Early childhood growth is associated with lung function at 7 years: a prospective population-based study

Approaches to reduce the risk of severe asthma in children with preschool wheeze

INTRODUCTION

Asthma is a common, serious condition. We can treat the symptoms of mild-moderate disease, but severe asthma is life-threatening despite treatment. We cannot cure asthma and have no specific preventive strategies.

AREAS COVERED

We performed a PubMed search using the terms 'Severe asthma' and 'Prevention' and 'Preschool wheeze' limited to children, humans and English language over the previous five years. We searched the bibliographies of relevant references and also our personal archives. We cover transgenerational, antenatal and early life factors which increase the risk of pre-school wheeze; the factors promoting or protecting the pre-school wheezer from developing school age asthma; and the factors leading to one of the three types of severe asthma defined by WHO (untreated, difficult to treat, and treatment resistant).

EXPERT OPINION

Currently we have no pharmacological preventive strategies. Risk can be reduced by public health measures such as reduction in smoking and environmental pollution, and there are tantalizing hints from comparison of farming to other environments that exploring how environmental modulation may lead to more specific, personalized strategies. The effects of the new RSV prevention strategies are awaited. We need a better understanding of the pathways driving disease progression, and biomarkers of risk.

Body mass index trajectories from birth to early adulthood and lung function development

BACKGROUND

Few studies have investigated the influence of body mass index (BMI) trajectories on lung function covering the entire growth period.

METHODS

We conducted a prospective study using data from the Swedish BAMSE birth cohort. Latent class mixture modelling was employed to examine the diversity in BMI z-scores from birth to 24 years of age. Participants with four or more BMI z-scores were included (n=3204, 78.4%). Pre-bronchodilator spirometry was tested at 8, 16 and 24 years, while post-bronchodilator spirometry, multiple-breath nitrogen washout (for lung clearance index) and urinary metabolomics data were assessed at 24 years.

RESULTS

Six distinct BMI development groups were identified. Compared to the stable normal BMI group, the accelerated increasing BMI group exhibited reduced pre- and post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio z-scores (pre: β= -0.26, 95% CI -0.44- -0.08; post: β= -0.22, 95% CI -0.39- -0.05), along with elevated lung clearance index (0.30, 95% CI 0.22-0.42) at 24 years. The persistent high BMI group demonstrated lower FEV1 (-0.24, 95% CI -0.42- -0.05) and FVC (-0.27, 95% CI -0.45- -0.01) z-score growth between 16 and 24 years, and elevated lung clearance index (0.20, 95% CI 0.03-0.39) at 24 years. However, those impairments were not observed in the accelerated resolving BMI group. Conversely, the persistent low BMI group displayed persistently decreased FEV1 and FVC from 8 to 24 years, as well as decreased lung function growth. Additionally, histidine-related metabolites were associated with pre- and post-bronchodilator FEV1 (hypergeometric false discovery rate=0.008 and <0.001, respectively).

CONCLUSIONS

Early interventions aiming for normal BMI during childhood may contribute to improved lung health later in life.

Prenatal Origins of Obstructive Airway Disease: Starting on the Wrong Trajectory?

From the results of well-performed population health studies, we now have excellent data demonstrating that deficits in adult lung function may be present early in life, possibly as a result of developmental disorders, incurring a lifelong risk of obstructive airway diseases such as asthma and chronic obstructive pulmonary disease. Suboptimal fetal development results in intrauterine growth restriction and low birth weight at term (an outcome distinct from preterm complications), which are associated with subsequent obstructive disease. Numerous prenatal exposures and disorders compromise fetal development and these are summarized herein. Various physiological, structural, and mechanical abnormalities may result from prenatal disruption, including changes to airway smooth muscle structure-function, goblet cell biology, airway stiffness, geometry of the bronchial tree, lung parenchymal structure and mechanics, respiratory skeletal muscle contraction, and pulmonary inflammation. The literature therefore supports the need for early life intervention to prevent or correct growth defects, which may include simple nutritional or antioxidant therapy. © 2024 American Physiological Society. Compr Physiol 14:5729-5762, 2024.

Evaluating Severe Therapy-Resistant Asthma in Children: Diagnostic and Therapeutic Strategies

Introduction: Worldwide, asthma is the most common non-communicable respiratory disease and causes considerable morbidity and mortality. Most people with asthma can be treated effectively with low-dose medications if these are taken correctly and regularly. Around 10% of people with asthma have an uncontrolled form of the disease or can only achieve control with high-dose medications, incurring disproportionately high health care costs. Areas Covered: PubMed and personal archives were searched for relevant articles on the definition, management and pharmacotherapy of severe asthma. The WHO classification of severe asthma and the treatment levels encompassed in the definition are discussed. Most children and young people referred for consideration of 'beyond-guidelines therapy' can in fact be managed on standard treatment after a multi-disciplinary team assessment focusing on ensuring correct basic management, and these steps are described in detail. Options for those with true therapy-resistant asthma are described. These include monoclonal antibodies, most of which target type 2 inflammation. Expert Opinion: Getting the basics right is still the most important aspect of asthma care. For those with severe, therapy-resistant asthma, an increasing number of life-transforming monoclonals have been developed, but there is still little understanding of, and a paucity of treatment options for, non-eosinophilic asthma.

Childhood physical inactivity and excess weight: Two potentially modifiable risk factors for COPD

See related article

An interdisciplinary consensus approach to pulmonary hypertension in developmental lung disease

It is increasingly recognised that diverse genetic respiratory disorders present as severe pulmonary hypertension (PH) in the neonate and young infant, but many controversies and uncertainties persist regarding optimal strategies for diagnosis and management to maximise long-term outcomes. To better define the nature of PH in the setting of developmental lung disease (DEVLD), in addition to the common diagnoses of bronchopulmonary dysplasia and congenital diaphragmatic hernia, we established a multidisciplinary group of expert clinicians from stakeholder paediatric specialties to highlight current challenges and recommendations for clinical approaches, as well as counselling and support of families. In this review, we characterise clinical features of infants with DEVLD/DEVLD-PH and identify decision-making challenges including genetic evaluations, the role of lung biopsies, the use of imaging modalities and treatment approaches. The importance of working with team members from multiple disciplines, enhancing communication and providing sufficient counselling services for families is emphasised to create an interdisciplinary consensus.

Physical activity and body mass related to catch-up lung function growth in childhood: a population-based accelerated cohort study

OBJECTIVE

The existence of catch-up lung function growth and its predictors is uncertain. We aimed to identify lung function trajectories and their predictors in a population-based birth cohort.

METHODS

We applied group-based trajectory modelling to z-scores of forced expiratory volume in 1 second (zFEV1) and z-scores of forced vital capacity (zFVC) from 1151 children assessed at around 4, 7, 9, 10, 11, 14 and 18 years. Multinomial logistic regression models were used to test whether potential prenatal and postnatal predictors were associated with lung function trajectories.

RESULTS

We identified four lung function trajectories: a low (19% and 19% of the sample for zFEV1 and zFVC, respectively), normal (62% and 63%), and high trajectory (16% and 13%) running in parallel, and a catch-up trajectory (2% and 5%) with catch-up occurring between 4 and 10 years. Fewer child allergic diseases and higher body mass index z-score (zBMI) at 4 years were associated with the high and normal compared with the low trajectories, both for zFEV1 and zFVC. Increased children's physical activity during early childhood and higher zBMI at 4 years were associated with the catch-up compared with the low zFEV1 trajectory (relative risk ratios: 1.59 per physical activity category (1.03-2.46) and 1.47 per zBMI (0.97-2.23), respectively). No predictors were identified for zFVC catch-up growth.

CONCLUSION

We found three parallel-running and one catch-up zFEV1 and zFVC trajectories, and identified physical activity and body mass at 4 years as predictors of zFEV1 but not zFVC catch-up growth.

Routine pulmonary lung function tests: Interpretative strategies and challenges

Introduction: The diagnosis and management of common chronic respiratory diseases depend on various parameters obtained from pulmonary function tests (PFTs), such as spirometry, plethysmography, and carbon monoxide diffusion capacity (DLCO). These tests are interpreted following guidelines established by reputable scientific societies like the European Respiratory Society and the American Thoracic Society (ERS/ATS). Aim and Methods: This review aimed to offer a comprehensive framework for interpreting PFTs, incorporating the latest ERS/ATS update (i.e.; 2022), and to briefly explore some complex cases to shed light on their implications for understanding PFTs. Results: The ERS/ATS update outlines a systematic approach to interpreting PFT results, which involves several steps. Initially, results are compared to those of a healthy reference population to determine normal, low, or high parameters. Then, potential ventilatory impairments (VIs), such as obstructive or restrictive VIs, are identified, which could indicate specific chronic respiratory or extra-respiratory diseases. The severity of identified VIs or reductions in DLCO is then assessed. If bronchodilator testing is performed, its response is evaluated. Lastly, any significant changes in PFT parameters over time are noted by comparing current results with previous ones, if available. Despite the clarity provided by the ERS/ATS update, certain uncertainties persist and require clarification, such as the identification of new patterns (e.g.; non-obstructive abnormal spirometry, isolated low forced expiratory volume in 1 s), and classifications of mixed VI or lung hyperinflation in terms of functional severity. Conclusion: This review is a comprehensive framework for interpreting PFTs. Since some issues pose uncertainty in clinical practice, it would be beneficial to the ERS/ATS to reconcile some inconsistencies and provide clearer guidance on different classifications and VIs.

Infant food allergy phenotypes and association with lung function deficits and asthma at age 6 years: a population-based, prospective cohort study in Australia

BACKGROUND

Food allergy is considered a precursor to asthma in the context of the atopic march, but the relationship between infant food allergy phenotypes and lung function and asthma in childhood is unclear. We aimed to examine the association between food sensitisation and challenge-confirmed food allergy in infancy, as well as persistent and resolved food allergy up to age 6 years, and the risk of lung function deficits and asthma at age 6 years.

METHODS

The longitudinal, population-based HealthNuts cohort study in Melbourne, VIC, Australia, recruited 5276 infants children aged 1 year who attended council-run immunisation sessions between Sept 28, 2007, and Aug 5, 2011. At age 1 year, all children completed skin prick testing to four food allergens (egg, peanut, sesame, and either shrimp or cow's milk) and an oral food challenge (egg, peanut, and sesame) at the Royal Children's Hospital in Melbourne. Parents completed questionnaires about their infant's allergy history, demographic characteristics, and environmental exposures. At age 6 years, children were invited for a health assessment that included skin prick testing for ten foods (milk, egg, peanut, wheat, sesame, soy, shrimp, cashew, almond, and hazelnut) and eight aeroallergens (alternaria, cladasporum, house dust mite, cat hair, dog hair, bermuda grass, rye grass, and birch mix), oral food challenges, and lung function testing by spirometry. Questionnaires completed by parents (different to those completed at age 1 year) captured the child's allergy and respiratory history and demographics. We investigated associations between food allergy phenotypes (food-sensitised tolerance or food allergy; and ever, transient, persistent, or late-onset food allergy), lung function spirometry measures (forced expiratory volume in 1 sec [FEV1] and forced vital capacity [FVC] z-scores, FEV1/FVC ratio, forced expiratory flow at 25% and 75% of the pulmonary volume [FEF25-75%], and bronchodilator responsiveness), and asthma using regression methods. Only children with complete data on the exposure, outcome, and confounders were included in models. Infants without food sensitisation or food allergy at age 1 year and 6 years served as the reference group.

FINDINGS

Of 5276 participants, 3233 completed the health assessment at age 6 years and were included in this analysis. Food allergy, but not food-sensitised tolerance, at age 1 year was associated with reduced FEV1 and FVC (aβ -0·19 [95% CI -0·32 to -0·06] and -0·17 [-0·31 to -0·04], respectively) at age 6 years. Transient egg allergy was associated with reduced FEV1 and FVC compared with never having egg allergy (-0·18 [95% CI -0·33 to -0·03] and -0·15 [-0·31 to 0·00], respectively), whereas persistent egg allergy was not (FEV1 -0·09 [-0·48 to 0·31]; FVC -0·20 [-0·62 to 0·21]). Transient peanut allergy was associated with reduced FEV1 and FVC (FEV1 aβ -0·37 [-0·79 to 0·04] and FVC aβ -0·55 [-0·98 to -0·12]), in addition to persistent peanut allergy (FEV1 aβ -0·30 [-0·54 to -0·06] and FVC aβ-0·30 [-0·55 to -0·05]), and late-onset peanut allergy (FEV1 aβ -0·62 [-1·06 to -0·18] and FVC aβ-0·49 [-0·96 to -0·03]). Estimates suggested that food-sensitised tolerance and food allergy were associated with reduced FEF25-75%, although some estimates were imprecise. Food allergy phenotypes were not associated with an FEV1/FVC ratio. Late-onset peanut allergy was the only allergy phenotype that was possibly associated with increased risk of bronchodilator responsiveness (2·95 [95% CI 0·77 to 11·38]). 430 (13·7%) of 3135 children were diagnosed with asthma before age 6 years (95% CI 12·5-15·0). Both food-sensitised tolerance and food allergy at age 1 year were associated with increased asthma risk at age 6 years (adjusted odds ratio 1·97 [95% CI 1·23 to 3·15] and 3·69 [2·81 to 4·85], respectively). Persistent and late-onset peanut allergy were associated with higher asthma risk (3·87 [2·39 to 6·26] and 5·06 [2·15 to 11·90], respectively).

INTERPRETATION

Food allergy in infancy, whether it resolves or not, is associated with lung function deficits and asthma at age 6 years. Follow-up studies of interventions to prevent food allergy present an opportunity to examine whether preventing these food allergies improves respiratory health.

FUNDING

National Health & Medical Research Council of Australia, Ilhan Food Allergy Foundation, AnaphylaxiStop, the Charles and Sylvia Viertel Medical Research Foundation, the Victorian Government's Operational Infrastructure Support Program.

Early Origins of Chronic Obstructive Pulmonary Disease: Prenatal and Early Life Risk Factors

The main risk factor for chronic obstructive pulmonary disease (COPD) is active smoking. However, a considerable amount of people with COPD never smoked, and increasing evidence suggests that adult lung disease can have its origins in prenatal and early life. This article reviews some of the factors that can potentially affect lung development and lung function trajectories throughout the lifespan from genetics and prematurity to respiratory tract infections and childhood asthma. Maternal smoking and air pollution exposure were also analyzed among the environmental factors. The adoption of preventive strategies to avoid these risk factors since the prenatal period may be crucial to prevent, delay the onset or modify the progression of COPD lung disease throughout life.

Green and blue spaces and lung function in the Generation XXI cohort: a life-course approach

BACKGROUND

Exposure to natural environments may affect respiratory health. This study examined the association of exposure to green and blue spaces with lung function in children, and assessed the mediation effect of air pollution and physical activity.

METHODS

The study used data from the Generation XXI, a population-based birth cohort from the Porto Metropolitan Area (Portugal). Residential Normalised Difference Vegetation Index (NDVI) at different buffers (100, 250 and 500 m), the accessibility to urban green spaces (UGS) within 400 and 800 m and the minimum distance to the nearest UGS and to the nearest blue spaces were assessed at birth, 4, 7 and 10 years of age. Three life-course measures were calculated: averaged exposure, early-life exposure (birth) and exposure trend over time (change in exposure). Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1) and forced expiratory flow between 25% and 75% of FVC (FEF25-75%) at 10 years were used as outcomes. To assess associations, linear regression models and path analysis were used.

RESULTS

This study included 3278 children. The adjusted models showed that increasing the NDVI exposure over time within 100 m of the child's residence was associated with higher values of FEV1 (L) and FEF25-75% (L·s-1) (β 0.01, 95% CI 0.0002-0.03 and β 0.02, 95% CI 0.001-0.05, respectively). No significant associations were observed for the remaining measures of exposure, and no mediation effect was found for pollution or physical activity.

CONCLUSION

Increasing exposure to greenness at close proximity from residences was associated with improved lung function. While the mechanism remains unknown, this study brings evidence that city greening may improve children's respiratory health.

Association of growth patterns during infancy and puberty with lung function, wheezing and asthma in adolescents aged 17.5 years: evidence from ‘Children of 1997’ Hong Kong Chinese Birth Cohort

Background

Rapid growth is related to adverse respiratory outcomes although possibly confounded or limited by growth modelling methods. We investigated the association of infant and pubertal growth with lung function, wheezing and asthma in a non-Western setting.

Methods

In Hong Kong’s ‘Children of 1997’ Chinese birth cohort (n = 8327), weight during infancy and weight, height and body mass index (BMI) during puberty were modelled using a super-imposition by translation and rotation model to identify (larger or smaller) size, (earlier or later) tempo and (slower or faster) velocity. Sex-specific associations with forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), FEV1/FVC (Global Lung function Initiative z-score) and self-reported wheezing and asthma at ∼17.5 years were assessed.

Results

For each fraction higher than average weight growth velocity during infancy, FVC was higher in boys (0.90 SD, 95% CI 0.35; 1.44) and girls (0.77 SD, 95% CI 0.24; 1.30), FEV1/FVC was lower (–0.74 SD, 95% CI –1.38; –0.10) and wheezing was higher (odds ratio 6.92, 95% CI 1.60; 29.99) in boys and an inverse association with FVC was observed for tempo but not for size. Associations for weight growth velocity in puberty were similar but weaker. Greater size and higher velocity of BMI growth was associated with higher FVC, lower FEV1/FVC and higher asthma and wheezing risk.

Conclusion

Accelerated infant and pubertal weight growth were associated with disproportionate lung size and airway growth, and higher risk of asthma; optimizing early-life growth patterns could be important.

The First 4 Years – Outcome of Children Identified by Newborn Screening for CF in Germany

Background Newborn screening (NBS) has been shown to improve cystic fibrosis (CF) disease course and has been widely implemented worldwide. This monocentric study compared children diagnosed by NBS vs. a cohort preceding the implementation of NBS in Germany in 2016 to evaluate ascribed benefits of NBS.

Methods We compared all children with confirmed CF diagnosis (n=19, “NBS group”) out of all children presenting with positive NBS at our center after implementation of NBS (n=100) to children diagnosed with CF at our center within 4 years before NBS implementation (n=29, “pre-NBS group”) for outcomes of anthropometry, gastrointestinal and pulmonary disease manifestations and respiratory microbiology.

Results Children diagnosed by NBS had a lower incidence of initial difficulty to thrive (15 vs. 41%) and showed higher mean z-scores for Body-Mass-Index (BMI), weight and length at diagnosis and during study period. Children in the pre-NBS group displayed higher proportions of oxygen-dependent pulmonary exacerbations (10 vs. 0%). They show a significantly lower amount of normal bacterial flora (p=0.005) along with a significantly higher number of throat swab cultures positive for Pseudomonas aeruginosa (p=0.0154) in the first year of life. Yet, pulmonary imaging did not reveal less pulmonary morbidity in the NBS group.

Conclusions Our results confirm that NBS for CF leads to earlier diagnosis and improves nutritional outcomes in early childhood. Although trajectories of structural lung damage at early age were unaffected by NBS, NBS positive CF patients at preschool age displayed less pulmonary exacerbations and pathological bacteria in throat swabs.

How to Choose the Correct Drug in Severe Pediatric Asthma

When a child with severe asthma (asthma defined clinically for the purposes of this review as wheeze, breathlessness, and chest tightness sometimes with cough) does not respond to treatment, it is important to be sure that an alternative or additional diagnosis is not being missed. In school age children, the next step is a detailed protocolized assessment to determine the nature of the problem, whether within the airway or related to co-morbidities or social/environmental factors, in order to personalize the treatment. For example, those with refractory difficult asthma due to persistent non-adherence may benefit from using budesonide and formoterol combined in a single inhaler [single maintenance and reliever treatment (SMART)] as both a reliever and preventer. For those with steroid-resistant Type 2 airway inflammation, the use of biologicals such as omalizumab and mepolizumab should be considered, but for mepolizumab at least, there is a paucity of pediatric data. Protocols are less well developed in preschool asthma, where steroid insensitive disease is much more common, but the use of two simple measurements, aeroallergen sensitization, and peripheral blood eosinophil count, allows the targeted use of inhaled corticosteroids (ICSs). There is also increasing evidence that chronic airway infection may be important in preschool wheeze, increasing the possibility that targeted antibiotics may be beneficial. Asthma in the first year of life is not driven by Type 2 inflammation, so beyond avoiding prescribing ICSs, no evidence based recommendations can be made. In the future, we urgently need to develop objective biomarkers, especially of risk, so that treatment can be targeted effectively; we need to address the scandal of the lack of data in children compared with adults, precluding making evidence-based therapeutic decisions and move from guiding treatment by phenotypes, which will change as the environment changes, to endotype based therapy.

Spirometric phenotypes from early childhood to young adulthood: a Chronic Airway Disease Early Stratification study

BACKGROUND

The prevalences of obstructive and restrictive spirometric phenotypes, and their relation to early-life risk factors from childhood to young adulthood remain poorly understood. The aim was to explore these phenotypes and associations with well-known respiratory risk factors across ages and populations in European cohorts.

METHODS

We studied 49 334 participants from 14 population-based cohorts in different age groups (≤10, >10-15, >15-20, >20-25 years, and overall, 5-25 years). The obstructive phenotype was defined as forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) z-score less than the lower limit of normal (LLN), whereas the restrictive phenotype was defined as FEV1/FVC z-score ≥LLN, and FVC z-score

RESULTS

The prevalence of obstructive and restrictive phenotypes varied from 3.2-10.9% and 1.8-7.7%, respectively, without clear age trends. A diagnosis of asthma (adjusted odds ratio (aOR=2.55, 95% CI 2.14-3.04), preterm birth (aOR=1.84, 1.27-2.66), maternal smoking during pregnancy (aOR=1.16, 95% CI 1.01-1.35) and family history of asthma (aOR=1.44, 95% CI 1.25-1.66) were associated with a higher prevalence of obstructive, but not restrictive, phenotype across ages (5-25 years). A higher current body mass index (BMI was more often observed in those with the obstructive phenotype but less in those with the restrictive phenotype (aOR=1.05, 95% CI 1.03-1.06 and aOR=0.81, 95% CI 0.78-0.85, per kg·m-2 increase in BMI, respectively). Current smoking was associated with the obstructive phenotype in participants older than 10 years (aOR=1.24, 95% CI 1.05-1.46).

CONCLUSION

Obstructive and restrictive phenotypes were found to be relatively prevalent during childhood, which supports the early origins concept. Several well-known respiratory risk factors were associated with the obstructive phenotype, whereas only low BMI was associated with the restrictive phenotype, suggesting different underlying pathobiology of these two phenotypes.

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Grants

• MR/K002449/1 Medical Research Council
• MR/S002359/1 Medical Research Council
• G0601361 Medical Research Council
• MR/K002449/2 Medical Research Council
• MR/S025340/1 Medical Research Council
• European Respiratory Society

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Affiliation(s)

Gang Wang Dept of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Sichuan, China Dept of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden Shared first authors
Jenny Hallberg Dept of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden Sachs’ Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden Shared first authors
Dimitrios Charalampopoulos MRC Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
Maribel Casas Sanahuja ISGlobal, Barcelona, Spain Universitat Pompeu Fabra, Barcelona, Spain Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain
Robab Breyer-Kohansal Ludwig Boltzmann Institute for Lung Health, Vienna, Austria Dept of Respiratory and Critical Care Medicine, Clinic Penzing, Vienna, Austria
Arnulf Langhammer Dept of Public Health and Nursing, Faculty of Medicine and Health Sciences, HUNT Research Centre, Norwegian University of Science and Technology (NTNU), Levanger, Norway
Raquel Granell MRC Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
Judith M. Vonk Dept of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, The Netherlands
Annemiek Mian The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands Division of Respiratory Medicine and Allergology, and Neonatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
Núria Olvera Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain Institut d'investigacions biomediques August Pi I Sunyer, Barcelona, Spain
Lisbeth Mølgaard Laustsen Dept of Public Health, Environment Occupation and Health, Danish Ramazzini Centre, Aarhus University, Aarhus, Denmark
Eva Rönmark Dept of Public Health and Clinical Medicine, Section for Sustainable Health, The OLIN Unit, Umeå University, Umeå, Sweden
Alicia Abellan ISGlobal, Barcelona, Spain Universitat Pompeu Fabra, Barcelona, Spain Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain
Alvar Agusti Institut d'investigacions biomediques August Pi I Sunyer, Barcelona, Spain Respiratory Institute, Hospital Clinic, Univ. Barcelona, Barcelona, Spain CIBERESP (ISCiii), Barcelona, Spain
Syed Hasan Arshad David Hide Asthma and Allergy Research Centre, Newport, UK NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
Anna Bergström Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden Centre for Occupational and Environmental Medicine, Region Stockholm, Stockholm, Sweden
H. Marike Boezen Dept of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
Marie-Kathrin Breyer Ludwig Boltzmann Institute for Lung Health, Vienna, Austria Dept of Respiratory and Critical Care Medicine, Clinic Penzing, Vienna, Austria
Otto Burghuber Ludwig Boltzmann Institute for Lung Health, Vienna, Austria Faculty of Medicine, Sigmund Freud University, Vienna, Austria
Anneli Clea Bolund Dept of Public Health, Environment Occupation and Health, Danish Ramazzini Centre, Aarhus University, Aarhus, Denmark
Adnan Custovic National Heart and Lung Institute, Imperial College London, London, UK
Graham Devereux Liverpool School of Tropical Medicine, Liverpool, UK
Gavin C. Donaldson National Heart and Lung Institute, Imperial College London, London, UK
Liesbeth Duijts The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands Division of Respiratory Medicine and Allergology, and Neonatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands Division of Neonatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
Ana Esplugues Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain Nursing Department, Faculty of Nursing and Chiropody, Universitat de València, Valencia, Spain Epidemiology and Environmental Health Joint Research Unit, FISABIO−Universitat Jaume I−Universitat de València, Valencia, Spain
Rosa Faner Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain
Ferran Ballester Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain Nursing Department, Faculty of Nursing and Chiropody, Universitat de València, Valencia, Spain Epidemiology and Environmental Health Joint Research Unit, FISABIO−Universitat Jaume I−Universitat de València, Valencia, Spain
Judith Garcia-Aymerich ISGlobal, Barcelona, Spain Universitat Pompeu Fabra, Barcelona, Spain Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain
Ulrike Gehring Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
Sadia Haider National Heart and Lung Institute, Imperial College London, London, UK
Sylvia Hartl Ludwig Boltzmann Institute for Lung Health, Vienna, Austria Dept of Respiratory and Critical Care Medicine, Clinic Penzing, Vienna, Austria Faculty of Medicine, Sigmund Freud University, Vienna, Austria
Helena Backman Dept of Public Health and Clinical Medicine, Section for Sustainable Health, The OLIN Unit, Umeå University, Umeå, Sweden
John W. Holloway NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
Gerard H. Koppelman University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, The Netherlands Dept of Pediatric Pulmonology and Pediatric Allergology, University Medical Center Groningen, Beatrix Children's Hospital, University of Groningen, Groningen, The Netherlands
Aitana Lertxundi Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain Dept of Preventive Medicine and Public Health, Faculty of Medicine, University of the Basque Country (UPV/EHU), Leioa, Spain BIODONOSTIA Health Research Institute, Donostia-San Sebastian, Spain
Turid Lingaas Holmen Dept of Public Health and General Practice, HUNT Research Center, NTNU, Levanger, Norway
Lesley Lowe Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester Academic Health Science Centre, NIHR, Manchester, UK Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
Sara M. Mensink-Bout The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
Clare S. Murray Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester Academic Health Science Centre, NIHR, Manchester, UK Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
Graham Roberts David Hide Asthma and Allergy Research Centre, Newport, UK NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
Linnea Hedman Dept of Public Health and Clinical Medicine, Section for Sustainable Health, The OLIN Unit, Umeå University, Umeå, Sweden
Vivi Schlünssen Dept of Public Health, Environment Occupation and Health, Danish Ramazzini Centre, Aarhus University, Aarhus, Denmark
Torben Sigsgaard Dept of Public Health, Environment Occupation and Health, Danish Ramazzini Centre, Aarhus University, Aarhus, Denmark
Angela Simpson Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester Academic Health Science Centre, NIHR, Manchester, UK Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
Jordi Sunyer ISGlobal, Barcelona, Spain Universitat Pompeu Fabra, Barcelona, Spain IMIM-Parc Salut Mar, Barcelona, Spain
Maties Torrent ib-salut, Area de Salut de Menorca, Menorca, Spain
Stephen Turner Royal Aberdeen Children's Hospital NHS Grampian, Aberdeen, UK
Maarten Van den Berge University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, The Netherlands Dept of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
Roel C.H. Vermeulen Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
Sigrid Anna Aalberg Vikjord Dept of Public Health and Nursing, Faculty of Medicine and Health Sciences, HUNT Research Centre, Norwegian University of Science and Technology (NTNU), Levanger, Norway Dept of Medicine and Rehabilitation, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
Jadwiga A. Wedzicha National Heart and Lung Institute, Imperial College London, London, UK
Anke H. Maitland van der Zee Dept of Respiratory Medicine, Amsterdam University Medical Centers (UMC), University of Amsterdam Pediatric Respiratory Medicine, Emma Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands Shared last authors
Erik Melén Dept of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden Sachs’ Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden Shared last authors

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