE

To identify changes in the prevalence and severity of recurrent wheezing (RW) in infants using data obtained from two surveys administered seven years apart.

METHODS

A cross-sectional, international, population-based study in infants aged 12-15 months was conducted. Data were obtained from two surveys (S1 and S2, in 2005 and 2012, respectively) using the same methodology in three large Latin American cities: Curitiba (Brazil), São Paulo (Brazil), and Santiago (Chile).

RESULTS

A decrease in the overall prevalence of RW was identified between S1 (23.3%) and S2 (20.4%), p = 0.004, but it was mainly driven by the reduction observed in São Paulo; in Curitiba and Santiago, this change was not significant. The mean prevalence of the following RW severity indicators remained high and stable: severe wheezing episodes (56.9% in S1 and 54.2% in S2, p = 0.32) and emergency department (ED) visits for wheezing (S1 = 68.1%, S2 70.9%, p = 0.21). A significant increase in admissions for wheezing (21.1% to 26.7%, p = 0.004) was observed. In Curitiba and São Paulo, there were significant increases in the prevalence of physician-diagnosed asthma and in the use of inhaled corticosteroids and oral antileukotrienes.

CONCLUSIONS

The prevalence and severity of RW during the first year of life remained high over time, with remarkably high rates of ED visits, admissions for wheezing and use of asthma medications. This study suggests the need for considering early asthma diagnosis and to establish an appropriate treatment in infants with recurrent and severe asthma-like symptoms.

[Recurrent wheezing: prevalence and associated factors in infants from Buenos Aires City, Argentina]

BACKGROUND

The episodes of bronchial obstruction at early age constitute a frequent problem in Pediatrics. The aim of this study was to evaluate the prevalence of recurrent wheezing in infants in Buenos Aires City, as well as to identify any associated factors.

METHODS

Cross-sectional study performed from 2011 to 2012 in the Children Hospital Ricardo Gutiérrez, Buenos Aires City, as part of the International Study of Wheezing in Infants. A validated questionnaire was applied to parents of infants aged between 12 and 15 months. The prevalence of wheezing, mostly the recurrent episodes (three or more), and their probable associated factors were evaluated. Data were statistically analyzed with χ², Fisher's test, binary and logistics multiple regression analysis. The significance level was 0.05.

RESULTS

Over 1063 infants, 58.9% (confidence interval (CI) 95% 55.9-61.9) presented at least one episode of wheezing and 26.3% (CI95% 23.8-29.9) three or more episodes (recurrent wheezing). Risk factors associated to wheezing were male gender (p=0.001), six or more episodes of cold during the first year of life (p <0.0001), age at first cold <4 months (p <0.0001); pneumonia (p <0.0001) and smoking during pregnancy (tobacco) (p=0.01). For recurrent wheezing, risk factors we considered as six or more episodes of cold during the first year of life (p <0.0001), early (< 4 month of age) onset wheezing (p <0.0001) and nocturnal wheezing (p <0.0001).

CONCLUSIONS

The prevalence of recurrent wheezing among infants in Buenos Aires Ciy was high (26.3%). Some identified associated factors can be preventable.

[Bench-test evaluation of spacer devices for fluticasone delivery to infants]

INTRODUCTION

Use of a spacer device to optimize the delivery of fluticasone to infants with asthma is an important issue and clinicians require guidance around the choice of device. This in vitro study characterizes the particle size and the fluticasone delivery via 9 spacers.

METHODS

We used an in vitro infant nasal cast with two different inspiratory flow rates (50 and 100mL/s). Fluticasone particle size in the aerosol was evaluated by laser diffractometry and tracheal deposition by spectrophotometric assay.

RESULTS

Significant differences in particle size were observed between the 9 spacers (similar D50 but D90 from 5.65±0.65 to 8.80±1.35μm). A 75 % or higher respirable fraction was obtained for only 5 spacers. The 50mL/s flow rate lead to the best drug delivery. At this flow, OptiChamber^® (62±3 %) and Vortex^® (91±8.5 %) had a tracheal deposition over 50 % of the initial dose of fluticasone, although the 7 other spacers exhibited a fluticasone deposition less than 25 %.

DISCUSSION

This study shows a wide variation of drug delivery between the 9 spacers studied. We demonstrate that a low inspiratory flow and a spacer showing antistatic properties facilitate drug delivery.

Intermittent steroid inhalation for the treatment of childhood asthma

Inhaled corticosteroids have long been considered a mainstay of therapy for asthma in children. However, concerns over long-term side effects of chronic steroid administration have led providers to turn to intermittent dosing of these medications in an attempt to treat exacerbations while limiting total corticosteroid received. The data have been somewhat mixed in this area, likely at least partially due to the difficulty providers have in classifying asthma phenotypes in young children. This review will analyze the evidence for chronic daily inhaled corticosteroid use, intermittent inhaled corticosteroid use, and dynamic dosing approaches utilizing inhaled corticosteroid/long-acting beta agonist combination therapy.

Effectiveness of drug treatment strategies to prevent asthma exacerbations and increase symptom-free days in asthmatic children: a network meta-analysis

OBJECTIVE

To determine the effectiveness and safety of current maintenance therapies that include inhaled corticosteroids (ICS), long-acting β-agonists (LABA) and/or leukotriene receptor antagonists (LTRAs) in preventing exacerbations and improving symptoms in pediatric asthma.

METHODS

A systematic review with network meta-analysis was conducted after a comprehensive search for relevant studies in the PubMed, Cochrane Library, Embase and Clinical Trials databases, up to July 2014. Randomized clinical trials were selected comparing treatment strategies of the Global Initiative for Asthma guidelines. The full-text randomized clinical trials compared maintenance treatments for asthma in children (≤18 years) of ≥4 weeks duration, reporting exacerbations or symptom-free days. The primary and secondary effectiveness outcomes were the rates of moderate/severe exacerbations and symptom-free days from baseline, respectively. Withdrawal rates were taken as the safety outcome.

RESULTS

Included in the network meta-analysis was 35 trials, comprising 12,010 patients. For both primary and secondary outcomes, combined ICS and LABA was ranked first in effectiveness (OR 0.70, 95% CI: 0.52-0.97 and OR 1.23, 95% CI: 0.94-1.61, respectively, compared with low-dose ICS), but the result of secondary outcomes was statistically insignificant. Low-dose ICS, medium- or high-dose ICS and combined ICS and LTRA strategies were comparable in effectiveness. ICS monotherapies, and ICS + LABA and ICS + LTRA strategies were similarly safe. High-dose ICS had the highest rate of total withdrawals, but the difference was not significant.

CONCLUSIONS

Combined ICS and LABA treatments were most effective in preventing exacerbations among pediatric asthma patients. Medium- or high-dose ICS, combined ICS and LTRAs, and low-dose ICS treatments seem to be equally effective.

Asthma across the ages: knowledge gaps in childhood asthma

The Eunice Kennedy Shriver National Institute of Child Health and Human Development convened an Asthma Group in response to the Best Pharmaceuticals for Children Act. The overall goal of the Best Pharmaceuticals for Children Act Program is to improve pediatric therapeutics through preclinical and clinical drug trials that lead to drug-labeling changes. Although significant advances have been made in the understanding and management of asthma in adults with appropriately labeled medications, less information is available on the management of asthma in children. Indeed, many medications are inadequately labeled for use in children. In general, the younger the child, the less information there is available to guide clinicians. Because asthma often begins in early childhood, it is incumbent on us to continue to address the primary questions raised in this review and carefully evaluate the medications used to manage asthma in children. Meanwhile, continued efforts should be made in defining effective strategies that reduce the risk of exacerbations. If the areas of defined need are addressed in the coming years, namely prevention of exacerbations and progression of disease, as well as primary intervention, we will see continuing reduction in asthma mortality and morbidity along with improved quality of life for children with asthma.

Assessment of controversial pediatric asthma management options using GRADE

OBJECTIVES

To develop explicit and transparent recommendations on controversial asthma management issues in children and to illustrate the usefulness of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach in rating the quality of evidence and strength of recommendations.

METHODS

Health care questions were formulated for 3 controversies in clinical practice: what is the most effective treatment in asthma not under control with standard-dose inhaled corticosteroids (ICS; step 3), the use of leukotriene receptor antagonist for viral wheeze, and the role of extra fine particle aerosols. GRADE was used to rate the quality of evidence and strength of recommendations after performing systematic literature searches. We provide evidence profiles and considerations about benefit and harm, preferences and values, and resource use, all of which played a role in formulating final recommendations.

RESULTS

By applying GRADE and focusing on outcomes that are important to patients and explicit other considerations, our recommendations differ from those in other international guidelines. We prefer to double the dose of ICS instead of adding a long-acting β-agonist in step 3; ICS instead of leukotriene receptor antagonist are the first choice in preschool wheeze, and extra fine particle ICS formulations are not first-line treatment in children with asthma. Recommendations are weak and based on low-quality evidence for critical outcomes.

CONCLUSIONS

We provide systematically and transparently developed recommendations about controversial asthma management options. Using GRADE for guideline development may change recommendations, enhance guideline implementation, and define remaining research gaps.

A US postmarketing evaluation of the frequency and safety of live attenuated influenza vaccine use in nonrecommended children younger than 5 years: 2009-2010 season

The 2007 US approval for use of Ann Arbor strain live attenuated influenza vaccine (LAIV) in children aged 24 through 59 months included precautions against use in (1) children <24 months and children aged 24 through 59 months with (2) asthma, (3) recurrent wheezing, and (4) altered immunocompetence. Results from the third season (2009-2010) of a 3-year study postmarketing commitment to monitor LAIV vaccination rates and frequency of hospitalizations or emergency department visits within 42 days after LAIV are reported here. As in the first 2 seasons, LAIV usage in cohorts 1, 2, and 4 were low relative to those in LAIV-recommended populations. The only numerically increased risk observed was for respiratory events in children aged <24 months administered LAIV, compared to those administered trivalent inactivated influenza vaccine (TIV). The number of children vaccinated with LAIV was small and precluded precise quantification of rare event.

A pilot trial on the treatment of gastroesophageal reflux-related cough in infants

BACKGROUND

Diagnosing asthma in infancy is largely made on the basis of the symptoms of cough and wheeze. A similar presentation can be seen in neurologically normal infants with excessive gastroesophageal reflux (GER). There are no randomized placebo controlled studies in infants using proton pump inhibitors (PPI) alone or in addition to prokinetic agents.

OBJECTIVES

The primary objective was to confirm the presence of excessive GER in a population of infants that also had respiratory symptoms suggestive of asthma. Second, in a randomized placebo-controlled fashion, we determined whether treatment of GER with bethanacol and omeprazole could improve these respiratory symptoms.

METHODS

Infants (n=22) with a history of chronic cough and wheeze were enrolled, if they had evidence of GER by history and an abnormal pH probe or gastric emptying scan. Infants were randomly allocated to four treatment groups: placebo/placebo (PP), omeprazole plus bethanacol (OB), omeprazole/placebo (OP), bethanacol/placebo (BP). Evaluations by clinic questionnaire and exam, home diary, and pH probe data were done before, after study-medication and after open label of OB.

RESULTS

Nineteen children were studied. PP did not affect GER or respiratory symptoms, and did not decrease GER measured by pH probe. In contrast, OB decreased GER as measured by pH probe indices and parental assessment. In association, OB significantly decreased daytime coughing and improved respiratory scores. No adverse effects were reported.

CONCLUSIONS

In infants with a clinical presentation suggestive of chronic GER-related cough, the use of omeprazole and bethanacol appears to be viable therapeutic option.

Daily or intermittent budesonide in preschool children with recurrent wheezing

BACKGROUND

Daily inhaled glucocorticoids are recommended for young children at risk for asthma exacerbations, as indicated by a positive value on the modified asthma predictive index (API) and an exacerbation in the preceding year, but concern remains about daily adherence and effects on growth. We compared daily therapy with intermittent therapy.

METHODS

We studied 278 children between the ages of 12 and 53 months who had positive values on the modified API, recurrent wheezing episodes, and at least one exacerbation in the previous year but a low degree of impairment. Children were randomly assigned to receive a budesonide inhalation suspension for 1 year as either an intermittent high-dose regimen (1 mg twice daily for 7 days, starting early during a predefined respiratory tract illness) or a daily low-dose regimen (0.5 mg nightly) with corresponding placebos. The primary outcome was the frequency of exacerbations requiring oral glucocorticoid therapy.

RESULTS

The daily regimen of budesonide did not differ significantly from the intermittent regimen with respect to the frequency of exacerbations, with a rate per patient-year for the daily regimen of 0.97 (95% confidence interval [CI], 0.76 to 1.22) versus a rate of 0.95 (95% CI, 0.75 to 1.20) for the intermittent regimen (relative rate in the intermittent-regimen group, 0.99; 95% CI, 0.71 to 1.35; P=0.60). There were also no significant between-group differences in several other measures of asthma severity, including the time to the first exacerbation, or adverse events. The mean exposure to budesonide was 104 mg less with the intermittent regimen than with the daily regimen.

CONCLUSIONS

A daily low-dose regimen of budesonide was not superior to an intermittent high-dose regimen in reducing asthma exacerbations. Daily administration led to greater exposure to the drug at 1 year. (Funded by the National Heart, Lung, and Blood Institute and others; MIST ClinicalTrials.gov number, NCT00675584.).

A postmarketing evaluation of the frequency of use and safety of live attenuated influenza vaccine use in nonrecommended children younger than 5 years

The 2007 US approval for use of live attenuated influenza vaccine (LAIV) in children aged 24-59 months included precautions against use in (1) children <24 months and children aged 24-59 months with (2) asthma, (3) recurrent wheezing, and (4) altered immunocompetence. A postmarketing commitment was initiated to monitor LAIV use and the frequency of select safety outcomes in these cohorts. Vaccination rates and the frequency of hospitalizations or emergency department visits within 42 days after LAIV and trivalent inactivated influenza vaccine (TIV) administration were estimated from 2007 to 2009 claims data from a health insurance database. Rates of LAIV use per 10,000 child-days among cohorts 1, 2, and 4 were low relative to rates among the LAIV-recommended population (2007-2008; 0.03-0.78 vs. 1.32, 2008-2009; 0.08-3.26 vs. 5.94). However, rates of LAIV use per 10,000 child-days in cohort 3 were similar to rates among the LAIV-recommended population (2007-2008; 1.55 vs. 1.32, 2008-2009; 5.01 vs. 5.94). The rate of emergency department visits/hospitalizations within 42 days of vaccination with LAIV was the same as or less than the rate within 42 days of vaccination with TIV. Less restricted LAIV use in children with past wheezing may be related to the broad definition of recurrent wheezing used in national guidelines and the current study. In the small number of nonrecommended children receiving LAIV, no safety signals were identified.

Inhaled Corticosteroids Should Be Used in Infants and Preschoolers with Recurrent Wheezing

The infant or child presenting to the physician's office with persistent or recurrent wheezing during the first 2 years of life poses, often times, a diagnostic dilemma, and a therapeutic challenge. Until very recently, no guidelines were present to help the clinician navigate the very limited treatment options. The diagnosis of asthma in the very young is primarily difficult because of the lack of consistency of what is called asthma, and the failure to recognize the different phenotypes of asthma at different ages. Many classification and phenotypic descriptions have been proposed, but they continue to cause more confusion to already confused parents and perplexed physicians. Although these studies have provided much insight into the natural history of wheezy disorders, they have failed to affect clinical management to a large extent. Controversy persists as to when and why and how long inhaled corticosteroids (ICS) should be used in wheezy infants. Based on the current knowledge in this age group, ICS seems to be indicated in infants with multi-triggers wheeze, and in infants with a positive asthma predictive index. This article reviews the different phenotypic presentations of wheezy infant, the role and indications of ICS in this situation, and, finally, suggests a treatment plan based on the apparent cause of wheezing.

Lung function at 10 yrs is not improved by early corticosteroid treatment in asthmatic children

Early intervention with inhaled corticosteroid (ICS) treatment for lung function development in childhood is debated. In view of lung function at birth, we aimed to assess if early use of ICS influenced lung function at 10 yrs of age. A 10-yr follow-up study of 614/802 children (mean age 10.9 +/- 0.9 yrs) with lung function measurements at birth in the Environment and Childhood Asthma study in Oslo included information on ICS treatment (124 with history of asthma) obtained at 2 and 10 yrs by parental interviews. Main outcomes at 10 yrs were the best values (% predicted and Z-scores) of forced expiratory volume in 1 s (FEV(1)) and mid-expiratory flow. The main explanatory factors were never, past or current use of ICS and Z-scores of the tidal flow-volume ratio t(PTEF)/t(E) [time to peak expiratory flow (t(PTEF)) and total expiratory time (t(E))] at birth. ICS treatment, reported by 11.9% of children in the population sample and 71.6% with current asthma, did not significantly influence lung function from birth to 10 yrs. The best values (and Z-scores) of FEV(1), and mid-expiratory flow were similar (p > 0.1) in subjects receiving ICS during and after 0-3 yrs of age, after 3 yrs only or currently compared with steroid naïve children. Almost half of the change in lung function 0-10 yrs was explained by gender, a history of asthma and t(PTEF)/t(E) at birth. ICS treatment for asthma, reported in every eighth child by age 10 yrs, did not significantly improve lung function from birth to 10 yrs.

Early intervention for infantile and childhood asthma

Asthma is a chronic airway inflammatory disease and it is accepted that early initiation of anti-inflammatory medication is beneficial for adult asthma. Pathological and epidemiological studies suggested that early intervention with anti-inflammatory drugs such as inhaled corticosteroids (ICS) should take place before preschool age, possibly between 1 and 3 years of age. However, the effect of early intervention using ICS in young children is considered controversial as several clinical studies have suggested that ICS does not alter the natural history of asthma in young children. Although there is limited and some negative evidence for the effect of ICS in young children, ICS remains the most effective medication for controlling asthma of the currently available drugs for all ages. Therefore, pediatricians should prescribe ICS to control the active symptoms of asthma, owing to the well-known, beneficial effects of ICS on decreasing the symptom burden of young children with asthma.

Regular vs prn nebulized treatment in wheeze preschool children

BACKGROUND

International guidelines recommend regular treatment with inhaled glucocorticoids for children with frequent wheezing; however, prn inhaled bronchodilator alone or in combination with glucocorticoid is also often used in practice. We aimed to evaluate whether regular nebulized glucocorticoid plus a prn bronchodilator or a prn nebulized bronchodilator/glucocorticoid combination is more effective than prn bronchodilator alone in preschool children with frequent wheeze.

METHODS

Double-blind, double-dummy, randomized, parallel-group trial. After a 2-week run-in period, 276 symptomatic children with frequent wheeze, aged 1-4 years, were randomly assigned to three groups for a 3-month nebulized treatment: (1) 400 microg beclomethasone bid plus 2500 microg salbutamol prn; (2) placebo bid plus 800 microg beclomethasone/1600 microg salbutamol combination prn; (3) placebo bid plus 2500 microg salbutamol prn. The percentage of symptom-free days was the primary outcome measure. Secondary outcomes included symptom scores, use of relief medication and exacerbation frequency.

RESULTS

As compared with prn salbutamol (61.0 +/- 24.83 [SD]), the percentage of symptom-free days was higher with regular beclomethasone (69.6%, SD 20.89; P = 0.034) but not with prn combination (64.9%, SD 24.74). Results were no different in children with or without risk factors for developing persistent asthma. The effect of prn combination was no different from that of regular beclomethasone on the primary and on several important secondary outcomes.

CONCLUSIONS

Regular inhaled glucocorticoid is the most effective treatment for frequent wheezing in preschool children. However, prn bronchodilator/glucocorticoid combination might be an alternative option, but it requires further study.

Effect of inhaled fluticasone on lung function in infants with recurrent wheezing: a randomised controlled trial

BACKGROUND

Inhaled corticosteroids are used to treat infants with troublesome asthma-like symptoms but their effect on the lung function of these young patients is controversial.

MATERIAL AND METHODS

Forty-four infants with recurrent wheezing (more than 3 episodes) and family history of asthma completed this randomised, parallel, double-blind, controlled trial to compare the effect on lung function (main endpoint) of once-daily inhaled fluticasone (375 microg) versus placebo for 3 months. Pulmonary function was measured while infants were asymptomatic, using the raised volume rapid thoracic compression technique (spirometry-like), and values were converted to z-scores.

RESULTS

The fluticasone group showed a significant increase in forced flows, (p < 0.001), a lower number of physician diagnosed wheezing episodes (p < 0.002), and a significant decrease in the parent-reported number of wheezing episodes per month (p < 0.03), as compared to placebo. One third of parents in the placebo group reported a clinical improvement in their infants. There was no significant difference in morning plasma cortisol between groups at entry or discharge.

CONCLUSIONS

We conclude that once-daily treatment with 375 microg fluticasone increased forced flows and controlled symptoms in infants with recurrent wheezing without altering plasma cortisol levels. The spirometry-like technique is a useful tool to objectively assess the efficacy of anti-asthma medications in infants with repeated troublesome asthma-like symptoms.

Prediction and treatment of asthma in preschool children at risk: study design and baseline data of a prospective cohort study in general practice (ARCADE)

Background

Asthma is a difficult diagnosis to establish in preschool children. A few years ago, our group presented a prediction rule for young children at risk for asthma in general practice. Before this prediction rule can safely be used in practice, cross-validation is required. In addition, general practitioners face many therapeutic management decisions in children at risk for asthma. The objectives of the study are: (1) identification of predictors for asthma in preschool children at risk for asthma with the aim of cross-validating an earlier derived prediction rule; (2) compare the effects of different treatment strategies in preschool children.

Design

In this prospective cohort study one to five year old children at risk of developing asthma were selected from general practices. At risk was defined as 'visited the general practitioner with recurrent coughing (≥ 2 visits), wheezing (≥ 1) or shortness of breath (≥ 1) in the previous 12 months'. All children in this prospective cohort study will be followed until the age of six. For our prediction rule, demographic data, data with respect to clinical history and additional tests (specific immunoglobulin E (IgE), fractional exhaled nitric oxide (FENO), peak expiratory flow (PEF)) are collected. History of airway specific medication use, symptom severity and health-related quality of life (QoL) are collected to estimate the effect of different treatment intensities (as expressed in GINA levels) using recently developed statistical techniques. In total, 1,938 children at risk of asthma were selected from general practice and 771 children (40%) were enrolled. At the time of writing, follow-up for all 5-year olds and the majority of the 4-year olds is complete. The total and specific IgE measurements at baseline were carried out by 87% of the children. Response rates to the repeated questionnaires varied from 93% at baseline to 73% after 18 months follow-up; 89% and 87% performed PEF and FENO measurements, respectively.

Discussion

In this study a prediction rule for asthma in young children, to be used in (general) practice, will be cross-validated. Our study will also provide more insight in the effect of treatment of asthma in preschool children.

[Recurrent wheezing in three year-olds: facts and opportunities]

The 3 year-old group of children has an increased incidence and prevalence of recurrent wheezing episodes. There are different subgroups, who give different inflammatory responses to different triggering agents, and subgroups that differ in aetiopathology and immunopathology. Current diagnostic methods (exhaled nitric oxide in multiple breaths, nitric oxide in exhaled air condensate, induced sputum, broncho-alveolar lavage and endo-bronchial biopsy), enable the inflammatory pattern to be identified and to give the most effective and safe treatment. The various therapeutic options for treatment are reviewed, such as inhaled glucocorticoids when the inflammatory phenotype is eosinophilic, and leukotriene receptor antagonists, when the inflammatory phenotype is predominantly neutrophilic. In accordance with the current recommendations, for the diagnosis as well as for the therapy initiated in children of this age, they must be regularly reviewed, so that if the benefit is not clear, the treatment must be stopped and an alternative diagnosis and treatment considered. The start of treatment should be determined depending on the intensity and frequency of the symptoms, with the aim of decreasing morbidity and increasing the quality of life of the patient.

Efficacy of inhaled corticosteroids in infants and preschoolers with recurrent wheezing and asthma: a systematic review with meta-analysis

OBJECTIVE

To compare the efficacy of inhaled corticosteroids in infants and preschoolers with recurrent wheezing or asthma.

METHODS

Randomized, prospective, controlled trials published January 1996 to March 2008 with a minimum of 4 weeks of inhaled corticosteroids versus placebo were retrieved through Medline, Embase, and Central databases. The primary outcome was wheezing/asthma exacerbations; secondary outcomes were withdrawal caused by wheezing/asthma exacerbations, changes in symptoms score, pulmonary function (peak expiratory flow and forced expiratory volume in 1 second), or albuterol use.

RESULTS

Of eighty-nine studies identified, 29 (N = 3592 subjects) met the criteria for inclusion. Patients who received inhaled corticosteroids had significantly less wheezing/asthma exacerbations than those on placebo (18.0% vs 32.1%); posthoc subgroup analysis suggests that this effect was higher in those with a diagnosis of asthma than wheeze but was independent of age (infants versus preschoolers), atopic condition, type of inhaled corticosteroid (budesonide metered-dose inhaler versus fluticasone metered-dose inhaler), mode of delivery (metered-dose inhaler versus nebulizer), and study quality (Jadad score: <4 vs >/=4) and duration (<12 vs >/=12 weeks). In addition, children treated with inhaled corticosteroids had significantly fewer withdrawals caused by wheezing/asthma exacerbations, less albuterol use, and more clinical and functional improvement than those on placebo.

CONCLUSIONS

Infants and preschoolers with recurrent wheezing or asthma had less wheezing/asthma exacerbations and improve their symptoms and lung function during treatment with inhaled corticosteroids.

Management of asthma in preschool children with inhaled corticosteroids and leukotriene receptor antagonists

PURPOSE OF REVIEW

The aim of this article is to review the recently published studies addressing various treatment approaches for asthma in preschool children.

RECENT FINDINGS

The heterogeneity of wheezing in the preschool years complicates the study of asthma in this age group. Once children at highest risk for persistence of wheezing are identified, various management strategies may be thoroughly studied. Several recent studies have confirmed the efficacy and safety of both inhaled corticosteroids and leukotriene receptor antagonists in the management of early childhood asthma. In addition to examining clinical efficacy, studies investigating the effects of these treatment modalities on the underlying airway inflammation have recently increased in number and quality and confirm the anti-inflammatory actions of these therapeutic strategies in the preschool child with asthma.

SUMMARY

Evidence for the preferred treatment strategies for persistent asthma in young children remains incomplete. Based on the current body of evidence, there is rationale for further investigation of these management strategies, including direct comparisons between inhaled corticosteroids and leukotriene receptor antagonists, as well as the role of long-acting beta-agonists, potentially targeting the subpopulations of early childhood with wheezing who are at highest risk for persistence of asthma symptoms.

No evidence that early use of inhaled corticosteroids reduces current asthma at 10 years of age

BACKGROUND

It is debated whether early treatment with inhaled corticosteroids (ICS) can change the natural course of childhood asthma.

AIM

To assess if ICS treatment before 2 years of age in children with obstructive airways disease reduces current asthma at 10 years of age.

METHODS

Children with (n=233) and without (n=219) recurrent (r) bronchial obstruction (BO) attending clinical examination at 2 years of age in the birth cohort Environment and Childhood Asthma study in Oslo, were reinvestigated at 10 years of age. Current asthma (CA) at 10 years was defined as asthma with either symptoms and/or asthma treatment during the last year, and/or 10% fall in forced expired volume in 1s after standardized treadmill run. The risk of CA was assessed by logistic regression and propensity modelling (including gender, parental atopy and severity score at 2 years) in children with rBO who received ICS or not by 2 years.

RESULTS

CA was found in 97 children, more often among rBO children with (56.9%) and without ICS treatment (30.8%) compared to no-BO children (5.5%) (p<0.001). In rBO children logistic regression analyses (adjusted odds ratio aOR (95% confidence interval)) identified male gender (aOR 1.82 (1.01-3.27), p=0.046) and severity score at 2 years 1.14 (1.03-1.28), (p=0.01), as significant and ICS treatment as non-significant 2.00 (0.98-4.12) risk factors for CA. With propensity modelling adjusting for disease severity, ICS treatment by 2 years caused a non-significant increased risk aOR of CA of 1.84 (0.89-3.82).

CONCLUSION

No evidence was found that early use of ICS before age two in children with rBO reduces current asthma 8 years later.

Increased diagnosis of asthma in hospitalized infants: the next target population for care management?

Hospitalization of children with asthma declined at our institution between 1996 and 2000, before stabilizing for the past 5 years. The ages of children hospitalized since 2000 were examined to see if the demographics of the hospitalized population have changed to better understand why the hospitalization rate has remained the same despite continued, aggressive screening and education efforts. Data were gathered for our hospital through the Department of Defense Medical Health System Management Analysis and Reporting System (M2). The mean age (+/- SD) of children hospitalized in 2003 (2.84 +/- 2.53) was less than the mean age for 2000 and 2002 (4.85 +/- 3.7 and 4.61 +/- 4.45), respectively (p < 0.05), and more infants less than 2 years of age were hospitalized in 2003 (33/60, 55% p < 0.01) and 2004 (32/68, 47% p < 0.05) than in 2000 (19/70, 27%). The diagnosis of asthma in hospitalized infants and young children has increased over the past 5 years, suggesting better recognition and providing a new target population for intervention with early asthma controller therapy.

Anti-inflammatory pharmacotherapy for wheezing in preschool children

Accumulating evidence indicates that there are at least two phenotypes of wheezing in preschool years with distinct natural history. Frequent wheezing in the first 3 years of life with risk factors for asthma (e.g., eczema, maternal asthma) predicts symptoms in older age, while infrequent viral-associated wheezing without risk factors for asthma has a benign prognosis. This systematic review summarizes evidence on the use of anti-inflammatory medications in preschool children with wheezing. Literature search was performed using Medline and the Cochrane Library. Retrieved articles were critically appraised. Episodic use of high-dose inhaled corticosteroids (>1,600 mcg/day of beclomethasone) may ameliorate severity of intermittent viral-associated wheezing. Maintenance inhaled corticosteroids can control symptoms in children with frequent wheezing associated with risk factors for asthma. Inhaled corticosteroids do not alter the natural history of wheezing even when started early in life and could have a negative impact on linear growth rate. Short courses of oral corticosteroids have been proposed as an effective measure to control exacerbations of symptoms although there is little evidence supporting their use. Some studies support the administration of non-steroidal anti-inflammatory medications (leukotriene pathway modifiers, cromones, methylxanthines) for mild frequent wheezing. Maintenance inhaled corticosteroids is the most effective measure for controlling frequent wheezing in preschool children, especially when accompanied by risk factors for asthma. This treatment does not affect the natural history of wheezing, although deceleration of linear growth rate is the most commonly recognized systemic adverse effect.

[Fluticasone propionate in children and infants with asthma]

The known efficacy of fluticasone propionate in adults, comparable at half-dosage of corticosteroids has been validated by the market authorization (MA) and by the national and international guidelines for beclomethasone. This could be partly explained by its pharmacological properties, affinity for glucocorticosteroid receptors, lung deposition and lipophilicity. The limited systemic adverse events is due to its low bioavailability, optimal hepatic clearance, high plasma protein binding. The efficacy in asthmatic children has been confirmed in clinical studies showing a "plateau" efficacy between 100 and 200 microg/d for the majority of children. Most children are controlled by such dosages: the added value of increasing posology on asthma control exists but is small. A high off-label posology does not allow more quickly asthma control and therefore is not justified. A twice daily dosing is more efficient, particularly for initiation of maintenance therapy, than a once daily dosing. A literature survey confirms that, at MA recommended daily doses in children (100-200 microg), fluticasone propionate has no clinically significant effect either on hypothalamic-pituitary-adrenal (HPA) axis (basal function or stimulation tests), bone or growth velocity. However, high daily doses (higher to 500 microg/day) for long periods expose to systemic adverse effects with measurable consequences on growth rate, bone density (decreasing biochemical makers of bone formation) and HPA function. Several cases of adrenal insufficiency that may have led to acute adrenal crisis have been reported in 4- to 10-year-old children receiving fluticasone propionate in doses between 500 to 2000 microg daily. In case of surgery or infection, a preventive treatment of adrenal insufficiency with hydrocortisone should be proposed for children treated for more than 6 months with such high daily doses. Such children need definitely an advice from paediatricians specialized in chest diseases as well as in endocrinology. It is important to recall that the clinical benefit of daily doses of inhaled corticosteroids higher than recommended is low and that the good use of inhaled corticosteroids particularly in children lays on the careful search of the minimal efficient daily doses.

Inhaled corticosteroids for recurrent respiratory symptoms in preschool children in general practice: randomized controlled trial

BACKGROUND

Therapy with inhaled corticosteroids (ICS) is beneficial in patients with asthma. However, in preschool children with symptoms like cough, wheeze, or shortness of breath diagnosing asthma is difficult. Therefore, the role of ICS in the management of preschool children with recurrent respiratory symptoms is unclear. We assessed the effectiveness of ICS in preschool children with recurrent respiratory symptoms in general practice.

METHODS

In this multicenter, randomized, double blind, placebo controlled trial, 96 children aged 1-5 years consulting their general practitioners for recurrent respiratory symptoms and in whom treatment with ICS was considered by the general practitioner were randomly allocated to receive ICS (fluticasone propionate 200 mcg/day by metered dose inhaler/spacer combination) or placebo for 6 months. Outcome assessments were carried out 1, 3, and 6 months after randomization. The primary outcome measure was the symptom score (cough, shortness of breath and wheeze during day and night) as measured by a symptom diary card. Secondary endpoints were symptom-free days, use of rescue medication, adverse events, and lung function variables as measured by the interrupter technique and forced oscillation technique.

RESULTS

During the 6 months treatment period, symptoms improved in both groups, with no differences between ICS and placebo. In addition, none of the secondary outcome parameters showed differences between both treatment groups.

CONCLUSION

ICS treatment has no beneficial effect in preschool children with recurrent respiratory symptoms in general practice. We therefore recommend a watchful waiting policy with only symptomatic treatment in these children. General practitioners and pediatricians should be aware of the high probability of overtreatment when prescribing ICS in these children.

Lung bioavailability of hydrofluoroalkane fluticasone in young children when delivered by an antistatic chamber/mask

OBJECTIVE

To determine whether an antistatic valved holding chamber/mask improves lung bioavailability of hydrofluoroalkane (HFA) fluticasone in young children.

STUDY DESIGN

Twelve patients, age 1 to 6 years, with well-controlled asthma were treated with an HFA fluticasone metered-dose inhaler (Flovent HFA) twice daily (440 microg/day). The drug was delivered by tidal breathing through conventional (AeroChamber Plus) and antistatic (AeroChamber MAX) valved holding chambers (VHCs) with masks in a randomized, crossover manner, each for 3 to 7 days. When adherence was 100% at home, blood was collected for measurement of steady-state fluticasone plasma concentration (FPC) 1 hour after the last dose was administered in the clinic. FPC indicates systemic exposure directly and airway delivery indirectly. It was measured by liquid chromatography-mass spectrometry. Data were analyzed by regression analysis.

RESULTS

The mean +/- SD FPC was 107 +/- 30 pg/mL after conventional VHC and 186 +/- 134 pg/mL after the antistatic VHC (P = .03). In 5 patients (40%), the antistatic VHC increased FPC by >/= 100%, to potentially excessive levels in 4 of them; it had little effect in 7 patients.

CONCLUSIONS

HFA fluticasone was delivered to the airways by both devices even though the patients could not inhale deeply and breath hold. The antistatic VHC variably increased lung bioavailability. To reduce systemic exposure, the dose should be weaned to the minimum required to maintain asthma control.

Secondary prevention of asthma by the use of Inhaled Fluticasone propionate in Wheezy INfants (IFWIN): double-blind, randomised, controlled study

BACKGROUND

Wheezing and asthma often begins in early childhood, but it is difficult to predict whether or not a wheezy infant will develop asthma. Some researchers suggest that treatment with inhaled corticosteroids at the first signs of wheezing in childhood could prevent the development of asthma later in life. However, other investigators have reported that although such treatment could help control symptoms, the benefits can disappear within months of stopping treatment. We tested our hypothesis that to prevent loss of lung function and worsening asthma later in childhood, anti-inflammatory treatment needs to be started early in life.

METHODS

We did a randomised, double-blind, controlled study of inhaled fluticasone propionate 100 mug twice daily in young children who were followed prospectively and randomised after either one prolonged (>1 month) or two medically confirmed wheezy episodes. The dose of study drug was reduced every 3 months to the minimum needed. If the symptoms were not under control by 3 months, open-label fluticasone propionate 100 mug twice daily was added to the treatment. Children were followed-up to 5 years of age, at which point we gave their parents or guardians questionnaires, and measured the children's lung function (specific airways resistance [sR(aw)], forced expiratory volume in 1s [FEV1]) and airway reactivity (eucapnic voluntary hyperventilation [EVH] challenge). This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN86717853.

FINDINGS

We followed 1073 children prospectively, of whom 333 were eligible, and 200 of these began treatment (130 male, median age 1.2 years [range 0.5-4.9]; 101 placebo, 99 treatment); 173 (85 treatment, 88 placebo) completed the follow-up at age five years. The groups did not differ significantly in the proportion of children with current wheeze, physician-diagnosed asthma or use of asthma medication, lung function, or airway reactivity (percentage change in FEV1, adjusted mean for placebo 5.5% [95% CI -2.5 to 13.4]) vs for treatment 5.0% [-2.2 to 12.2], p=0.87). There were no differences in the results after adjustment for open-label fluticasone propionate, nor between the two groups in the time before the open-label drug was added (estimated hazard ratio 1.12 [95% CI 0.73-1.73], p=0.60), or the proportion needing the open-label drug (43 [42.57%] placebo, 41 [41.41%] treatment).

INTERPRETATION

The early use of inhaled fluticasone propionate for wheezing in preschool children had no effect on the natural history of asthma or wheeze later in childhood, and did not prevent lung function decline or reduce airway reactivity.

Treatment with inhaled corticosteroids improves pulmonary function in children under 2 years old with risk factors for asthma

PURPOSE OF REVIEW

To report on recent studies on the effect of inhaled corticosteroids on pulmonary function in young children with asthma.

RECENT FINDINGS

Inhaled corticosteroids are considered the most effective treatment for persistent asthma in children. Appropriate control of childhood asthma may prevent more serious disease or irreversible obstruction in later years. While some authors have described an improvement with the use of inhaled corticosteroids in young children, others found no clinical or functional benefit. Various studies have shown that inhaled corticosteroids ameliorate clinical outcomes, and recently a study demonstrated improvement in pulmonary function in young children with asthma. The use of different study designs may explain the lack of consistent results and disagreement regarding the efficacy of inhaled corticosteroids in these patients.

SUMMARY

Based on the preponderance of evidence, treatment with inhaled corticosteroids in infants and young children with recurrent wheeze and risk factors of developing asthma appears to allow better control of the illness and improve the pulmonary function.

Asthma therapy for children under 5 years of age

PURPOSE OF REVIEW

The evidence for effectiveness of currently used asthma medication for wheeze in young children is reviewed.

RECENT FINDINGS

The management of the infant and preschool child with wheezing is complicated by the uncertainty with respect to the aetiology. Difficulties in defining phenotypes and objective outcome parameters combined with the transient nature of symptoms which often resolve spontaneously have confounded many therapeutic studies. Recent studies on the effect of pharmacotherapy in wheezing infants have tried to define a more homogeneous phenotype as well as make a selection of patients that are likely to respond to the studied drug. In addition, these studies have used lung function parameters and nitric oxide as one of the outcome measurements. Studies on the nature of inflammation and the development of airway remodelling in infants and young children are done to further define phenotypes.

SUMMARY

Currently, there are no evidence-based guidelines and not even consensus statements on the right approach in pharmacological treatment of wheezing in infants and preschool children. The main issue still is the difficulty in coming to a correct diagnosis. Further studies are needed on the nature and the diagnostics of phenotypes and on the effect of early intervention.

Current asthma guidelines may not identify young children who have experienced significant morbidity

BACKGROUND

The current guideline for classifying asthma severity, the National Asthma Education Prevention Program (NAEPP) 2002, is not evidence-based. We had the opportunity to validate this guideline in an untreated inner-city population, both in those < or =5 and those >5 years of age. The basis for this retrospective validation model was to determine how well the NAEPP severity classification based on symptom-frequency criteria alone identified patients in those age groups demonstrating significant morbidity the previous year and thus the potential need for controller therapy.

METHODS

Using a mobile asthma van (Breathmobile) at the school site, children not receiving controller medication were evaluated by an asthma specialist for severity according to NAEPP guideline clinical criteria. Validation was determined by the relationship of guideline severity to > or =2 emergency department (ED) visits, any hospitalization, health care utilization (any ED visit, hospitalization), number of exacerbations, and school absenteeism resulting from asthma the prior year.

RESULTS

Eight hundred twenty-six asthmatic children were evaluated; 89 (10.8%) were < or =2 years, 222 (26.9%) were 3 to 5 years, and 515 (62.3%) were >5 years of age; 60.5% were male, and 80.9% were Hispanic. Classification of asthma severity included 34.4% with mild intermittent, 10.2% with mild persistent, 31.5% with moderate persistent, and 24.0% with severe persistent asthma categories. There were significantly more Hispanic children and children < or =5 years classified as having mild intermittant asthma. Morbidity was clearly related to severity in the overall population. However, although the health care utilization was significantly related to severity, it was borderline in those 3 to 5 years and nonsignificant in children < or =2 years.

CONCLUSIONS

The NAEPP guidelines 2002, based on symptom-frequency criteria as assessed in this study, seem to offer a valid basis for classifying asthma severity in those >5 years of age but may underclassify younger children. Our data suggest that morbidity experienced in the prior year may provide a useful additional criterion for classifying asthma severity, particularly in those children < or =5 years of age.

Childhood asthma: breakthroughs and challenges

As we move forward, our goal is to control and eliminate asthma and other allergic disorders. This may come through broadly applied manipulation of environmental, dietary, and infectious risk factors, possibly during the perinatal period. Or we may learn to identify genetically susceptible children and to intervene with individualized genotype-specific treatment before the onset of disease. Maybe we'll learn how to block the mechanisms that give rise to chronic inflammation, or how to subdue Th2 activation. However, as the Swedish proverb says--Don't throw away the old bucket until you know whether the new one holds water. To continue using the old bucket, we have to fix the leaks. One approach to reducing asthma disparities is through traditional disease prevention stages. Primary prevention targets asthma incidence; secondary prevention mitigates established disease and involves disease detection, management, and control; and tertiary prevention is the reduction of complications caused by severe disease. Once causative factors at each level of disease prevention are understood, this knowledge can be translated into clinical practice and public health policy. We need reliable diagnostic criteria to provide correct treatment for infants and toddlers. This will require longitudinal cohort studies supported by assessment of pulmonary function and inflammatory markers. We must find ways to convince more physicians to embrace controller therapy for more severe disease, and to identify the patients with less severe disease who also require ongoing controller therapy. We need to close the gap between what we know and what we do in practice. We need to link basic research to healthcare delivery, and to gain acceptance and support from the intended recipients of new interventions. We need better strategies for improving adherence. We need accountability, foresight, and imagination.

Evaluation of the safety and efficacy of levalbuterol in 2-5-year-old patients with asthma

The purpose of this study was to evaluate the safety and efficacy of single-isomer (R)-albuterol (levalbuterol, LEV) in children aged 2-5 years. Children aged 2-5 years (n = 211) participated in this multicenter, randomized, double-blind study of 21 days of t.i.d. LEV (0.31 mg or 0.63 mg without regard to weight), racemic albuterol (RAC, 1.25 mg for children <33 pounds (lb); 2.5 mg for children >/=33 lb), or placebo (PBO). Endpoints included adverse-event (AE) reporting, safety parameters, peak expiratory flow (PEF), the Pediatric Asthma Questionnaire(c) (PAQ), and the Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ). Baseline disease severity was generally mild in all groups, as defined by PAQ scores that ranged from 6.3-7.3 on a scale of 0-27 and 1.5 days/week of uncontrolled asthma. After treatment, the PAQ decreased in all groups (P = NS). In the subset of subjects able to perform PEF (51.7%), all active treatments improved in-clinic PEF after the first dose (mean +/- SD: PBO, 1.4 +/- 20.8; LEV 0.31 mg, 12.4 +/- 12; LEV 0.63 mg, 16.7 +/- 15.4; RAC, 18.0 +/- 16.5 l/min; P < 0.01). PACQLQ measurements improved more than the minimally important difference only in the LEV-treated groups, and were significant in children <33 lb (P < 0.05). Asthma exacerbations occurred primarily in children >/=33 lb, and one serious asthma exacerbation occurred in the 2.5-mg RAC group. RAC and LEV 0.63 mg, but not LEV 0.31 mg or placebo, led to significant increases in ventricular heart rate. In this study of levalbuterol in children aged 2-5 years with asthma, LEV was generally well-tolerated, and in children able to perform PEF, led to significant bronchodilation compared with placebo.