Childhood asthma in low income countries: an invisible killer?

Global, regional and national epidemiology of allergic disorders in children from 1990 to 2019: findings from the Global Burden of Disease study 2019

OBJECTIVE

This modelling study aimed to estimate the burden for allergic diseases in children during a period of 30 years.

DESIGN

Population-based observational study.

MAIN OUTCOMES AND MEASURES

The data on the incidence, mortality and disability-adjusted life years (DALYs) for childhood allergic diseases, such as atopic dermatitis (AD) and asthma, were retrieved from the Global Burden of Disease study 2019 online database. This data set spans various groups, including different regions, ages, genders and Socio-Demographic Indices (SDI), covering the period from 1990 to 2019.

RESULTS

In 2019, there were approximately 81 million children with asthma and 5.6 million children with AD worldwide. The global incidence of asthma in children was 20 million. Age-standardised incidence rates showed a decrease of 4.17% for asthma, from 1075.14 (95% uncertainty intervals (UI), 724.63 to 1504.93) per 100 000 population in 1990 to 1030.33 (95% UI, 683.66 to 1449.53) in 2019. Similarly, the rates for AD decreased by 5.46%, from 594.05 (95% UI, 547.98 to 642.88) per 100 000 population in 1990 to 561.61 (95% UI, 519.03 to 608.29) in 2019. The incidence of both asthma and AD was highest in children under 5 years of age, gradually decreasing with age. Interestingly, an increase in SDI was associated with a rise in the incidence of both conditions. However, the mortality rate and DALYs for asthma showed a contrasting trend.

CONCLUSIONS

Over the past three decades, there has been a worldwide increase in new asthma and AD cases, even though mortality rates have significantly declined. However, the prevalence of these allergic diseases among children varies considerably across regions, countries and age groups. This variation highlights the need for precise prevalence assessments. These assessments are vital in formulating effective strategies for prevention and treatment.

Global, regional, and national burden of allergic disorders and their risk factors in 204 countries and territories, from 1990 to 2019: A systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Asthma and atopic dermatitis (AD) are chronic allergic conditions, along with allergic rhinitis and food allergy and cause high morbidity and mortality both in children and adults. This study aims to evaluate the global, regional, national, and temporal trends of the burden of asthma and AD from 1990 to 2019 and analyze their associations with geographic, demographic, social, and clinical factors.

METHODS

Using data from the Global Burden of Diseases (GBD), Injuries, and Risk Factors Study 2019, we assessed the age-standardized prevalence, incidence, mortality, and disability-adjusted life years (DALYs) of both asthma and AD from 1990 to 2019, stratified by geographic region, age, sex, and socio-demographic index (SDI). DALYs were calculated as the sum of years lived with disability and years of life lost to premature mortality. Additionally, the disease burden of asthma attributable to high body mass index, occupational asthmagens, and smoking was described.

RESULTS

In 2019, there were a total of 262 million [95% uncertainty interval (UI): 224-309 million] cases of asthma and 171 million [95% UI: 165-178 million] total cases of AD globally; age-standardized prevalence rates were 3416 [95% UI: 2899-4066] and 2277 [95% UI: 2192-2369] per 100,000 population for asthma and AD, respectively, a 24.1% [95% UI: -27.2 to -20.8] decrease for asthma and a 4.3% [95% UI: 3.8-4.8] decrease for AD compared to baseline in 1990. Both asthma and AD had similar trends according to age, with age-specific prevalence rates peaking at age 5-9 years and rising again in adulthood. The prevalence and incidence of asthma and AD were both higher for individuals with higher SDI; however, mortality and DALYs rates of individuals with asthma had a reverse trend, with higher mortality and DALYs rates in those in the lower SDI quintiles. Of the three risk factors, high body mass index contributed to the highest DALYs and deaths due to asthma, accounting for a total of 3.65 million [95% UI: 2.14-5.60 million] asthma DALYs and 75,377 [95% UI: 40,615-122,841] asthma deaths.

CONCLUSIONS

Asthma and AD continue to cause significant morbidity worldwide, having increased in total prevalence and incidence cases worldwide, but having decreased in age-standardized prevalence rates from 1990 to 2019. Although both are more frequent at younger ages and more prevalent in high-SDI countries, each condition has distinct temporal and regional characteristics. Understanding the temporospatial trends in the disease burden of asthma and AD could guide future policies and interventions to better manage these diseases worldwide and achieve equity in prevention, diagnosis, and treatment.

Challenges in the diagnosis of asthma in children, what are the solutions? A scoping review of 3 countries in sub Saharan Africa

Background

Asthma is the commonest chronic respiratory tract disease in children. In low-income countries, challenges exist in asthma diagnosis. In surveys done in children, the prevalence of ‘asthma’ defined by symptoms is high compared to ‘doctor diagnosed asthma’. The questions answered by this review are (i) What challenges have been experienced in the diagnosis of asthma in children? (ii) What solutions will address these challenges?

Methods

The Arksey and O’Malley’s framework for scoping reviews was used for the study methodology, while the PRISMA-ScR checklist guided the reporting process. Electronic databases: PubMed Central, EMBASE and Google Scholar were searched. Primary quantitative and qualitative studies and reviews from 2010 to 2021, from Nigeria, South Africa and Uganda written in English or translated to English, which answered the study questions were included. The author, title, country, study type, methods, purpose, findings and references were captured onto a predefined data collection table. The ‘Preview, Question, Read, Summarise’ system was used and a narrative report was used to summarise the findings.

Results

A total of 28 studies were included. The causes of under-diagnosis of asthma include lack of community knowledge and perception of asthma, poor accessibility to health care, strained health systems, lack of diagnostic tests including spirometry, low levels of knowledge among health-care workers and lack of or non-implementation of asthma guidelines. Strategies to improve asthma diagnosis will include community and school based education programmes, revision of asthma diagnostic terms, guideline development and implementation and health systems strengthening.

Conclusion

This scoping review provides research evidence for policy makers and health-workers involved in the care of asthmatic children on challenges faced in asthma diagnosis and strategies to improve asthma diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02170-y.

Association between early viral lower respiratory tract infections and subsequent asthma development

BACKGROUND

The association between hospitalization for human respiratory syncytial virus (HRSV) bronchiolitis in early childhood and subsequent asthma is well established. The long-term prognosis for non-bronchiolitis lower respiratory tract infections (LRTI) caused by viruses different from HRSV and rhinovirus, on the other hand, has received less interest.

AIM

To investigate the relationship between infant LRTI and later asthma and examine the influence of confounding factors.

METHODS

The PubMed and Global Index Medicus bibliographic databases were used to search for articles published up to October 2021 for this systematic review. We included cohort studies comparing the incidence of asthma between patients with and without LRTI at ≤ 2 years regardless of the virus responsible. The meta-analysis was performed using the random effects model. Sources of heterogeneity were assessed by stratified analyses.

RESULTS

This review included 15 articles (18 unique studies) that met the inclusion criteria. LRTIs at ≤ 2 years were associated with an increased risk of subsequent asthma up to 20 years [odds ratio (OR) = 5.0, 95%CI: 3.3-7.5], with doctor-diagnosed asthma (OR = 5.3, 95%CI: 3.3-8.6), current asthma (OR = 5.4, 95%CI: 2.7-10.6), and current medication for asthma (OR = 1.2, 95%CI: 0.7-3.9). Our overall estimates were not affected by publication bias (P = 0.671), but there was significant heterogeneity [I² = 58.8% (30.6-75.5)]. Compared to studies with hospitalized controls without LRTI, those with ambulatory controls had a significantly higher strength of association between LRTIs and subsequent asthma. The strength of the association between LRTIs and later asthma varied significantly by country and age at the time of the interview. The sensitivity analyses including only studies with similar proportions of confounding factors (gender, age at LRTI development, age at interview, gestational age, birth weight, weight, height, smoking exposure, crowding, family history of atopy, and family history of asthma) between cases and controls did not alter the overall estimates.

CONCLUSION

Regardless of the causative virus and confounding factors, viral LRTIs in children < 2 years are associated with an increased risk of developing a subsequent asthma. Parents and pediatricians should be informed of this risk.

Risk Factors Associated With Health Care Utilization in Preschool Recurrent Wheezers in a Tropical Environment

Introduction: The severity of wheezing episodes is related with the need for health services, but the factors associated with health care utilization in preschool recurrent wheezers in underdeveloped regions are unclear.

Objective: To evaluate the factors associated with health care utilization in preschool recurrent wheezers in Cartagena, Colombia.

Methods: One hundred twenty-seven recurrent wheezers (age 2–6 years old) who were admitted to the emergency room (ER) due to wheezing in a Pediatric reference hospital in Cartagena were included. Children were evaluated by means of questionnaires and classified according to the number of ER visits, need for hospitalization and history of intensive care unit (ICU) admission due to wheezing within the last year. Total serum IgE and specific IgE to house dust mite allergens (HDM) were measured by ImmunoCAP® and allergen sensitization was evaluated by skin prick tests (SPT).

Results: The maternal report of nocturnal cough without fever in their children increased the risk to have ≥5 ER visits in the last year due to wheezing. The use of montelukast was negatively associated with hospitalization, while a history of pneumonia and lack of tap water, increased the risk of hospitalization due to wheezing. A history of bronchiolitis, family history of asthma, cohabiting with two or more siblings, passive exposure to smoke and lack of sewage facilities increased the risk of ICU admission due to wheezing. The presence of atopy evaluated by SPT reactivity, total IgE levels or specific IgE to HDM were not associated with health care utilization. We also found that seroprevalence of positive IgE (≥0.35 kU/L) was 27% to B. tropicalis and 20.3% to D. pteronyssinus but the prevalence of positive IgE sensitization to these allergens was below 2% and 8% when evaluated by SPT, respectively.

Conclusions: Poverty indicators are associated with ICU admission in a group of preschool recurrent wheezers and should be considered as aggravating factors for wheezing. These factors must be systematically assessed in the medical approach in underdeveloped regions in the tropics. Nocturnal cough without fever is a symptom associated with frequent ER visits while atopy was not associated with health care utilization in preschool recurrent wheezers.

Zhike pingchuan granules improve bronchial asthma by regulating the IL-6/JAK2/STAT3 pathway

The present study aimed to investigate the effects of zhike pingchuan granules (ZKPC) on bronchial asthma and the underlying mechanism. A bronchial asthma mouse model was established by aerosol inhalation of ovalbumin. The changes in lung pathomorphology were observed by hematoxylin and eosin staining. The levels of IL-1β, TNF-α and IL-6 in bronchoalveolar lavage fluid (BALF) and serum were detected by corresponding ELISA kits. Levels of reactive oxygen species, malondialdehyde and superoxide dismutase in lung tissues were analyzed using corresponding kits. The expression of proteins related to apoptosis and the IL-6/janus kinase 2 (JAK2)/STAT3 pathway was detected by western blot analysis. The results showed that ZKPC significantly restored the dry/wet ratio and alleviated lung pathomorphology of bronchial asthmatic mice. In addition, ZKPC inhibits inflammation, oxidative stress levels and cell apoptosis in bronchial asthmatic mice and also suppressed the IL-6/JAK2/STAT3 pathway. Fedratinib (a JAK2 inhibitor) further strengthened the alleviative effects of ZKPC on bronchial asthma. In conclusion, ZKPC improved bronchial asthma by suppressing the IL-6/JAK2/STAT3 pathway.

Health Workers' Practices in Assessment and Management of Children with Respiratory Symptoms in Primary Care Facilities in Uganda: A FRESH AIR Descriptive Study

INTRODUCTION

Globally, acute lower respiratory infections are the leading cause of mortality among children under 5 years. Following World Health Organization primary care guidelines, pneumonia is diagnosed based on cough/difficult breathing and fast breathing. We aimed to describe the practices of healthcare workers in primary care health facilities in Uganda in the management of young children with respiratory symptoms especially regarding asthma as opposed to pneumonia.

METHODS

Health workers were observed during clinical consultations with children 1-59 months of age presenting with cough and/or difficult breathing at recruitment. Afterward, an exit interview with the caregiver was conducted. Health center availability of clinical guidelines, equipment and supplies for management of children with respiratory symptoms was assessed systematically.

RESULTS

A total of 218 consultations with 50 health workers at six health centers were included. Median consultation time was 4 min. Health workers asked history relevant to distinguishing asthma from pneumonia in 16% of consultations. The respiratory rate was counted in 10%. Antibiotics were prescribed to 32% of all the children and to 39% of children diagnosed with pneumonia. Caregivers reported being informed of findings and possible diagnosis in 5% of cases. Medicine and equipment needed for diagnosing and treating asthma were generally unavailable.

CONCLUSION

Clinical practices among Ugandan health workers in primary care are insufficient to distinguish between main causes of respiratory symptoms, especially asthma as opposed to pneumonia, in children under five. Irrational use of antibiotics is widespread. Clear communication with caregivers is lacking. This could be due to lack of relevant competencies, medicines, time and supplies.

LAY SUMMARY

Globally, the most frequent cause of death for children under five is infections in the lower airways. The World Health Organization recommends that in local health clinics this is defined as cough/difficult breathing and fast breathing. This article focuses on the practices of local health workers in Uganda and how they in practice diagnose and treat children under five with these symptoms. In addition, we try to estimate how much the caregivers of the children understand from the consultation. This is done by observing the healthcare workers (HCWs) and by interviewing the caregivers. In general, we found that the consultations were too short, that too few of the health workers looked for important signs for lower airways disease such as fast breathing and that antibiotics were prescribed in too many of the consultations. Also, the length and quality of the consultations and the supplies at the local health clinics were not sufficient to diagnose and treat asthma, which can often be mistaken for an infection. We believe that it is an important problem that too few children with asthma are being diagnosed correctly and that antibiotics are being prescribed too frequently, the latter being an important cause of antibiotic resistance. Relevant action must be taken to improve this.

Community health worker case-detection of asthma or reactive airways disease in a resource-poor community in Nicaragua

INTRODUCTION

Asthma is a major cause of morbidity and mortality in children worldwide, but many cases may remain undiagnosed. Community health worker (CHW) programs have improved detection of other diseases such as childhood pneumonia, but none have been validated for detection of asthma in resource-poor settings. We hypothesized that a CHW administered questionnaire would be effective in case-detection of asthma in a poor Nicaraguan community.

METHODS

We enrolled children aged 2-17 from a small semiurban Nicaraguan community. A trained CHW administered a questionnaire based on a previously validated school-based screening questionnaire, which was compared to pediatric pulmonologist evaluation as a reference standard. We determined the questionnaire's sensitivity, specificity, and positive and negative likelihood ratios at different score cut-points.

RESULTS

A total of 199 out of 218 eligible children were enrolled. Total asthma prevalence based on physician diagnosis was 33%. Mean scores on the CHW questionnaire were 3.6 points out of 22 (SD = 4.3) for nonasthmatics and 11.0 points (SD = 5.3) for children with asthma (p < .001). Area under the curve was 0.87. Multivariable analysis showed increased association of asthma/reactive airways disease with respiratory infection in the first 3 months of life and with family history of asthma.

CONCLUSIONS

Prevalence of asthma in this community was high compared to previously reported national prevalence (15.2%), possibly due to increased exposure to risk factors. The questionnaire had a high area under the receiver operating characteristic curve, making it an excellent screening tool. This questionnaire could greatly increase the detection of asthma, allowing for education and referral for ongoing care.

Diagnostic Errors Are Common in Acute Pediatric Respiratory Disease: A Prospective, Single-Blinded Multicenter Diagnostic Accuracy Study in Australian Emergency Departments

Background: Diagnostic errors are a global health priority and a common cause of preventable harm. There is limited data available for the prevalence of misdiagnosis in pediatric acute-care settings. Respiratory illnesses, which are particularly challenging to diagnose, are the most frequent reason for presentation to pediatric emergency departments. Objective: To evaluate the diagnostic accuracy of emergency department clinicians in diagnosing acute childhood respiratory diseases, as compared with expert panel consensus (reference standard). Methods: Prospective, multicenter, single-blinded, diagnostic accuracy study in two well-resourced pediatric emergency departments in a large Australian city. Between September 2016 and August 2018, a convenience sample of children aged 29 days to 12 years who presented with respiratory symptoms was enrolled. The emergency department discharge diagnoses were reported by clinicians based upon standard clinical diagnostic definitions. These diagnoses were compared against consensus diagnoses given by an expert panel of pediatric specialists using standardized disease definitions after they reviewed all medical records. Results: For 620 participants, the sensitivity and specificity (%, [95% CI]) of the emergency department compared with the expert panel diagnoses were generally poor: isolated upper respiratory tract disease (64.9 [54.6, 74.4], 91.0 [88.2, 93.3]), croup (76.8 [66.2, 85.4], 97.9 [96.2, 98.9]), lower respiratory tract disease (86.6 [83.1, 89.6], 92.9 [87.6, 96.4]), bronchiolitis (66.9 [58.6, 74.5], 94.3 [80.8, 99.3]), asthma/reactive airway disease (91.0 [85.8, 94.8], 93.0 [90.1, 95.3]), clinical pneumonia (63·9 [50.6, 75·8], 95·0 [92·8, 96·7]), focal (consolidative) pneumonia (54·8 [38·7, 70·2], 86.2 [79.3, 91.5]). Only 59% of chest x-rays with consolidation were correctly identified. Between 6.9 and 14.5% of children were inappropriately prescribed based on their eventual diagnosis. Conclusion: In well-resourced emergency departments, we have identified a previously unrecognized high diagnostic error rate for acute childhood respiratory disorders, particularly in pneumonia and bronchiolitis. These errors lead to the potential of avoidable harm and the administration of inappropriate treatment.

Prevalence of asthma at a school-based health clinic in Nicaragua

BACKGROUND

Worldwide, it is estimated that 235-334 million people have been diagnosed with asthma. In Nicaragua, the current asthma rate for children 13-14 years of age was 15.2%.

PURPOSE

The purpose of this study was to determine the prevalence of asthma at this school-based health clinic in Managua, Nicaragua, associated symptoms or diseases, determine asthma classification, medications, and hospitalization rates.

METHODS

A retrospective chart review was performed on all pediatric patient's medical records seen in the clinic during a 5-day period (n = 105).

RESULTS

A total of 23 patients (21.9%) had asthma documented in the medical chart and were included in the analysis. Of the 23 patients, 3 (13%) patients were classified with intermittent asthma while the rest of the patients (87%) were not classified. Albuterol was prescribed for 19 (86%) of the patients with two patients who had both albuterol and QVAR® prescribed. Six (26%) patients had a family history of asthma.

DISCUSSION

This study demonstrated the prevalence of asthma in school-aged children in Nicaragua is significant and higher than previously reported. The lack of a classification of asthma prevents patients from potentially being treated appropriately.

Accessibility of basic paediatric emergency care in Malawi: analysis of a national facility census

BACKGROUND

Emergency care is among the weakest parts of health systems in low-income countries with both quality and accessibility constraints. Previous studies estimated accessibility to surgical or emergency care based on population travel times to nearest hospital with no assessment of hospital readiness to provide such care. We analysed a Malawi national facility census with comprehensive inventory audits and geocoded facility locations to identify hospitals equipped to provide basic paediatric emergency care with estimated travel times to these hospitals from non-equipped facilities and in relation to Malawi's population distribution.

METHODS

We analysed a Malawi national facility census in 2013-2014 to identify hospitals equipped to manage critically ill children according to an extended version of WHO Emergency Triage, Assessment and Treatment (ETAT) guidelines. These guidelines include 25 components including staff, transport, equipment, diagnostics, medications, fluids, feeds and consumables that defined an emergency-equipped hospital in our study. We estimated travel times to emergency-equipped hospitals from non-equipped facilities and relative to population distributions using geocoded facility locations and an established accessibility mapping approach using global road network datasets from OpenStreetMap and Google.

RESULTS

Four (3.5, 95% CI: 1.3-8.9) of 116 Malawi hospitals were emergency-equipped. Least available items were nasogastric tubes in 34.5% of hospitals (95% CI: 26.4-43.6), blood typing services (40.4, 95% CI: 31.9-49.6), micro nebulizers (50.9, 95% CI: 41.9-60.0), and radiology (54.2, 95% CI: 45.1-63.0). Nationally, the median travel time from non-equipped facilities to the nearest emergency-equipped hospital was 73 min (95% CI: 67-77) ranging 1-507 min. Approximately one-quarter (27%) of Malawians lived over 120 min from an emergency-equipped hospital with significantly better accessibility in Central than North and South regions (16% vs. 38 and 35%, p < 0.001).

CONCLUSIONS

There are unacceptable deficiencies in accessibility of basic paediatric emergency care in Malawi. Reliable supply chains for essential drugs and commodities are needed, particularly nasogastric tubes, asthma drugs and blood, along with improved capacity for time-sensitive referral. Further child mortality reductions will require substantial investments to expand basic paediatric emergency care into all Malawi hospitals for better managing critically ill children at highest mortality risk.

Symptom-based screening tool for asthma syndrome among young children in Uganda

Under-diagnosis of asthma in ‘under-fives’ may be alleviated by improved inquiry into disease history. We assessed a questionnaire-based screening tool for asthma among 614 ‘under-fives’ with severe respiratory illness in Uganda. The questionnaire responses were compared to post hoc consensus diagnoses by three pediatricians who were guided by study definitions that were based on medical history, physical examination findings, laboratory and radiological tests, and response to bronchodilators. Children with asthma or bronchiolitis were categorized as “asthma syndrome”. Using this approach, 253 (41.2%) had asthma syndrome. History of and present breathing difficulties and present cough and wheezing was the best performing combination of four questionnaire items [sensitivity 80.8% (95% CI 77.6–84.0); specificity 84.7% (95% CI 81.8–87.6)]. The screening tool for asthma syndrome in ‘under-fives’ may provide a simple, cheap and quick method of identifying children with possible asthma. The validity and reliability of this tool in primary care settings should be tested.

Diagnosis and treatment of acute respiratory illness in children under five in primary care in low-, middle-, and high-income countries: A descriptive FRESH AIR study

BACKGROUND

Respiratory disease and, specifically, pneumonia, is the major cause of mortality and morbidity in young children. Diagnosis of both pneumonia and asthma in primary care rests principally on clinical signs, history taking, and bronchodilator responsiveness. This study aimed to describe clinical practices in diverse global primary care settings concerning differential diagnosis of respiratory disease in young children, especially between pneumonia and asthma.

METHODS

Health professionals in Greece, Kyrgyzstan, Vietnam, and Uganda were observed during consultations with children aged 2-59 months, presenting with cough and/or difficult breathing. Data were analyzed descriptively and included consultation duration, practices, diagnoses and availability/use of medications and equipment. The study is part of the European Horizon 2020 FRESH AIR project.

RESULTS

In total, 771 consultations by 127 health professionals at 74 facilities in the four countries were observed. Consultations were shorter in Vietnam and Uganda (3 to 4 minutes) compared to Greece and Kyrgyzstan (15 to 20 minutes). History taking was most comprehensive in Greece. Clinical examination was more comprehensive in Vietnam and Kyrgyzstan and less in Uganda. Viral upper respiratory tract infections were the most common diagnoses (41.7% to 67%). Pneumonia was diagnosed frequently in Uganda (16.3% of children), and rarely in other countries (0.8% to 2.9%). Asthma diagnosis was rare (0% to 2.8%). Antibiotics were prescribed frequently in all countries (32% to 69%). Short acting β-agonist trials were seldom available and used during consultations in Kyrgyzstan (0%) and Uganda (1.8%), and often in Greece (38.9%) and Vietnam (12.6%).

CONCLUSIONS

Duration and comprehensiveness of clinical consultations observed in this study seemed insufficient to guide respiratory diagnosis in young children. Appropriate treatment options may further not be available in certain studied settings. Actions aiming at educating and raising professional awareness, along with developing easy-to-use tools to support diagnosis and a general strengthening of health systems are important goals.

[Levels of airway inflammatory mediators in peripheral blood in infants and young children with wheezing]

OBJECTIVE

To examine the levels of airway inflammatory mediators in peripheral blood in infants and young children with wheezing and to study the possible pathogenesis of wheezing from the aspects of T helper cell 1 (Th1)/T helper cell 2 (Th2) imbalance and airway inflammation.

METHODS

A total of 50 children aged 1 month to 3 years with an acute wheezing episode were enrolled as the wheezing group, and 25 age-matched healthy infants were enrolled as the healthy control group. According to the number of wheezing episodes, the wheezing group was divided into a first-episode group (n=25) and a recurrent wheezing (number of episodes ≥2) group (n=25). According to the presence or absence of high-risk factors for asthma, the wheezing group was divided into a high-risk factor group (n=22) and a non-high-risk factor group (n=28). According to the results of pathogen detection, the wheezing group was divided into a positive pathogen group (n=23) and a negative pathogen group (n=27). Levels of interleukin-2 (IL-2), interleukin-4 (IL-4), interleukin-5 (IL-5), interleukin-13 (IL-13), transforming growth factor-β1 (TGF-β1), and total IgE (TIgE) in peripheral blood were measured for each group. For children with wheezing, eosinophil (EOS) count in peripheral blood was measured, and related samples were collected for respiratory pathogen detection.

RESULTS

The wheezing group had significantly higher levels of IL-4, IL-5, IL-13, TGF-β1, and TIgE in peripheral blood than the healthy control group (P<0.05). There were no significant differences in the levels of IL-2, IL-4, IL-5, IL-13, TGF-β1, and TIgE in peripheral blood between the first-episode and recurrent wheezing groups, between the high-risk factor and non-high-risk factor groups, and between the positive pathogen and negative pathogen groups (P>0.05). The correlation analysis showed that in children with wheezing, EOS count was positively correlated with IL-4 level (P<0.01), IL-4 level was positively correlated with IL-5 and IL-13 levels (P<0.01), IL-5 level was positively correlated with IL-13 level (P<0.01), and IL-2 level was positively correlated with TGF-β1 level (P<0.05).

CONCLUSIONS

Th1/Th2 imbalance with a predominance of Th2 is observed in infants and young children with wheezing. IL-4, IL-5, IL-13, TGF-β1, and IgE are involved in the pathogenesis of wheezing in these children. Airway inflammation is also observed in these children with wheezing, but it is not associated with the number of wheezing episodes, presence or absence of high-risk factors for asthma, or results of pathogen detection.

Characterisation of children hospitalised with pneumonia in central Vietnam: a prospective study

Pneumonia is the most common reason for paediatric hospital admission in Vietnam. The potential value of using the World Health Organization (WHO) case management approach in Vietnam has not been documented.We performed a prospective descriptive study of all children (2-59 months) admitted with "pneumonia" (as assessed by the admitting clinician) to the Da Nang Hospital for Women and Children to characterise their disease profiles and assess risk factors for an adverse outcome. The disease profile was classified using WHO pneumonia criteria, with tachypnoea or chest indrawing as defining clinical signs. Adverse outcome was defined as death, intensive care unit admission, tertiary care transfer or hospital stay >10 days.Of 4206 admissions, 1758 (41.8%) were classified as "no pneumonia" using WHO criteria and only 252 (6.0%) met revised criteria for "severe pneumonia". The inpatient death rate was low (0.4% of admissions) with most deaths (11 out of 16; 68.8%) occurring in the "severe pneumonia" group. An adverse outcome was recorded in 18.7% of all admissions and 60.7% of the "severe pneumonia" group. Children were hospitalised for a median of 7 days at an average cost of 253 USD per admission. Risk factors for adverse outcome included WHO-classified "severe pneumonia", age <1 year, low birth weight, previous recent admission with an acute respiratory infection and recent tuberculosis exposure. Breastfeeding, day-care attendance and pre-admission antibiotic use were associated with reduced risk.Few hospital admissions met WHO criteria for "severe pneumonia", suggesting potential unnecessary hospitalisation and use of intravenous antibiotics. Better characterisation of the underlying diagnosis requires careful consideration.

A prospective multicentre study testing the diagnostic accuracy of an automated cough sound centred analytic system for the identification of common respiratory disorders in children

BACKGROUND

The differential diagnosis of paediatric respiratory conditions is difficult and suboptimal. Existing diagnostic algorithms are associated with significant error rates, resulting in misdiagnoses, inappropriate use of antibiotics and unacceptable morbidity and mortality. Recent advances in acoustic engineering and artificial intelligence have shown promise in the identification of respiratory conditions based on sound analysis, reducing dependence on diagnostic support services and clinical expertise. We present the results of a diagnostic accuracy study for paediatric respiratory disease using an automated cough-sound analyser.

METHODS

We recorded cough sounds in typical clinical environments and the first five coughs were used in analyses. Analyses were performed using cough data and up to five-symptom input derived from patient/parent-reported history. Comparison was made between the automated cough analyser diagnoses and consensus clinical diagnoses reached by a panel of paediatricians after review of hospital charts and all available investigations.

RESULTS

A total of 585 subjects aged 29 days to 12 years were included for analysis. The Positive Percent and Negative Percent Agreement values between the automated analyser and the clinical reference were as follows: asthma (97, 91%); pneumonia (87, 85%); lower respiratory tract disease (83, 82%); croup (85, 82%); bronchiolitis (84, 81%).

CONCLUSION

The results indicate that this technology has a role as a high-level diagnostic aid in the assessment of common childhood respiratory disorders.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry (retrospective) - ACTRN12618001521213 : 11.09.2018.

Nutritional status and disease severity in children acutely presenting to a primary health clinic in rural Gambia

BACKGROUND

Accurate and timely data on the health of a population are key for evidence-based decision making at both the policy and programmatic level. In many low-income settings, such data are unavailable or outdated. Using an electronic medical records system, we determined the association between nutritional status and severe illness and mortality among young children presenting to a rural primary health care facility in the Gambia.

METHODS

Clinical data collected over five years (2010-2014) on children aged under 60 months making acute visits to a primary health care clinic in the rural Gambian district of Kiang West were retrospectively extracted from the medical records system. Generalised estimating equation models were used to investigate associations between nutritional status and illness severity, accounting for repeat visits, gender, age and access to transport to the clinic. The Population Attributable Fraction (PAF) was used to determine the proportion of severe illness likely attributable to different grades of malnutrition.

RESULTS

3839/5021 (77%) children under 60 months of age living in Kiang West presented acutely to the clinic at least once, yielding 21,278 visits (47% girls, median age 20.2 months (Interquartile Range (IQR) 23.92 months)) and 26,001 diagnoses, 86% being infectious diseases. Severe illness was seen in 4.5% of visits (961/21,278). Wasting was associated with an increased risk of severe illness in a dose-dependent manner, ('WHZ < -1' adjusted Odds Ratio (aOR) 1.68, 95% CI:1.43-1.98, p < 0.001, 'WHZ <-2 and ≥-3' aOR 2.78, 95% CI:2.31-3.36, p < 0.001 and 'WHZ < -3' aOR 7.82, 95% CI:6.40-9.55, p < 0.001) the PAF for wasting (WHZ < -2) was 0.21 (95% CI: 0.18-0.24). Stunting, even in the most severe form (HAZ < -3), was not significantly associated with severe illness (aOR 1.19 95% CI:0.94-1.51) but was associated with a significantly increased risk of death (aOR 6.04 95% CI:1.94-18.78).

CONCLUSION

In this population-based cohort of young children in rural Gambia, wasting was associated with disease severity in a dose-dependent manner. Further research is needed into strategies to identify and reach these children with effective interventions to improve their nutritional status.

Recurrent lower respiratory illnesses among young children in rural Kyrgyzstan: overuse of antibiotics and possible under-diagnosis of asthma. A qualitative FRESH AIR study

Lower respiratory tract illnesses (LRT-illnesses) in children under 5 years (U5s) are a leading cause of morbidity, hospitalisations and mortality worldwide, particularly in low-income countries. It is pertinent to understand possible inconsistent management. This study explored perceptions and practices among caregivers and health professionals on recurrent LRT-illnesses in U5s. Semi-structured interviews with 13 caregivers to U5s with recurrent LRT-illnesses and with 22 primary care health professional interviews in two rural provinces in Kyrgyzstan were triangulated. Data were thematically analysed. The majority (8/13) of caregivers described their young children as having recurrent coughing, noisy breathing and respiratory distress of whom several had responded positively to acute salbutamol and/or had been repeatedly hospitalised for LRT-illness. Family stress and financial burdens were significant. The health professionals classified young children with recurrent LRT-illnesses primarily with pneumonia and/or a multitude of bronchitis diagnoses. Broad-spectrum antibiotics and supportive medicine were used repeatedly, prescribed by health professionals or purchased un-prescribed by the caregivers at the pharmacy. The health professionals had never applied the asthma diagnosis to U5s nor had they prescribed inhaled steroids, and none of the interviewed caregivers’ U5s were diagnosed with asthma. Health professionals and caregivers shared a common concern for the children’s recurrent respiratory illnesses developing into a severe chronic pulmonary condition, including asthma. In conclusion, the study identified an inconsistent management of LRT-illnesses in U5s, with exorbitant use of antibiotics and an apparently systemic under-diagnosis of asthma/wheeze. When the diagnosis asthma is not used, the illness is not considered as a long-term condition, requiring preventer/controller medication.

Community-Acquired Pneumonia in Children: the Challenges of Microbiological Diagnosis

Community-acquired pneumonia (CAP) is the leading cause of mortality in children under 5 years of age globally. To improve the management of CAP, we must distinguish CAP from other common pediatric conditions and develop better diagnostic methods to detect the causative organism, so as to best direct appropriate resources in both industrialized and developing countries. Here, we review the diagnostic modalities available for identifying viruses and bacteria in the upper and lower respiratory tract of children, with a discussion of their utility and limitations in diagnosing CAP in children.

Impact of childhood wheezing on lung function in adulthood: A meta-analysis

BACKGROUND

A growing body of evidence shows that childhood wheezing may lead to recurrent or persistent symptoms in adulthood, such that persistent wheezing associated with lung function deficits often have their roots in the first few years of life.

OBJECTIVES

We summarized information from several prospective cohort studies following children with or without wheezing into adulthood, to estimate the effect of childhood wheezing on adulthood lung function.

METHODS

Medical literatures were searched in the Medline, PubMed, ScienceDirect, Web of Science and Embase databases up to October 31, 2016. The adulthood lung function was selected as primary outcome, and chronic obstructive pulmonary disease (COPD) prevalence was selected as secondary outcome. The meta-analysis was performed with the Stata Version 14.0. A random-effects model was applied to estimate standardized mean difference (SMD) of lung function, and relative risk (RR) of COPD.

RESULTS

Six articles enrolling 1141 and 1005 children with and without wheezing, respectively. Meta-analysis showed that childhood wheezing decreased adulthood lung function as compared with no-wheezing subjects (SMD = -0.365, 95% confidence interval (CI): -0.569~-0.161, P = 0.000). Subgroup analyses indicated that childhood atopic wheezing reduced adulthood FEV1/FVC and FEV1%pred when compared with no-wheezing subjects. In addition, childhood atopic wheezing was significantly associated with COPD prevalence (RR = 5.307, 95% CI:1.033~27.271, P = 0.046).

CONCLUSIONS

Our meta-analysis suggests that childhood wheezing may induce ongoing declined lung function that extends into adult life, as well as an increased risk of COPD prevalence when accompanied with atopy.

Predictive Accuracy of Chest Radiographs in Diagnosing Tachypneic Children

OBJECTIVE

To test the predictive accuracy and reporting reproducibility of digital chest radiographs under low-resource conditions.

METHODS

One hundred thirty four tachypneic children who presented to two Indian hospitals were enrolled. Based on review of 16 variables recorded in the Emergency Room (ER) by a senior pediatrician, children were given one of the four clinical diagnoses: pneumonia, wheezy disease, mixed and non-respiratory. Every child also had a digital CXR. It was interpreted by ER physician, pediatrician and two independent radiologists. All used the same standardized interpretation system (one or more of: normal, minor patches, major patches, hyperinflation, lobar change, pleural effusion).

RESULTS

The 10 % of CXRs showing pleural effusions reliably predicted pneumonia and disease severity. For all other CXR findings, the correlation between CXR interpretation and clinical diagnosis was moderate to poor. Apart from pleural effusions, inter-observer agreements between interpretations made by ER physician, pediatrician and radiologist were also poor (kappa <0.4).

CONCLUSIONS

With the exception of pleural effusions, CXR findings, interpreted by a radiologist, had moderate to poor power to predict respiratory diagnosis or disease severity defined by a pediatrician. Value of CXRs was further reduced by poor inter-observer agreement. When investigating tachypneic children under low-resource conditions, CXRs should be used with a clear understanding of their limitations.

FRESH AIR: an implementation research project funded through Horizon 2020 exploring the prevention, diagnosis and treatment of chronic respiratory diseases in low-resource settings

This protocol describes FRESH AIR, an implementation science project exploring how to improve the prevention, diagnosis and treatment of chronic lung diseases in contexts with limited healthcare resources. It consists of inter-related studies that take place in four countries that are part of the International Primary Care Respiratory Group’s (IPCRG) global network: Uganda, the Kyrgyz Republic, Vietnam and Greece. The project has been funded by the European Commission Horizon 2020 research programme and runs from October 2015 until September 2018.

Clinical outcomes of children with acute asthma and pneumonia in Mulago hospital, Uganda: a prospective study

BACKGROUND

Little attention has been paid to asthma in 'under-fives' in Sub-Saharan Africa. In 'under-fives', acute asthma and pneumonia have similar clinical presentation and most children with acute respiratory symptoms are diagnosed with pneumonia according to the WHO criteria. The mortality associated with acute respiratory diseases in Uganda is high but improving, dropping from 24% in 2004 to 11.9% in 2012. We describe the immediate clinical outcomes of children with acute asthma and pneumonia and document the factors associated with prolonged hospitalization and mortality.

METHODS

We enrolled 614 children aged 2 to 59 months with acute respiratory symptoms presenting at the emergency paediatric unit of Mulago hospital. Clinical histories, physical examination, blood and radiological tests were done. Children with asthma and bronchiolitis were collectively referred to as 'Asthma syndrome'. Hospitalized children were monitored every 12 hours for a maximum of 7 days. Survival analysis was done to compare outcome of children with asthma and pneumonia. Cox regression analysis was done to determine factors associated with prolonged hospitalization and mortality.

RESULTS

Overall mortality was 3.6%. The highest case fatality was due to pneumocystis jirovecii pneumonia (2/4) and pulmonary tuberculosis (2/7). None of the children with asthma syndrome died. Children with 'asthma syndrome' had a significantly shorter hospital stay compared to those with pneumonia (p<0.001). Factors independently associated with mortality included hypoxemia (HR = 10.7, 95% CI 1.4- 81.1) and severe malnutrition (HR = 5.7, 95% CI 2.1- 15.8). Factors independently associated with prolonged hospitalization among children with asthma syndrome included age less than 12 months (RR = 1.2, 95% CI 1.0-1.4), hypoxemia (RR = 1.4, 95% CI 1.2-1.7), and severe malnutrition (RR = 1.5 95% CI 1.3-1.8). Similar factors were associated with long duration of hospital stay among children with pneumonia.

CONCLUSION

This study identified a sharp decline in acute respiratory mortality compared to the previous studies in Mulago hospital. This may be related to focus on and treatment of asthma in this study, and will be analysed in a later study. Bacterial pneumonia is still associated with high case fatality. Hypoxemia, severe malnutrition, and being an infant were associated with poor prognosis among children with acute asthma and pneumonia and need to be addressed in the management protocols.

Can we distinguish pneumonia from wheezy diseases in tachypnoeic children under low-resource conditions? A prospective observational study in four Indian hospitals

BACKGROUND

Acute respiratory infections are the commonest cause of mortality and morbidity in children worldwide. A quarter of all deaths occur in India alone. In order to reduce this disease burden, there is a need for better diagnostic criteria, particularly ones allowing early detection of high-risk children.

METHODS

We enrolled 516 under 5 year olds, in four Indian hospitals, who met WHO age-dependent tachypnoea criteria for pneumonia at presentation. Patients underwent a protocolised examination assessing 29 items, including history, examination, O2 saturation, plus scores for chest X-ray, auscultation and conscious level. Treatment was determined by the emergency room (ER) physician. All children were reviewed at day 4 by a paediatrician and placed into four diagnostic categories: pneumonia, wheezy disease, mixed and non-respiratory.

RESULTS

The majority had wheezy diseases (42.8%). The remainder had pneumonia (35.9%), mixed disease (18.6%) and non-respiratory (2.7%). Best diagnostic predictors for wheezy disease were (auscultation/previous similar episodes) and for pneumonia (auscultation/CXR score). Mortality was 1.6%. Best disease severity predictors were conscious level, weight/age z score and respiratory/pulse rates.

INTERPRETATION

Current tachypnoea-based algorithms significantly overdiagnose pneumonia in children and underdiagnose wheezy diseases. Diagnostic accuracy can be improved by various combinations of clinical variables, but the best single diagnostic predictor is auscultation. Simple criteria can also be defined that reliably detect which tachypnoeic children are at high risk of death or deterioration. Management plans based on these protocols could reduce unnecessary antibiotic use, improve the management of wheezy diseases and reduce mortality by earlier identification of high-risk children.

Burden of asthma among children in a developing megacity: childhood asthma study, Pakistan

OBJECTIVES

Global burden of childhood asthma has increased in the past few decades, particularly in low-income countries. In Pakistan, there is a lack of community-based epidemiological studies estimating the burden of asthma among children. This study determined the prevalence and predictors of asthma among children 3-17 years of age in Karachi, Pakistan.

METHODS

A two-stage community-based representative cross-sectional survey was conducted in Karachi from March 2012 to April 2013 comprising 1046 children aged 3-17 years. Of 7500 clusters, 80 were randomly selected, and of these, 15 children per cluster were enrolled randomly. A translated and pre-tested version of International Study of Asthma and Allergies in Children questionnaire was administered.

RESULTS

The overall prevalence of asthma among study participants was 10.2% (95% CI: 8.4-12.0). Asthma was more likely to occur among boys (adj. OR: 2.5, 95% CI: 1.6-4.0), children in the younger age group (3-7 years) (adj. OR: 2.9, 95% CI: 1.7-4.8), those living in households with ill-ventilated kitchens (adj. OR: 1.8, 95% CI: 1.1-3.1), having family history of asthma (adj. OR: 2.3, 95% CI: 1.3-3.9) and those of the Sindhi ethnicity (adj. OR: 2.2, 95% CI: 1.1-4.4).

CONCLUSION

This study is the first robust evidence regarding asthma among children in Pakistan, reporting a high burden in this group. Family history, male gender, Sindhi ethnicity and ill-ventilated kitchen were identified as important predictors of asthma. Targeted preventive measures and intervention studies are required to better understand and reduce the burden of asthma among children in Pakistan.

Diagnosis, management, and prognosis of preschool wheeze

Preschool children (ie, those aged 5 years or younger) with wheeze consume a disproportionately high amount of health-care resources compared with older children and adults with wheeze or asthma, representing a diagnostic challenge. Although several phenotype classifications have been described, none have been validated to identify individuals responding to specific therapeutic approaches. Several risk factors related to genetic, prenatal, and postnatal environment are associated with preschool wheezing. Findings from several cohort studies have shown that preschool children with wheeze have deficits in lung function at 6 years of age that persisted until early and middle adulthood, suggesting increased susceptibility in the first years of life that might lead to persistent sequelae. Daily inhaled corticosteroids seem to be the most effective therapy for recurrent wheezing in trials of children with interim symptoms or atopy; intermittent high-dose inhaled corticosteroids are effective in moderate-to-severe viral-induced wheezing without interim symptoms. The role of leukotriene receptor antagonist is less clear. Interventions to modify the short-term and long-term outcomes of preschool wheeze should be a research priority.

Asthma and pneumonia among children less than five years with acute respiratory symptoms in Mulago Hospital, Uganda: evidence of under-diagnosis of asthma

Background

Pneumonia is considered the major cause of mortality among children with acute respiratory disease in low-income countries but may be over-diagnosed at the cost of under-diagnosing asthma. We report the magnitude of asthma and pneumonia among “under-fives” with cough and difficulty breathing, based on stringent clinical criteria. We also describe the treatment for children with acute respiratory symptoms in Mulago Hospital.

Methods

We enrolled 614 children aged 2–59 months with cough and difficulty breathing. Interviews, physical examination, blood and radiological investigations were done. We defined asthma according to Global Initiative for Asthma guidelines. Pneumonia was defined according to World Health Organization guidelines, which were modified by including fever and white cell count, C-reactive protein, blood culture and chest x-ray. Children with asthma or bronchiolitis were collectively referred to as “asthma syndrome” due to challenges of differentiating the two conditions in young children. Three pediatricians reviewed each participant’s case report post hoc and made a diagnosis according to the study criteria.

Results

Of the 614 children, 41.2% (95% CI: 37.3–45.2) had asthma syndrome, 27.2% (95% CI: 23.7–30.9) had bacterial pneumonia, 26.5% (95% CI: 23.1–30.2) had viral pneumonia, while 5.1% (95% CI: 3.5–7.1) had other diagnoses including tuberculosis. Only 9.5% of the children with asthma syndrome had been previously diagnosed as asthma. Of the 253 children with asthma syndrome, 95.3% (95% CI: 91.9–97.5) had a prescription for antibiotics, 87.7% (95% CI: 83.1–91.5) for bronchodilators and 43.1% (95% CI: 36.9–49.4) for steroids.

Conclusion

Although reports indicate that acute respiratory symptoms in children are predominantly due to pneumonia, asthma syndrome contributes a significant proportion. Antibiotics are used irrationally due to misdiagnosis of asthma as pneumonia. There is need for better diagnostic tools for childhood asthma and pneumonia in Uganda.

Improving the Diagnosis, Management, and Outcomes of Children with Pneumonia: Where are the Gaps?

Pneumonia is the greatest contributor to childhood mortality and morbidity in resource-poor regions, while in high-income countries it is one of the most common reasons for clinic attendance and hospitalization in this age group. Furthermore, pneumonia in children increases the risk of developing chronic pulmonary disorders in later adult life. While substantial advances in managing childhood pneumonia have been made, many issues remain, some of which are highlighted in this perspective. Multiple studies are required as many factors that influence outcomes, such as etiology, patient characteristics, and prevention strategies can vary between and within countries and regions. Also, outside of vaccine studies, most randomized controlled trials (RCTs) on pneumonia have been based in resource-poor countries where the primary aim is usually prevention of mortality. Few RCTs have focused on medium to long-term outcomes or prevention. We propose different tiers of primary outcomes, where in resource-rich countries medium to long-term sequelae should also be included and not just the length of hospitalization and readmission rates.

Asthma

Asthma is a heterogeneous group of conditions that result in recurrent, reversible bronchial obstruction. Although the disease can start at any age, the first symptoms occur during childhood in most cases. Asthma has a strong genetic component, and genome-wide association studies have identified variations in several genes that slightly increase the risk of disease. Asthma is often associated with increased susceptibility to infection with rhinoviruses and with changes in the composition of microbial communities colonising the airways, but whether these changes are a cause or consequence of the disease is unknown. There is currently no proven prevention strategy; however, the finding that exposure to microbial products in early life, particularly in farming environments, seems to be protective against asthma offers hope that surrogates of such exposure could be used to prevent the disease. Genetic and immunological studies point to defective responses of lung resident cells, especially those associated with the mucosal epithelium, as crucial elements in the pathogenesis of asthma. Inhaled corticosteroids continue to be the mainstay for the treatment of mild and moderate asthma, but limited adherence to daily inhaled medication is a major obstacle to the success of such therapy. Severe asthma that is refractory to usual treatment continues to be a challenge, but new biological therapies, such as humanised antibodies against IgE, interleukin 5, and interleukin 13, offer hope to improve the quality of life and long-term prognosis of severe asthmatics with specific molecular phenotypes.

Factors associated with asthma among under-fives in Mulago hospital, Kampala Uganda: a cross sectional study

BACKGROUND

Asthma is the most common chronic childhood illness, with rapidly increasing prevalence in low-income countries. Among young children, asthma is often under-diagnosed.We investigated the factors associated with asthma among under-fives presenting with acute respiratory symptoms at Mulago hospital, Uganda.

METHODS

A hospital-based cross sectional study of 614 children with cough and/or difficult breathing, and fast breathing, was conducted between August 2011 and June 2012. A questionnaire focusing on clinical history of the child was administered to the caretakers. A physical examination and, laboratory and radiological investigations were done. Asthma was defined according to GINA (Global Initiative for Asthma) guidelines which were modified by excluding the symptom of "chest tightness", spirometry/peak expiratory flow measurements and by adding chest x-ray findings to distinguish asthma from pneumonia. A panel of three paediatricians reviewed the participants' case reports and, guided by the study definitions, made a diagnosis of asthma or other. Multivariable logistic regression analysis was done to determine factors independently associated with asthma.

RESULTS

Of the 614 children, 128 (20.8%) had asthma, 125 (20.4%) bronchiolitis, 167 (27.2%) bacterial pneumonia only, 163 (26.5%) viral pneumonia while 31 (5.1%) had other diagnoses including pulmonary tuberculosis. The majority (71.1%) of children with asthma were aged ≥ 12 months. Factors associated with asthma included maternal asthma (AOR 2.4, 95% CI 1.2, 4.6), a history of allergy in the patient (AOR 2.6, 95% CI 1.2, 5.4,), use of gas for cooking (AOR 3.8, 95% CI 1.2, 13.3), prematurity (AOR 9.3, 95% CI 1.2, 83.3) and high level of education of caretaker (AOR 9.1, 95% CI 1.1, 72.8).

CONCLUSION

Maternal asthma, a history of allergy in the patient, use of gas for cooking, prematurity and high level of education of caretaker were significantly associated with asthma. There is need for studies to explore the role of the above factors in development and exacerbation of childhood asthma to provide information that can be used to design strategies for asthma prevention and control.