Enantiomers are one of several possible molecular configurations present in a drug that has at least 1 chiral center. A drug containing 2 or more enatiomers is called a racemic mixture. Enatiomers are being developed from racemic mixtures as drugs in their own right often to extend patent protection of highly popular drugs. However, the therapeutic advantages of single enantiomer drugs developed for respiratory use such as levalbuterol, arformoterol, and levocetirizine over their racemate has been disappointing. In addition, single enantiomer drugs may be several fold more expensive than the racemic drug. New single enantiomer drugs, which are stable (no interconversion back to the racemate) and have fewer adverse effects and a more predictable pharmacodynamic or pharmacokinetic profile would confer a therapeutic advantage and thus would be beneficial for clinical use.
Factors underlying high healthcare utilization among Hispanic and African American (AA) children with asthma are not well known. We hypothesized that low parental knowledge and suboptimal practices are associated with high healthcare utlization and sought to elucidate these factors and identify ethnicity-specific differences. We also hypothesized that a targeted educational intervention will decrease emergency department (ED) visits and hospitalizations. A 57-item questionnaire investigating asthma knowledge, aptitude, and practice was administered during a hospitalization to 268 caregivers (158 Hispanic and 110 AA) of high healthcare utilizer children. Responses were compared between ethnicities. Participants were randomized into an education group and a control group to investigate the impact of an in-hospital educational intervention on future ED visits and hospitalizations. More than 80% of caregivers knew that asthma is associated with muscle constriction and mucus production. Overall, 66.7%–86.9% of caregivers found preventive steps including allergen avoidance, regular primary care physician (PCP) follow–up, and medication adherence helpful, but only 45.2% reported adherence to controller medications. Similarly, caregivers found management steps, including albuterol use, avoidance of ineffective medications, and need to contact PCP helpful but 33% Hispanic caregivers contacted their child's PCP at the time of the exacerbation leading the current hospitalization, compared with 17% AA caregivers (P=0.006). Moreover, 40% and 30% Hispanic and 27% and 18% AA caregivers felt stressed and helpless, respectively, about their child's asthma. Despite high baseline levels of knowledge, there were fewer ED visits in the education group (1.56±1.94) compared with the control group (2.05±2.32) (P=0.02) 2 years after the intervention. Although Hispanic and AA caregivers of children with high healthcare utilization were knowledgeable of asthma pathophysiology, and preventive and management steps, they reported being stressed and helpless and were unable to implement the steps at the time of an exacerbation, seeking care at the ED rather than contacting their PCP. The high health utilizers who underwent a targeted educational intervention had fewer ED visits 2 years following the intervention.
Race and ethnicity affect children's risk of secondhand smoke exposure. However, little is known about how race and language preference impact parents' self-reported smoking and stopping smoking rates. We analyzed data for 16,523 children aged 0–11 years from a pediatric computer decision support system (Child Health Improvement through Computer Automation [CHICA]). CHICA asks families in the waiting room about household smokers. We examined associations between race, insurance, language preference, and household smoking and reported stopping smoking rates using logistic regression. Almost a quarter (23%) of the children's families reported a smoker at home. Hispanic children are least likely (odds ratio [OR]: 0.17, confidence interval [CI]: 0.12–0.24) to have secondhand smoke exposure when compared to African American and white children, as were those with private insurance (OR: 0.52, CI: 0.43–0.64) or no insurance (OR: 0.79, CI: 0.71–0.88) compared to publicly insured. Children from English speaking families were more likely (OR: 1.55, CI: 1.24–1.95) to have secondhand smoke exposure compared to Spanish speaking families. Among smoking families, 30% reported stopping smoking subsequently. Stopping rates were higher in Hispanic (OR: 3.25, CI: 2.06–5.13) and African American (OR: 1.39, CI: 1.01–1.91) families compared to white children's families. Uninsured families were less likely than publicly insured families to report stopping smoking (OR: 0.76, CI: 0.63–0.92). English speaking families were less likely (OR: 0.56, CI: 0.41–0.75) to report stopping smoking compared to Spanish speaking even in a subgroup analyses of Hispanic families (OR: 0.55, CI: 0.39–0.76). In our safety net practices serving children predominantly on public insurance, Spanish speaking families reported the lowest risk of secondhand smoke exposure in children and the highest rate of stopping smoking in the household. Hispanic families may have increasing secondhand exposure and decreasing rates of stopping smoking as they acculturate.
The purpose of this review is to discuss the effect of daily inhaled corticosteroids (ICSs) on the height of children with asthma. The effect of ICSs on growth and height is dependent on the dose and the therapeutic index of the ICS; however, the effect on final adult height was not clear until recently. New data suggest that if growth suppression occurs with the use of ICSs in children, it is sustained, but not cumulative over the years. The observed reduction in the final adult height is small and does not outweigh the benefits of ICSs, and the growth effect may be minimized by use of newer ICSs and other approaches for management of asthma in children with mild to moderate asthma.
Little is known about how pediatric providers assess parental health literacy, how concordant they are with validated measures of health literacy, and how these perceptions may influence treatment recommendations, how instructions are given or how reliable they perceive parents to be in carrying out instructions. Two hundred and eighty-one parents of 6–12-year-old asthma patients attending a pediatric clinic visit were recruited to a cross-sectional study of health literacy and asthma outcomes. Fourteen pediatric healthcare providers participated. Parents completed surveys that included 2 measures of health literacy: the Test of Function Health Literacy in Adults (TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM). Immediately postvisit, pediatric providers completed a brief survey asking their assessment of the parent's health literacy and how it impacted treatment instructions and recommendations. Kappa statistics tested concordance; chi square and logistic regression tested associations among provider ratings, rating concordance, and demographic factors. Six providers were interviewed regarding the bases for their ratings. Providers' perceptions influenced asthma treatment recommendations (p=0.001) and how treatment instructions were given (p=0.001). Providers indicated that their perceptions were shaped by parent's verbal communication skills and patterns of past behavior related to children's asthma management. Data from 277 parents indicated that most had adequate health literacy with a lower percentage scored as adequate by the REALM versus the TOFHLA. Pediatric provider estimates of parental health literacy had low concordance with the validated measures. Providers were more likely to designate whites as adequately health literate. Pediatric asthma providers' perceptions of parents' health literacy can influence treatment recommendations and instructional practices.
This study has investigated a potential role of common Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene variants in the etiology of noncystic fibrosis bronchiectasis in Serbian children. The study has encompassed 48 patients (19 male and 29 female, aged between 5 and 18 years, median age 10.6±3.3), diagnosed with idiopathic bronchiectasis based on high-resolution computed tomography of thorax and pathologic examination of lobectomy materials. The CFTR gene analysis was performed on genomic DNA extracted from peripheral blood samples of patients by polymerase chain reaction (PCR)-Mediated Site-Directed Mutagenesis method, Denaturing Gradient Gel Electrophoresis method, and DNA sequencing. Mutation c.1521_1523delCTT (F508del) was detected with an allelic frequency of 1.0%, and c.224G>A (R75Q) variant. Carriers of c.1210-12T (IVS8-5T) allele were significantly more common than in the general population (10.4% vs. 5.0%, P=0.0302). The frequency of homozygotes for Met 470 allele was higher in patients than in the general population (33% vs. 20%), while heterozygotes for p.Met470Val were less frequent (31% vs. 50%), and this difference was statistically significant (P=0.0222). The results obtained in this study indicate involvement of 2 common CFTR variants, c.1210-12T and c.1408A, in idiopathic bronchiectasis in children, but this observation should be further confirmed by more extensive analysis of the CFTR gene in a larger group of patients.
Schools are effective venues for providing pediatric asthma education programs. Resources are limited, however, so ideally, these programs should be provided to schools with the highest prevalence. National and state asthma surveillance data cannot be extrapolated to local geographic areas. The objective of this study was to survey local schools on Long Island to obtain this information. Survey forms were mailed to the school nurses at every school in Nassau and Suffolk Counties, New York, in 2004, 2006, 2008, and 2010 asking for the number of children with asthma and the number who had permission to access rescue medication in the school. School nurses completed and returned the forms. We analyzed data from elementary and high schools separately, as high-school students often carry their medications with them without obtaining permission. Of the 3,327 surveys sent, 2,060 (61.9%) were returned and 1,807 (54.3%) could be included in the analyses. Overall, asthma prevalence increased from 7.6% in 2004 to 8.7% in 2010. This mirrored the New York State and national trends, although the rates we found were generally lower. The rate of asthmatic children with permission to access rescue medication in school was about the same throughout the study period (39.7% in 2004 and only 42.3% in 2010). Both rates were lower in elementary schools in low socioeconomic areas. These methods allowed us to compare the burden of childhood asthma in individual responder schools in a relatively large geographic area.
To assess the influence of dietary patterns on the prevalence of wheezing in the child and adolescent population in Northeastern Brazil. This is a cross-sectional study of male and female students, 6–12 years old, from the public elementary schools of São Francisco do Conde, Bahia, Northeastern Brazil. The report of wheezing in the past 12 months was collected using a questionnaire from the International Study of Asthma and Allergies in Childhood Program phase III, adapted to Portuguese. Consumption patterns were derived from principal component analysis based on the frequency of consumption of 97 food items by the food frequency questionnaire. We also obtained the anthropometric status, level of physical activity, pubertal development, and socioeconomic information, for each participant. Multivariate logistic regression analyses were used to assess the associations of interest. Of the children surveyed, 10.6% reported having wheezing. We identified 2 dietary patterns named Western and Prudent. We found a positive statistically significant association of the Western pattern with wheeze (odds ratio=1.77, 95% confidence interval: 1.10–2.84) after adjustment for total energy intake and controlling for potential confounders. The results showed that the Western dietary pattern was associated with wheezing. Our result is according with previous findings reported in several other studies.
Adolescents with asthma have a higher risk of morbidity and mortality than other age groups. Asthma self-management has been shown to improve outcomes; however, the concept of asthma self-management is not explicitly defined.
We use the Norris method of concept clarification to delineate what constitutes the concept of asthma self-management in adolescents. Five databases were searched to identify components of the concept of adolescent asthma self-management, and lists of relevant subconcepts were compiled and categorized.
Analysis revealed 4 specific domains of self-management behaviors: (1) symptom prevention; (2) symptom monitoring; (3) acute symptom management; and (4) communication with important others. These domains of self-management were mediated by intrapersonal/cognitive and interpersonal/contextual factors.
Based on the analysis, we offer a research-based operational definition for adolescent asthma self-management and a preliminary model that can serve as a conceptual base for further research.
Asthma disproportionally affects different ethnic/racial groups, with Puerto Ricans and African Americans suffering the highest asthma prevalence and morbidity, Mexicans the lowest, and non-Hispanic whites in between. Genome-wide association studies of asthma have found both shared and race/ethnic-specific genetic risks factors for asthma. However, the majority of genetic asthma research is performed in populations of European descent, which limits the benefits of genetic research to European populations. It is important to biomedical and clinical research to include more diverse and underrepresented populations. The rich genetic diversity of all populations can be leveraged to scientific advantage. For example, admixture mapping provides a more powerful approach than traditional genome-wide allelic association studies in discovering genetic associations for complex diseases. By being more inclusive we can achieve a better understanding of the genetics of asthma, address health disparities, and ensure that scientific advances will benefit populations worldwide.
Asthma and obesity, which have reached epidemic proportions, impact urban youth to a great extent. Findings are inconsistent regarding their relationship; no studies have considered asthma management. We explored the association of obesity and asthma-related morbidity, asthma-related health care utilization, and asthma management in urban adolescents with uncontrolled asthma. We classified 373 early adolescents (mean age=12.8 years; 82% Hispanic or Black) from New York City public middle schools into 4 weight categories: normal (body mass index [BMI]<85th percentile); overweight (85th percentile≤BMI<95th percentile); obese (95th percentile≤BMI<97th percentile); and very obese (BMI≥97th percentile). We compared sample obesity prevalence to national estimates, and tested whether weight categories predicted caregiver reported asthma outcomes, adjusting for age and race/ethnicity. Obesity prevalence was 37%, with 28% of the sample being very obese; both rates were significantly higher than national estimates. We found no significant differences in asthma-related health care utilization or asthma management between weight categories, and a few differences in asthma-related morbidity. Relative to normal weight and obese youth, overweight youth had higher odds of never having any days with asthma-related activity limitations. They also had higher odds of never having asthma-related school absences compared with obese youth. Overweight youth with asthma-related activity limitations had more days with limitations compared with normal weight youth. Overweight, but not obese youth, missed more school due to asthma than normal weight youth. Overweight and obesity prevalence was very high in urban, Hispanic, and Black adolescents with uncontrolled asthma, but not strongly associated with asthma-related morbidity, asthma-related health care utilization, or asthma management practices.
Obesity rates have increased dramatically among children in many parts of the world, especially in North America and several other English-speaking countries. The impact of obesity on pediatric health has become a major prevention initiative by the Obama administration and several public health organizations. Children with obesity are at increased risk for developing asthma, which is already one of the most common chronic diseases among children. The cause underlying obesity's impact on asthma risk is unknown. Commonly cited potential etiologies include airway smooth muscle dysfunction from thoracic restriction, obesity-related circulating inflammation priming the lung, and obesity-related comorbidities mediating asthma symptom development. Each of these theories does not fit precisely with all of the data that have accumulated over the last decade. In this review, I will explore other possible causes including: (1) dietary characteristics common in Westernized countries that might lead to both obesity and asthma; (2) reductions in physical activity; and (3) genetic alterations that increase the propensity to both obesity and asthma together. Next, I will review the current data on how obesity affects common characteristics of asthma such as airway inflammation, lung function, risk of exacerbation, atopy, and response to treatment. Obesity in children with asthma appears to be associated with greater airflow obstruction and a mildly diminished response to inhaled corticosteroids. Little objective evidence in children suggests that obesity significantly heightens the risk of exacerbation or worsens disease stability in children. Lastly, I will discuss the current literature that suggests that obese children with asthma generally should receive the same guidelines-based management as lean children. However, interventions that encourage daily physical activity, weight-loss, normalization of nutrient levels, and monitoring of common obesity-related sequelae should be considered by healthcare providers managing obese children with difficult-to-control asthma.
Allergic disorders, including asthma, allergic rhinitis, atopic dermatitis, eosinophilic esophagitis, and food allergy, are a major global health burden. The study and management of allergic disorders is complicated by the considerable heterogeneity in both the presentation and natural history of these disorders. Biorepositories serve as an excellent source of data and biospecimens for delineating subphenotypes of allergic disorders, but such resources are lacking.
In order to define subphenotypes of allergic disease accurately, we established an infrastructure to link and efficiently utilize clinical and epidemiologic data with biospecimens into a single biorepository called the Greater Cincinnati Pediatric Clinic Repository (GCPCR). Children with allergic disorders as well as healthy controls are followed longitudinally at hospital clinic, emergency department, and inpatient visits. Subjects' asthma, allergy, and skin symptoms; past medical, family, social, diet, and environmental histories; physical activity; medication adherence; perceived quality of life; and demographics are ascertained. DNA is collected from all participants, and other biospecimens such as blood, hair, and nasal epithelial cells are collected on a subset.
To date, the GCPCR has 6,317 predominantly Caucasian and African American participants, and 93% have banked DNA. This large sample size supports adequately powered genetic, epidemiologic, environmental, and health disparities studies of childhood allergic diseases.
The GCPCR is a unique biorepository that is continuously evaluated and refined to achieve and maintain rigorous clinical phenotype and biological data. Development of similar disease-specific repositories using common data elements is necessary to enable studies across multiple populations of comprehensively phenotyped patients.
Fractional exhaled nitric oxide (FENO) levels are increased in children with asthma and in infants with recurrent wheezing, but the role of FENO in the acute phase of bronchiolitis is still not defined.
The aim of this study is to evaluate FENO values in the acute phase of bronchiolitis, compare them with healthy infants, and relate those values with the appearance of other wheezing episodes.
FENO values were determined in infants between 2 months and 2 years affected with RVS bronchiolitis by offline method. The FENO values collected in the acute phase were related with the respiratory clinical symptoms presented in the 2 years following the episode.
A total of 30 patients were recruited: 15 in the bronchiolitis group and 15 in the control group. The average of the FENO values in the acute phase was 18.74 ppb (range 2–88) in the bronchiolitis group, and 8.75 ppb (range 2–24) in the control group. However, these results showed no significant statistical differences (p=0.176). Nevertheless, we found a positive correlation between the FENO values and the clinical score (Downes) of the bronchiolitis episode (p=0.023). In infants that presented other wheezing episodes in the 2 years after, the average of FENO in the acute phase of the first episode was 23.1 ppb (average of 10.25 ppb) versus 8.4 ppb (average 5.4 ppb) in the group of patients with no other episodes. The comparison of averages has no statistical significance.
We found no differences in FENO between infants with bronchiolitis and healthy ones. The FENO values in the acute phase seems to be related to the severity of the disease but do not predict the appearance of wheezing episodes in the following 2 years.
This paper documents individual asthma action plan presence and quick relief medication (albuterol) availability for elementary students enrolled in five Alabama school systems.
Patients and Methods
Data were obtained during baseline data collection (fall 2005) of a school-based supervised asthma medication trial. All students attended 1 of 36 participating elementary schools across five school systems in Jefferson County, Alabama. In addition, they had to have physician-diagnosed asthma requiring daily controller medication. Each school system had its own superintendent and elected school board. Asthma action plan presence and albuterol availability was confirmed by study personnel. Asthma action plans had to contain daily and acute asthma management instructions. Predictors of asthma action plan presence and albuterol availability were also investigated. Associations between albuterol availability and self-reported characteristics including health care utilization prior to study enrollment and outcomes during the study baseline period were also investigated.
Enrolled students had a mean (SD) age of 11.0 (2.1) years, 91% were African American, and 79% had moderate persistent asthma. No student had a complete asthma action plan on file and only 14% had albuterol physically available at school. Albuterol availability was not predicted by gender, race, insurance status, second-hand smoke exposure, need for pre-exercise albuterol, asthma severity, or self-reported health care utilization prior to study enrollment. Albuterol availability did not predict school absences, red/yellow peak flow recordings, or medication adherence during the study's baseline period.
Despite policies permitting students to possess albuterol, few elementary students across five independent school systems in Alabama actually had it readily available at school.
According to National Institutes of Health (NIH) guidelines, asthma control and severity are unique constructs. Little is known about how asthma control and severity are distinguished by pediatricians and if they influence treatment recommendations.
We conducted a random-sample survey of 500 pediatricians using patient vignettes with different asthma status indicators (recent hospitalization, parental report of bother from asthma, frequent symptoms, parental report of worsening asthma, and wheeze during physical exam) and a visual analog scale (VAS) to rate control and severity. Regression models assessed the independent effects of these indicators on asthma control and severity ratings, and the effects of these ratings on treatment recommendations.
A total of 270 respondents provided usable data. Compared to patients with well-controlled asthma: (1) medication intensity influenced only severity ratings; (2) frequent symptoms and recent hospitalization influenced control and severity ratings; (3) wheeze and bother influenced control ratings only (p<0.001 for all comparisons); (4) a report of worse asthma did not significantly affect any ratings (p>0.2). Poorer VAS control ratings were associated with recommendations to step-up treatment (odds ratio [OR] 2.61, 95% confidence interval [CI], 2.2–3.1, p<0.001), but more severe VAS ratings were not (OR 1.02, 95% CI, 0.9–1.2, p=0.8). Recommendations to step-down treatment were associated with poorer VAS control ratings (OR 0.70, 95% CI, 0.6–0.8, p<0.001) and more severe VAS ratings (OR 0.82, 95% CI, 0.7–0.9, p<0.001).
Pediatricians who step-up asthma treatment base their assessments on asthma control, while assessments of both control and severity factor into their decision to step-down asthma therapy.
Primary ciliary dyskinesia (PCD) is a rare genetic condition that causes impaired mucociliary clearance due to poorly functioning cilia. PCD is one disease manifestation of the many recently recognized associations with ciliary malfunction, referred to as “ciliopathies.” Manifestations of PCD commonly begin in the neonatal period with cough, pneumonia, and chronic ear infections or effusions. Approximately half of the affected individuals have situs inversus totalis. The diagnosis is often made in later childhood or early adulthood, because symptoms mimic more common childhood illnesses and because the definitive diagnosis of PCD can be challenging. Treatment recommendations are largely based on therapies used for other conditions with impaired mucociliary clearance in the absence of evidence-based research specific for PCD. Early recognition and initiation of both otolaryngologic and pulmonary management might reduce potential long-term morbidities. The purpose of this article is to update primary care providers, allergists, and pediatric pulmonologists on recent advances in this interesting condition.
Recent studies have shown that osteopontin, a cytokine with suggested immunoregulatory functions, may contribute to pathogenesis of asthma. To determine whether single-nucleotide polymorphisms (SNPs) in SPP1, the gene encoding osteopontin, are associated with risk of asthma, we genotyped 6 known SNPs in SPP1 in the well-characterized Genetics of Asthma in Latino Americans population of 294 Mexican and 365 Puerto Rican parent–child asthma trios. The associations between SNPs and asthma or asthma-related phenotypes were examined by transmission disequilibrium tests as implemented in the family-based association test program. Three polymorphisms, 1 in exon 7 (rs1126616C) and 2 in the 3′-untranslated region (rs1126772A and rs9138A) of SPP1, were associated with diagnosis of asthma, severity of asthma, asthma in subjects with elevated immunoglobulin E (IgE) (IgE >100 IU/mL), and postbronchodilator FEV1 in Puerto Ricans (P values=0.00007–0.04). The CC genotype of rs1126616 conferred an odds ratio of 1.7 (95% CI=[1.3, 2.3], P value adjusted for multiple comparisons=0.001) for asthma compared with the CT and TT genotypes. Furthermore, haplotype analysis identified rs1126616C-rs1126772A-rs9138A to be associated with an increased risk for asthma, severity of asthma, and asthma in subjects with elevated IgE (P=0.03). There was no association between the SPP1 SNPs and asthma outcomes in Mexicans. Our findings suggest that the SPP1 gene is a risk factor for asthma and asthma-related phenotypes in Puerto Ricans, and are consistent with previous animal and human studies on the role of osteopontin in pathogenesis of asthma.
Latino and African American children with asthma are at increased risk for asthma morbidity compared with non–Latino White children. Environmental control (ie, environmental exposures and family strategies to control them) may contribute to greater asthma morbidity for ethnic minority children living in urban environments. This study examined ethnic differences in a semi-structured assessment of environmental control, associations between environmental control and asthma outcomes (asthma control, functional limitation, and emergency department [ED] use), and ethnic differences in environmental triggers in a sample of urban Latino, African American, and non–Latino White families. One hundred thirty-three children (6–13 years of age) and their caregivers completed demographic questionnaires, measures of asthma control and morbidity, and a semi-structured interview assessing environmental control. Reported environmental control differed significantly by ethnicity (P<0.05), with Latino families reporting higher levels of environmental control. Reported environmental control was significantly associated with asthma control (P<0.017) and functional limitation (P<0.017). Reported environmental control and ED use were significantly associated in Latino families (P<0.05). Non–Latino White and African American families reported more secondhand smoke exposure than Latino families (P<0.001). Latino families reported more optimal home environmental control than other ethnic groups. Substantial ethnic differences in asthma triggers suggest that observed ethnic disparities in asthma may be due, at least in part, to differences in the home environment.
Among adults, anxiety related to asthma has been acknowledged to influence asthma self-management. However, it has not been addressed in pediatric samples and there have been no measures developed to assess asthma-related anxiety in youth or parents. The objective of this study was to develop and test the psychometric properties of novel instruments assessing asthma-related anxiety: the Youth Asthma-Related Anxiety Scale (YAAS) and Parent Asthma-Related Anxiety Scale (PAAS). Scale items were analyzed for content validity. We determined the factor structure using exploratory factor analysis and tested the scales' psychometric properties with 285 Hispanic and African American early adolescents with uncontrolled asthma (mean age=12.8) and their parents (n=230) who participated in a larger randomized control trial testing the efficacy of an asthma intervention; control group families (134 youth and 103 parents) provided follow-up data to assess temporal stability. Both the YAAS and PAAS contained 2 factors with Cronbach alpha coefficients ranging from 0.75 to 0.90. The 2 factors, anxiety about asthma severity and about disease-related restrictions, were highly correlated within each measure. The measures displayed content and construct validity and demonstrated moderate temporal stability over 2–3 months (range: 0.36–0.42). The YAAS and PAAS have adequate psychometric properties and can meaningfully contribute to the assessment of asthma-related anxiety in adolescents and their parents, filling a clinical need in this population.
The fraction of exhaled nitric oxide (FeNO), a measure of airway inflammation, is a potential noninvasive tool to guide asthma management in children. It remains unclear, however, if FeNO adds any information beyond clinical assessment of asthma control. We evaluated the associations of FeNO level with short acting beta agonist use and compared it with other clinical asthma assessments. We examined a prospective cohort study of 225 tobacco-smoke-exposed children aged 6–12 years with doctor-diagnosed asthma, including measures of FeNO, reported days of short acting beta agonist use, and unscheduled asthma visits. FeNO was analyzed in relation to current and future (3 months later) short acting beta agonist use. Mean FeNO at baseline, 6, and 12 months was 15.5, 15.7, and 16.8 ppb. In multivariable analyses, higher FeNO level was associated with increased short acting beta agonist use but only among children who were not on inhaled corticosteroids. Among those not on an inhaled steroid, there was a 12% increase in current and 15% increase in future days of short acting beta agonist use for every 10 ppb increase in FeNO level. FeNO levels remained associated with current short acting beta agonist use even after adjusting for unscheduled asthma visits. FeNO levels remained associated with future short acting beta agonist use even after adjusting for current short acting beta agonist use or unscheduled asthma visits. We conclude that FeNO levels are associated with short acting beta agonist use but only among children who are not on an inhaled corticosteroid.
A number of studies have linked obesity with asthma in adults and children. Few longitudinal studies have evaluated the effect of maternal pre-pregnancy obesity on either asthma or early childhood respiratory morbidity, and these have not been in urban, nonwhite populations. We sought to determine whether pre-pregnancy obesity was associated with recurrent wheezing in an urban, nonwhite population. This study includes 1,191 children from the Boston Birth Cohort (1998–present) followed prospectively to a mean age of 3.0 ± 2.4 years with study visits aligned with the pediatric primary care schedule. Multivariate logistic regression was used to evaluate the associations of maternal pre-pregnancy obesity (body mass index ≥30) with recurrent wheezing (≥4 lifetime episodes). Secondary outcomes included log-transformed cord-blood immunoglobulin E (Phadia), and physician diagnoses of eczema and food allergy. Pre-pregnancy obesity was present in 20.7% of mothers. Of the 1,191 children, 60 (5%) developed recurrent wheezing. Children of obese mothers had an increased risk of recurrent wheezing (adjusted odds ratio, 95% confidence interval: 3.51, 1.68–7.32). These associations persisted even after adjustment for fetal growth status. In contrast, maternal obesity was not associated with eczema or food allergy, and was inversely associated with log cord-blood immunoglobulin E (β, 95% confidence interval: −0.34, −0.66 to −0.02). In this predominantly urban, multiracial/ethnic birth cohort, maternal pre-pregnancy obesity was associated with an increased risk of recurrent wheezing. This association was not explained by fetal growth or increased atopy. Maternal pre-pregnancy obesity is a prevalent risk factor for respiratory morbidity in this urban, nonwhite population.
The effect of food introduction timing on the development of food allergy remains controversial. We sought to examine whether the presence of childhood eczema changes the relationship between timing of food introduction and food allergy. The analysis includes 960 children recruited as part of a family-based food allergy cohort. Food allergy was determined by objective symptoms developing within 2 hours of ingestion, corroborated by skin prick testing/specific IgE. Physician diagnosis of eczema and timing of formula and solid food introduction were obtained by standardized interview. Cox Regression analysis provided hazard ratios for the development of food allergy for the same subgroups. Logistic regression models estimated the association of eczema and formula/food introduction with the risk of food allergy, individually and jointly. Of the 960 children, 411 (42.8%) were allergic to 1 or more foods and 391 (40.7%) had eczema. Children with eczema had a 8.4-fold higher risk of food allergy (OR, 95% CI: 8.4, 5.9–12.1). Among all children, later (>6 months) formula and rice/wheat cereal introduction lowered the risk of food allergy. In joint analysis, children without eczema who had later formula (OR, 95% CI: 0.5, 0.3–0.9) and later (>1 year) solid food (OR, 95% CI: 0.5, 0.3–0.95) introduction had a lower risk of food allergy. Among children with eczema, timing of food or formula introduction did not modify the risk of developing food allergy. Later food introduction was protective for food allergy in children without eczema but did not alter the risk of developing food allergy in children with eczema.
Tobacco use currently claims >5 million deaths per year worldwide and this number is projected to increase dramatically by 2030. The burden of death and disease is shifting to low- and middle-income countries. Tobacco control initiatives face numerous challenges including not being a high priority in many countries, government dependence upon immediate revenue from tobacco sales and production, and opposition of the tobacco industry. Tobacco leads to environmental harms, exploitation of workers in tobacco farming, and increased poverty. Children are especially vulnerable. Not only do they initiate tobacco use themselves, but also they are victimized by exposure to highly toxic secondhand smoke. Awareness of tobacco adverse health effects is often superficial even among health professionals. The tobacco industry continues to aggressively promote its products and recognizes that children are its future. The tools and knowledge exist, however, to dramatically reduce the global burden of tobacco. In 2003 the World Health Organization adopted the Framework Convention on Tobacco Control. Aggressive tobacco control initiatives have been undertaken not only in high-income countries but also in less-wealthy countries such as Uruguay and Thailand. Stakeholders must come together in coordinated efforts and there must be a broad and sustained investment in global tobacco control.