Prevalence and severity of wheezing in the first year of life

Associated factors with recurrent wheezing in infants: is there difference between the sexes?

OBJECTIVE

Identify associated factors for recurrent wheezing (RW) in male and female infants.

METHODS

Cross-sectional multicentric study using the standardized questionnaire from the Estudio Internacional sobre Sibilancias en Lactantes (EISL). The questionnaire was applied to parents of 9345 infants aged 12-15 months at the time of immunization/routine visits.

RESULTS

One thousand two hundred and sixty-one (13.5%) males and nine hundred sixty-three (10.3%) females have had RW (≥3 episodes), respectively (p10 colds episodes (OR = 3.46; IC 95% 2.35-5.07), air pollution (OR = 1.33; IC 95% 1.12-1.59), molds at home (OR = 1.23; IC 95% 1.03-1.47), Afro-descendants (OR = 1.42; IC 95% 1.20-1.69), bronchopneumonia (OR = 1.41; IC; 1.11-1.78), severe episodes of wheezing in the first year (OR = 1.56; IC 95% 1.29-1.89), treatment with bronchodilators (OR = 1.60; IC 95% 1.22-2,1) and treatment with oral corticosteroids (OR = 1,23; IC 95% 0.99-1,52). Associated factors for RW for females were passive smoking (OR = 1.24; IC 95% 1.01-1,51), parents diagnosed with asthma (OR = 1.32; IC 95% 1,08-1,62), parents with allergic rhinitis (OR = 1.26; IC 95% 1.04-1.53), daycare attendance (OR = 1.48; IC 95% 1.17-1,88), colds in the first 6 months of life (OR = 2.19; IC 95% 1.69-2.82), personal diagnosis of asthma (OR = 1.84; IC 95% 1.39-2.44), emergency room visits (OR = 1.78; IC 95% 1.44-2.21), nighttime symptoms (OR = 2.89; IC 95% 2.34-3.53) and updated immunization (OR = 0.62; IC 95% 0.41-0.96).

CONCLUSION

There are differences in associated factors for RW between genders. Identification of these differences could be useful to the approach and management of RW between boys and girls.

TEMPORAL COMPARISON OF WHEEZING PREVALENCE IN THE FIRST YEAR OF LIFE IN SÃO PAULO: INTERNATIONAL STUDY OF WHEEZING IN INFANTS

Objective:

To assess the prevalence and severity of wheezing in the first year of life of infants, using the standardized protocol of the Estudio Internacional de Sibilancias en Lactantes- phase 3, and compare the values obtained with those found in phase 1, conducted at the same center.

Methods:

Between 2009 and 2010, parents and guardians of infants answered the written questionnaire of the Estudio Internacional de Sibilancias en Lactantes - phase 3, and its results were compared to those of phase 1, performed between 2005 and 2006. We divided the infants into wheezing and non-wheezing. The wheezing group was stratified according to the frequency of episodes: occasional wheezing - less than three -, and recurrent wheezing - three or more.

Results:

Wheezing prevalence was similar in both phases (44.6 versus 46%). Regarding frequency, the prevalence of occasional wheezing increased (19.4 versus 23%; p=0.03) and recurrent wheezing decreased (26.7 versus 21.6%; p=0.005). Also, diagnosis of asthma (7.5 versus 21.8%), use of inhaled corticosteroids (11.7 versus35%), and hospitalization for wheezing (19.7 versus 32.6%) grew significantly in phase 3. This period coincides with the Influenza A (H1N1) pandemic, which could have contributed to this outcome.

Conclusions:

Wheezing prevalence in the first year of life remains high. Despite the temporal assessment showing a decrease in the prevalence of recurrent wheezing, a significant increase in its morbidity was identified due to the higher number of hospitalizations. In addition, there were signs of improvement in the wheezing management of infants, reflected by an increase in the diagnosis of asthma and a greater indication of preventive treatments.

Lung disease and vitamin D levels in cystic fibrosis infants and preschoolers

INTRODUCTION

Vitamin D acts on the immune system and lung response. Patients with cystic fibrosis (CF) may be deficient in this vitamin. The aims of the study were to evaluate vitamin D levels and severity of lung disease in infants and preschoolers diagnosed with CF, and to compare them to a group of children without pancreatic insufficiency (PI).

METHODS

Patients with CF up to 4 years old were included, and compared to an age-matched group of children without diagnosis of CF. CF group had medical records and High Resolution Thorax Computed Tomography (HRCCT) evaluated in order to verify the severity of lung disease. Information on demographic data, sun exposure habits, supplemental vitamin D therapy, and on the season at the time of vitamin D sampling were collected for both groups.

RESULTS

This study included 45 patients in the CF group and 102 in the non-CF group, with no differences in age (P = 0.327) between them. There was no association between vitamin D levels and markers of lung disease in the CF group. The non-CF group had lower daily sun exposure (P = 0.034), and lower supplementation than the CF group (P < 0.001). Supplementation and seasonality were the determinant variables for vitamin D levels, which were lower for non-supplemented children and for assessments during fall/winter.

CONCLUSION

There was no association between lung disease severity and vitamin D levels in CF group. Supplementation and seasonality were associated to higher vitamin levels.

Test for Respiratory and Asthma Control in Kids (TRACK): validation of the Portuguese version

Background

TRACK (Test for Respiratory and Asthma Control in Kids) questionnaire is an instrument developed and validated in English to evaluate the control of respiratory symptoms in children under 5 years of age.

Objective

To validate the Portuguese version of the TRACK questionnaire.

Methods

The validation was done in an observational, prospective and multicenter evaluation (six centers in Brazil) in children with recurrent respiratory symptoms. Children were classified according to symptoms, GINA criteria and medical evaluation. Parents and doctors rated child respiratory symptom control in the last month (VAS). Approval from the Institutional Review Board was obtained in each centre, and written informed consent was obtained from parents.

Results

Data from 299 children were obtained at baseline, and 195 at follow-up. The median score of the TRACK questionnaire was 65 and Cronbach’s α was 0.70. TRACK scores showed significant correlation with the medical and family opinions about symptom control (r: 0.74 and r: 0.61). TRACK scores were significantly lower in children who had used systemic steroids (median [IQR]: 45 [30–65] vs 75 [55–80]; p < 0.001) and had an emergency visit in the last month (45 [35–60] vs 70 [55–80]; p < 0.001). TRACK scores were also significantly different when children were separated by the medical opinion, GINA criteria and symptoms. Comparison of different respiratory symptom control cut-off points showed that the cut-off of 80 points had the highest area under ROC curve (0.800).

Conclusion

We have demonstrated that the Portuguese version of the TRACK questionnaire has satisfactory reliability (internal consistency), adequate criterion validity (compared against GINA levels of control) and constructive validity (compared against respiratory symptoms and medical opinion), showing that it can be a useful tool to discriminate among children with different levels of respiratory symptom control.

Trial registration

ClinicalTrials.gov: NCT03290222.

Meta-analysis of prevalence of wheezing and recurrent wheezing in infants

BACKGROUND

Wheezing affects children's quality of life, and is related with asthma in childhood. Although prevalence of wheezing has been previously studied in several countries, there is no reference of worldwide prevalence in infants. The aim of this meta-analysis is to estimate the prevalence of wheezing and recurrent wheezing in infants aged up to two years, and compare the prevalence across world regions.

METHODS

Literature search was conducted in MEDLINE and SCOPUS databases, looking for observational studies published up to June 2016, including as keywords "prevalence" or "epidemiology" combined with "wheeze", "wheezing" or "asthma symptoms" and "infant" or "preschool". Fast*Pro software and random effects Bayesian model were used. Heterogeneity was estimated using I² statistic, and sensitivity analyses were performed.

RESULTS

We identified 109 studies after duplicates were removed. After exclusions, 14 studies were included in the meta-analysis. Prevalence of wheezing and recurrent wheezing were 36.06% (95% CI 35.17-36.96), and 17.41% (95% CI 16.74-18.09), respectively. In European countries, prevalence of wheezing was 30.68% (95% CI 28.97-32.45), and 12.35% (95% CI 11.27-13.47) for recurrent wheezing. Prevalence of wheezing and recurrent wheezing in Latin America were higher, 40.55% (95% CI 39.40-41.71), and 19.27% (95% CI 18.44-20.11), respectively. In Africa, prevalence of wheezing was 15.97% (95% CI 14.05-18.00). Low or no heterogeneity was found in all cases.

CONCLUSIONS

More than one third of infants suffer from wheezing and almost one fifth from recurrent wheezing, being these illnesses especially prevalent in Latin American countries, pointing out an important public health problem.

More surprises in the global greenhouse: Human health impacts from recent toxic marine aerosol formations, due to centennial alterations of world-wide coastal food webs

Reductions of zooplankton biomasses and grazing pressures were observed during overfishing-induced trophic cascades and concurrent oil spills at global scales. Recent phytoplankton increments followed, once Fe-, P-, and N-nutrient limitations of commensal diazotrophs and dinoflagellates were also eliminated by respective human desertification, deforestation, and eutrophication during climate changes. Si-limitation of diatoms instead ensued during these last anthropogenic perturbations of agricultural effluents and sewage loadings. Consequently, ~15% of total world-wide annual asthma trigger responses, i.e. amounting to ~45 million adjacent humans during 2004, resulted from brevetoxin and palytoxin poisons in aerosol forms of western boundary current origins. They were denoted by greater global harmful algal bloom [HAB] abundances and breathing attacks among sea-side children during prior decadal surveys of asthma prevalence, compiled here in ten paired shelf ecosystems of western and eutrophied boundary currents. Since 1965, such inferred onshore fluxes of aerosolized DOC poisons of HABs may have served as additional wind-borne organic carriers of toxic marine MeHg, phthalate, and DDT/DDE vectors, traced by radio-iodine isotopes to potentially elicit carcinomas. During these exchanges, as much as 40% of mercury poisonings may instead have been effected by inhalation of collateral HAB-carried marine neurotoxic aerosols of MeHg, not just from eating marine fish. Health impacts in some areas were additional asthma and pneumonia episodes, as well as endocrine disruptions among the same adjacent humans, with known large local rates of thyroid cancers, physician-diagnosed pulmonary problems, and ubiquitous high indices of mercury in hair, pesticides in breast milk, and phthalates in urine.

[Prevalence and clinical characteristics of wheezing in children in the first year of life, living in Cuiabá, Mato Grosso, Brazil]

OBJECTIVE:

To evaluate the prevalence and the clinical characteristics of wheezing in infants aged 12 to 15 months in the city of Cuiabá, Mato Grosso State, Midwest Brazil.

METHODS:

Parents and/or guardians of infants were interviewed and completed a written standardized questionnaire of the Estudio Internacional de Sibilancia en Lactantes (EISL) - phase 3 at primary healthcare clinics at the same day of children vaccination or at home, from August of 2009 to November of 2010.

RESULTS:

1,060 parents and/or guardians completed the questionnaire, and 514 (48.5%) infants were male. Among the studied infants, 294 (27.7%) had at least one episode of wheezing during the first year of life, beggining at 5.8±3.0 months of age, with a predominance of male patients. The prevalence of occasional wheezing (<3 episodes of wheezing) was 15.0% and recurrent wheezing (≥3 episodes) was 12.7%. Among the infants with recurrent wheezing, the use of inhaled β2-agonist, oral corticosteroid, leukotriene receptor antagonist, as well as night symptoms, respiratory distress, and hospitalization due to severe episodes were significantly more frequent. Physician-diagnosed asthma was observed in 28 (9.5%) of the wheezing infants. Among the wheezing infants, 80 (27.7%) were diagnosed with pneumonia, of whom 33 (11.2%) required hospitalization; neverthless, no differences between occasional and recurrent wheezing infants were found.

CONCLUSIONS:

The prevalence of recurrent wheezing and physician-diagnosed asthma in infants were lower compared with those observed in other Brazilian studies. Recurrent wheezing had early onset and high morbity.

Recurrent Wheezing in Infants: A Population-Based Study

Recurrent wheezing (RW) has a significant impact on infants, caregivers, and society, but morbidity and related medical resource utilization (MRU) have not been thoroughly explored. The burden of RW needs to be documented with population-based data. The objective was to assess the characteristics, medical management, and MRU of RW infants identified from national claims data. Infants aged from 6 to 24 months, receiving ≥2 dispensations of respiratory drugs within 3 months, and presenting a marker of poor control (index date), were selected. During the 6 months after index date, MRU was described in the cohort and among 3 subgroups with more severe RW, defined as ≥4 dispensations of respiratory drugs, ≥3 dispensations of oral corticosteroids (OCS), or ≥1 hospitalization for respiratory symptoms. A total of 115,489 infants had RW, corresponding to 8.2% of subjects in this age group. During follow-up, 68.7% of infants received inhaled corticosteroids, but only 1.8 U (unit) were dispensed over 6 months, suggesting discontinuous use. Control was mostly inadequate: 61.7% of subjects received OCS, 80.2% antibiotics, and 71.2% short-acting beta-agonists, and medical/paramedical visits were numerous, particularly for physiotherapy. Severe RW concerned 39.0% of the cohort; 32.8% and 11.7% of infants had repeated use of respiratory drugs and OCS, respectively, and 5.5% were hospitalized for respiratory symptoms. In this real-life nation-wide study, RW was common and infants had poor control and high MRU. Interventions are needed to support adequate use of controller therapy, and to improve medical care.

Risk factors for recurrent wheezing--International Study of Wheezing in Infants (EISL) phase 3

BACKGROUND

We aimed to identify factors associated with recurrent wheezing (RW) in infants in the first year of life living in the Southern region of São Paulo city and participating in the "Estudio Internacional de Sibilancias en Lactantes (EISL)" - phase 3 (P3).

METHODS

1335 parents of infants who were attended in primary care health units in the Southern region of São Paulo city from 2009 to 2010 answered the EISL-P3 written questionnaire. The wheezing group was stratified in accordance to the frequency of wheezing episodes as occasional wheezing (OW, less than three episodes), or RW (three or more episodes). Wheezing-associated factors were evaluated using multivariate analysis and were expressed as odds ratio (OR) and 95% confidence interval (95%CI).

RESULTS

The most relevant factors related to OW were pneumonia (OR=3.10, 95%CI=1.68-5.73), hospitalisation due to pneumonia (OR=2.88, 95%CI=1.26-6.56) and recurrent upper respiratory infection (URI, OR=1.87, 95%CI=1.25-2.81). Regarding RW, recurrent URI (OR=5.34, 95%CI=3.83-7.45), pneumonia (OR=4.06, 95%CI=2.87-5.74) and asthmatic siblings (OR=3.02, 95%CI=1.67-5.45) were the most significantly associated factors.

CONCLUSIONS

In the present study, we found that recurrent URI, positive history of pneumonia and familiar history of asthma were the most relevant factors associated with RW. The precocious knowledge of these factors can enable the identification of the probable asthmatic infants and can improve both prevention strategies and treatment of these patients.

Epidemiological aspects of and risk factors for wheezing in the first year of life

OBJECTIVE:

To determine, in a sample of infants, the prevalence of and risk factors for occasional wheezing (OW) and recurrent wheezing-wheezy baby syndrome (WBS).

METHODS:

Parents of infants (12-15 months of age) completed the International Study of Wheezing in Infants questionnaire.

RESULTS:

We included 1,269 infants residing in the city of Blumenau, Brazil. Of those, 715 (56.34%) had a history of wheezing, which was more common among boys. The prevalences of OW and WBS were 27.03% (n = 343) and 29.31% (n = 372), respectively. On average, the first wheezing episode occurred at 5.55 ± 2.87 months of age. Among the 715 infants with a history of wheezing, the first episode occurred within the first six months of life in 479 (66.99%), and 372 (52.03%) had had three or more episodes. Factors associated with wheezing in general were pneumonia; oral corticosteroid use; a cold; attending daycare; having a parent with asthma or allergies; mother working outside the home; male gender; no breastfeeding; and mold. Factors associated with WBS were a cold; physician-diagnosed asthma; ER visits; corticosteroid use; pneumonia; bronchitis; dyspnea; attending daycare; bronchodilator use; having a parent with asthma; no breastfeeding; mother working outside the home; and a dog in the household.

CONCLUSIONS:

The prevalence of wheezing in the studied population was high (56.34%). The etiology was multifactorial, and the risk factors were intrinsic and extrinsic (respiratory tract infections, allergies, attending daycare, and early wheezing). The high prevalence and the intrinsic risk factors indicate the need and the opportunity for epidemiological and genetic studies in this population. In addition, mothers should be encouraged to prolong breastfeeding and to keep infants under six months of age out of daycare.

[Prevalence and severity of wheezing in the first year of life in the city of Santo André, Brazil]

Objective:

To determine the prevalence and the severity of wheezing in the first year of life for infants who live in Santo André, São Paulo, Brazil.

Methods:

Cross sectional study with the administration of the Estudio Internacional de Sibilancias en Lactantes (EISL), which is a standardized and validated written questionnaire applied to parents and/or guardians of infants aged 12-24 months treated at primary health units, vaccination centers, day care centers, or kindergartens. The questionnaire consisted of questions regarding demographic characteristics, presence of wheezing, respiratory infections, and risk factors. Results were analyzed using the SPSS for Windows, 20.0 (SPSS Inc. - Chicago, Il, United States). Logistic regression was applied to verify variables associated to recurrent wheezing.

Results:

Among the 1,028 infants studied, 48.5% had one or more episodes of wheezing during the first 12 months of life (wheezing once), and 23.9% had three or more episodes (recurrent wheezing). Nocturnal symptoms, severe breathing difficulty, and visits to the emergency room were observed in 67.3%, 42.4%, and 60.7% of infants, respectively. Among the studied infants, 19.4% were hospitalized, and 11.0% had a medical diagnosis of asthma in the first year of life. Use of β2-agonists, inhaled corticosteroids, oral corticosteroids, and leukotriene receptor antagonists were observed in 88.8%, 21.0%, 54.9%, and 3.2% of children with wheezing, respectively. Use of oral corticosteroids, perception of breathlessness by parents, diagnosis of asthma, pneumonia, and hospitalization for pneumonia were more frequent among infants with recurrent wheezing (p<0.001).

Conclusions:

In the city of Santo André, approximately half of infants had at least one episode of wheezing in the first year of life, and almost 25% had recurrent wheezing. Wheezing disorders in Santo André have early onset and high morbidity.

Prevalência de sibilância e fatores associados em crianças indígenas Guarani hospitalizadas por doença respiratória aguda no Sul e Sudeste do Brasil

Realizou-se estudo de prevalência de sibilância em crianças indígenas Guarani hospitalizadas por infecção respiratória aguda baixa no Sul e Sudeste do Brasil, recrutadas a partir de um sistema de vigilância implantado nas aldeias entre maio de 2007 e junho de 2008. Os dados foram extraídos por revisão dos prontuários hospitalares. Estimaram-se razões de prevalência de sibilância brutas e ajustadas segundo categorias das variáveis exploratórias, por regressão de Poisson com ajuste para variância robusta. A prevalência de sibilância foi de 58,1% (136/234). Permaneceram significativamente associadas à sibilância no modelo final: faixa etária, inversamente associada (0-11 meses: referência; 24-35 meses: 0,63, IC95%: 0,40-0,99); internação no outono (verão: referência; outono: 1,58, IC95%: 1,05-2,40); e sinais clínicos de dispneia (1,41, IC95%: 1,09-1,83), tiragem (1,42, IC95%: 1,16-1,73) e estertor (1,43, IC95%: 1,09-1,87). Os resultados revelam elevada carga de morbidade por sibilância e sugerem o fenótipo de sibilância persistente de início precoce, relacionada à recorrência de infecções respiratórias virais.

Recurrent wheezing is associated with intestinal protozoan infections in Warao Amerindian children in Venezuela: a cross-sectional survey

Background

While in developed countries the prevalence of allergic diseases is rising, inflammatory diseases are relatively uncommon in rural developing areas. High prevalence rates of helminth and protozoan infections are commonly found in children living in rural settings and several studies suggest an inverse association between helminth infections and allergies. No studies investigating the relationship between parasitic infections and atopic diseases in rural children of developing countries under the age of 2 years have been published so far. We performed a cross-sectional survey to investigate the association of helminth and protozoan infections and malnutrition with recurrent wheezing and atopic eczema in Warao Amerindian children in Venezuela.

Methods

From August to November 2012, 229 children aged 0 to 2 years residing in the Orinoco Delta in Venezuela were enrolled. Data were collected through standardized questionnaires and physical examination, including inspection of the skin and anthropometric measurements. A stool sample was requested from all participants and detection of different parasites was performed using microscopy and real time polymerase chain reaction (PCR).

Results

We observed high prevalence rates of atopic eczema and recurrent wheezing, respectively 19% and 23%. The prevalence of helminth infections was 26% and the prevalence of protozoan infections was 59%. Atopic eczema and recurrent wheezing were more frequently observed in stunted compared with non-stunted children in multivariable analysis (OR 4.3, 95% CI 1.3 – 13.6, p = 0.015 and OR 4.5, 95% CI 0.97 – 21.2, p = 0.055). Furthermore, recurrent wheezing was significantly more often observed in children with protozoan infections than in children without protozoan infections (OR 6.7, 95% CI 1.5 – 30.5).

Conclusions

High prevalence rates of atopic eczema and recurrent wheezing in Warao Amerindian children under 2 years of age were related to stunting and intestinal protozoan infections respectively. Helminth infections were not significantly associated with either atopic eczema or recurrent wheezing.

Pediatric allergy and immunology in Brazil

The subspecialty of pediatric allergy and immunology in Brazil is in its early years and progressing steadily. This review highlights the research developed in the past years aiming to show the characteristics of allergic and immunologic diseases in this vast country. Epidemiologic studies demonstrated the high prevalence of asthma in infants, children, and adolescents. Mortality rates and average annual variation of asthma hospitalization have reduced in all pediatric age groups. Indoor aeroallergen exposure is excessively high and contributes to the high rates of allergy sensitization. Prevalence of food allergy has increased to epidemic levels. Foods (35%), insect stings (30%), and drugs (23%) are the main etiological agents of anaphylaxis in children and adolescents. Molecular diagnosis of primary immunodeficiencies (PID) showed a high incidence of fungal infections including paracoccidioidomycosis in X-linked hyper-IgM syndrome, and the occurrence of BCG adverse reactions or other mycobacterial infections in patients with chronic granulomatous disease. Education in pediatric allergy and immunology is deficient for medical students, but residency programs are effective in training internists and pediatricians for the practice of allergy. The field of PID requires further training. Last, this review is a tribute to Prof. Dr. Charles Naspitz, one of the pioneers of our specialty in Brazil.

A survey of recently published cardiovascular, hematological and pneumological original articles in the Brazilian scientific press

Recent original scientific contributions published in selected Brazilian periodicals and classifiable under cardiovascular and pulmonary subject categories cover a wide range of sub specialties, both clinical and experimental. Because they appear in journals with only recently enhanced visibility, we have decided to highlight a number of specific items appeared in four Brazilian journals, because we understand that this is an important subsidy to keep our readership adequately informed. These papers cover extensive sub-areas in both fields.