The increased purchase of asthma medication for individuals born preterm seems to wane with age: A register-based longitudinal national cohort study

Early-Life Nutrition in Preterm Infants and Risk of Respiratory Infections and Wheezing: A Scoping Review

INTRODUCTION

Preterm birth is a common early-life event that can lead to long-term consequences. The incidence of wheezing, asthma, and respiratory tract infections is higher in children born prematurely than in the general population. The purpose of this review was to synthesize the existing literature on the role of early-life nutrition in the later risk of respiratory morbidities.

METHODS

A scoping review of the literature was performed by searching three online databases. Inclusion criteria were: infants born <37 GWk, comparing human milk versus any other type of milk feeding formulation. Our primary outcomes were wheezing or asthma or respiratory tract infections after discharge. Two authors independently screened the results and extracted study characteristics using a predefined charting form.

RESULTS

Nine articles were included (eight cohort studies and one randomized trial). Four studies supported the protective effect of breastfeeding on wheezing or respiratory infections or both. Four studies did not confirm this association. One study confirmed the protective role of breastfeeding only on the subgroup of girls. There was a high heterogeneity among the included studies, in the type of milk feeding, outcomes, and age at follow-up.

CONCLUSIONS

The current evidence is conflicting. The high heterogeneity and methodological flaws could have influenced the results of the studies. Carefully designed studies are required to define the role of early-life nutrition among preterm infants on their long-term respiratory outcomes.

Preterm birth and asthma and COPD in adulthood: a nationwide register study from two Nordic countries

BACKGROUND

Preterm birth affects lungs in several ways but few studies have follow-up until adulthood. We investigated the association of the entire spectrum of gestational ages with specialist care episodes for obstructive airway disease (asthma and chronic obstructive pulmonary disease (COPD)) at age 18-50 years.

METHODS

We used nationwide registry data on 706 717 people born 1987-1998 in Finland (4.8% preterm) and 1 669 528 born 1967-1999 in Norway (5.0% preterm). Care episodes of asthma and COPD were obtained from specialised healthcare registers, available in Finland for 2005-2016 and in Norway for 2008-2017. We used logistic regression to estimate odds ratios (ORs) for having a care episode with either disease outcome.

RESULTS

Odds of any obstructive airway disease in adulthood for those born at <28 or 28-31 completed weeks were 2-3-fold of those born full term (39-41 completed weeks), persisting after adjustments. For individuals born at 32-33, 34-36 or 37-38 weeks, the odds were 1.1- to 1.5-fold. Associations were similar in the Finnish and the Norwegian data and among people aged 18-29 and 30-50 years. For COPD at age 30-50 years, the OR was 7.44 (95% CI 3.49-15.85) for those born at <28 weeks, 3.18 (95% CI 2.23-4.54) for those born at 28-31 weeks and 2.32 (95% CI 1.72-3.12) for those born at 32-33 weeks. Bronchopulmonary dysplasia in infancy increased the odds further for those born at <28 and 28-31 weeks.

CONCLUSION

Preterm birth is a risk factor for asthma and COPD in adulthood. The high odds of COPD call for diagnostic vigilance when adults born very preterm present with respiratory symptoms.

Prevalence of asthma in preterm and associated risk factors based on prescription data from the Korean National Health Insurance database

We retrospectively analyzed National Health Insurance claims data (January 2002-December 2018) to determine the asthma prevalence and risk factors among preterm infants born in Korea. Patients with asthma were defined as those with a history of asthma medication prescriptions at least twice per year with International Classification of Diseases, Tenth Edition codes J45 and J46. We enrolled 99,139 preterm infants. The prevalence of asthma among preterm and term infants was 32.7% and 26.9%, 21.2% and 19.1%, 6.7% and 5.9%, 2.0%, and 1.6%, and 2.4% and 1.6% at 2, 5, 10, 15, and 16 years of age, respectively. The relative risk (RR) of asthma in preterm infants was 1.1-fold that in female preterm infants. The RR of asthma medication prescriptions for infants with extreme prematurity was 1.92-fold that of infants with moderate/late pre-term status. Among preterm with bronchopulmonary dysplasia (BPD) and respiratory distress syndrome (RDS) without comorbidities, the RRs for the number of asthma medication prescriptions were 1.34 and 1.06, respectively. This study revealed a higher prevalence of asthma among preterm infants than that in term infants. Male sex, extreme prematurity, BPD, and RDS were identified as risk factors for asthma medication prescriptions in preterm infants.

From neonatal lung function to lung function and respiratory morbidity at 6-year follow-up

BACKGROUND

Lung function is traceable from infancy to adulthood. Only a few studies have examined lung function from birth to childhood longitudinally in children born moderate to late preterm. We aimed to investigate how prematurity and lung function in the neonatal period are related to lung function and respiratory morbidity at age 6 in former moderate to late preterm children compared with children born at term.

METHODS

Lung function was measured in a cohort of moderately to late preterm (n = 48) and term-born (n = 53) infants in the neonatal period by FeNO, and tidal breathing flow-volume loops (TBFVL) and at age 6 (n = 52) by spirometry, whole-body plethysmograph and impulse oscillation combined with a respiratory symptom questionnaire.

RESULTS

Moderate to late preterm children had a higher T_PEF /T_E ratio neonatally (42.6% vs. 33.7%, p = 0.02) and a lower % predicted orced expiratory volume in the first second at age 6 (94.4% vs. 101.9%, p = 0.01) compared to term-born children. We found a significant association between the variability of neonatal tidal volume and effective airway resistance at age 6 (β = -0.34, p = 0.03). No association between neonatal FeNO or TBFVL and respiratory morbidity at 6-year follow-up was shown.

CONCLUSION

Children born moderate to late preterm had lower lung function at age 6 than term-born children. We did not find evidence for the use of neonatal tidal breathing parameters as a predictor for subsequent respiratory morbidity or lung function, however sample size was small.

Preterm birth and prescriptions for cardiovascular, antiseizure, antibiotics and antiasthmatic medication in children up to 10 years of age: a population-based data linkage cohort study across six European regions

OBJECTIVES

Preterm children are exposed to many medications in neonatal intensive care units, but little is known about the effect of prematurity on medication use throughout infancy and childhood. We examined prescriptions of cardiovascular medication (CVM), antiseizure medication (ASM), antiasthmatic medication and antibiotics issued/dispensed in the first 10 years of life for very and moderately preterm children compared with term.

DESIGN

Population-based data linkage cohort study linking information from birth records to prescription records.

SETTING

Six registries from five countries in the EUROlinkCAT study.

PARTICIPANTS

The study population included 1 722 912 children, of whom 10 820 (0.6%) were very preterm (<32 weeks gestational age (GA)), 92 814 (5.4%) were moderately preterm (32-36 weeks GA), 1 606 643 (93.3%) were born at term (≥37 weeks GA) and 0.7% had missing GA. Children with major or minor congenital anomalies were excluded (including patent ductus arteriosus).

MAIN OUTCOME MEASURES

Relative risk (RR) of receiving a prescription for CVM, ASM, antiasthmatic and antibiotics.

RESULTS

Very preterm children had a higher RR of receiving a prescription for CVM and ASM than preterm children. For all preterm children, the RR of having a CVM prescription was 3.58 (95% CI 2.06 to 6.23); 2.06 (95% CI 1.73 to 2.41) for ASM; 1.13 (95% CI 0.99 to 1.29) for antiasthmatics and 0.96 (95% CI 0.93 to 0.99) for antibiotics in the first year of life. Increased prescription of CVM, ASM and antiasthmatics persisted for all 10 years of follow-up. Although the RR was highest for CVM and ASM, in absolute numbers more children received prescriptions for antibiotics (42.34%, 95% CI 38.81% to 45.91%) and antiasthmatics (28.40%, 95% CI 16.07% to 42.649%) than for CVM (0.18%, 95% CI 0.12% to 0.25%) and ASM (0.16%, 95% CI 0.13% to 0.20%) in the first year of life.

CONCLUSION

Preterm children had a higher risk of being prescribed/dispensed CVM, ASM and antiasthmatics up to age 10. This study highlights a need for further research into morbidity beyond age 10.

Medication utilization in children born preterm in the first two years of life

OBJECTIVE

To compare medications dispensed during the first 2 years in children born preterm and full-term.

STUDY DESIGN

Retrospective analysis of claims data from a commercial national managed care plan 2008-2019. 329,855 beneficiaries were enrolled from birth through 2 years, of which 25,408 (7.7%) were preterm (<37 weeks). Filled prescription claims and paid amount over 2 years were identified.

RESULTS

In preterm children, the number of filled prescriptions was 1.4 times and cost was 3.8 times that of full-term children. Number and cost of medications were inversely related to gestational age. Differences peak at 4-9 months and resolve by 19 months after discharge. Palivizumab, ranitidine, albuterol, lansoprazole, budesonide, and prednisolone had the greatest differences in utilization.

CONCLUSION

Prescription medication utilization among preterm children under 2 years is driven by palivizumab, anti-reflux, and respiratory medications, despite little evidence regarding efficacy for many medications and concern for harm with certain classes.

Respiratory morbidity in very low birth weight infants through childhood and adolescence

OBJECTIVE

To describe the long-term (up to 18 years of age) respiratory outcomes of children and adolescents born at very low birth weight (VLBW; ≤1500 g) in comparison with that of children born >1500 g.

METHODS

An observational, longitudinal, retrospective study comparing VLBW infants with matched controls, registered at a large health maintenance organization in Israel. Pulmonary outcomes collected anonymously from the electronic medical files included respiratory illness diagnoses, purchased medications for respiratory problems, office visits with either a pediatric pulmonologist or cardiologist and composite respiratory morbidity combining all these parameters.

RESULTS

Our study included 5793 VLBW infants and 11,590 matched controls born between 1998 and 2012. The majority (99%) of VLBW infants were premature (born < 37 weeks' gestation), while 93% of controls were born at term. The composite respiratory morbidity was significantly higher in VLBW infants compared with controls in all age groups (relative risk [95% confidence interval]: 1 year: 1.22 [1.19-1.26], <2 years: 1.30 [1.27-1.34], 2-6 years: 1.29 [1.27-1.32], 6-12 years: 1.53 [1.47-1.59], 12-18 years: 1.46 [1.35-1.56]; respectively). Both VLBW infants and controls demonstrated a steady decline in the composite respiratory morbidity with aging. In VLBW infants, lower gestational age was associated with higher respiratory morbidity only until 2 years of age and the morbidity declined in each gestational age group until adolescence.

CONCLUSION

Our study confirmed a strong association between VLBW and pulmonary morbidity. The higher prevalence of respiratory composite morbidity in VLBW infants persists over the years until adolescence. The respiratory morbidity is most evident in the first year of life and declines afterward.

Long and winding road: from infant wheeze to adult asthma

PURPOSE OF REVIEW

This review aims to recognize the multifactorial cause of asthma, from the influence of mother until adulthood, highlight the main characteristics of the disease at different ages and summarize the evidence of potential prevention strategies.

RECENT FINDINGS

To date, regarding the prenatal period, the presence of specific genes, maternal asthma, drugs, and tobacco exposure are the most relevant predisposing features for an asthmatic offspring. For newborns, preterm, bronchopulmonary dysplasia, and low birth weight has been associated with low lung function. Among young children, atopic dermatitis, lower respiratory tract infections, and increased levels of total Immunoglobulin E (IgE) and allergen-specific IgE are important determinants.Breastfeeding has been demonstrated being protective for the onset of asthma. Allergen immunotherapy has also been shown to have significant preventive effect decreasing asthma development. Inhaled corticosteroids use in early childhood prevents exacerbations but does not alter the natural history of asthma. Other interventions, such as the use of palivizumab, probiotics, vitamin D supplementation, and fish consumption presented controversial results.

SUMMARY

A good knowledge of risk factors for asthma development, from prenatal period to adulthood, may lead to efficacious preventive strategies. Further data of long-term follow-up in population-based studies according to different phenotypes are needed.

The increased susceptibility to airway infections after preterm birth does not persist into adolescence

INTRODUCTION

Preterm birth is associated with increased risk of airway infections in childhood, more frequent purchase of prescription antibiotics and hospital admissions for airway infections. With this study, we aimed to investigate whether this association persists into adolescence.

METHODS

We conducted a longitudinal observational register-based study of a national cohort of all infants born in Denmark in 1992-2007. We used purchase of antibiotics, including penicillins and macrolides, and hospital admissions as proxies for milder and more severe forms of airway infections respectively in 1995-2010. Associations between gestational age (GA), age, year and repeated cross-sectional evaluations of antibiotic purchase and hospital admissions were explored by logistic regression analyses.

RESULTS

We included 1,043,411 children in our study population. We found a statistically significant association between GA and prescription of antibiotics as well as hospital admissions due to airway infections. In the youngest age groups, children with higher GA had lower adjusted mean rates of prescribed antibiotics for airway infections, but from the age of 10-11 years the opposite trend was noted in what appears to be a dose-response relationship. During childhood, we found an inverse dose-response relationship where ex-preterms with GA 23-27 at age 4-5 years had twice the odds of hospital admission compared to children in the same age group born at term. During adolescence, these higher odds diminished and appeared equivalent among teenagers born at term and preterm. We only found statistically significant interactions between gestational age and age.

CONCLUSION

We confirmed that preterm birth is associated with higher rates of prescribed antibiotics and higher odds of hospitalization for airway infections during childhood. However, in adolescence we found that there was no increase in hospital admissions for airway infections among ex-preterms, whereas adolescents with low GA actually appeared to purchase less prescribed antibiotics. Whether this trend persists into adulthood and the physiological explanation therefor remains to be investigated.