Childhood asthma--all that wheezes is not inflammation

Emergency management and asthma risk in young Medicaid-enrolled children with recurrent wheeze

OBJECTIVES

To describe clinical characteristics of young children presenting to the emergency department (ED) for early recurrent wheeze, and determine factors associated with subsequent persistent wheeze and risk for early childhood asthma.

METHODS

Retrospective cohort study of Medicaid-enrolled children 0-3 years old with an index ED visit for wheeze (e.g. bronchiolitis, reactive airway disease) from 2009 to 2013, and at least one prior documented episode of wheeze at an ED or primary care visit. The primary outcome was persistent wheeze between 4 and 6 years of age. Demographics and clinical characteristics were collected from the index ED visit. Logistic regression was used to estimate the association between potential risk factors and subsequent persistent wheeze.

RESULTS

During the study period, 41,710 children presented to the ED for recurrent wheeze. Mean age was 1.3 years; 59% were male, 42% Black, and 6% Hispanic. At index ED visits, the most common diagnosis was acute bronchiolitis (40%); 77% of children received an oral corticosteroid prescription. Between 4 and 6 years of age, 11,708 (28%) children had persistent wheeze. A greater number of wheezing episodes was associated with an increased odds of ED treatment with asthma medications. Subsequent persistent wheeze was associated with male sex, Black race, atopy, prescription for bronchodilators or corticosteroids, and greater number of visits for wheeze.

CONCLUSIONS

Young children with persistent wheeze are at risk for childhood asthma. Thus, identification of risk factors associated with persistent wheeze in young children with recurrent wheeze might aid in early detection of asthma and initiation of preventative therapies.

Leukotriene receptor antagonists in virus-induced wheezing : evidence to date

Virus-induced wheezing is a relatively benign entity that is usually transient in early childhood but is responsible for much health care utilization. The condition, seen traditionally as a subset of those children diagnosed as having frequent episodic asthma, is often treated with inhaled corticosteroids, despite their lack of efficacy. However, there remains some confusion differentiating atopic asthma from virus-induced wheezing in young children and their respective treatment strategies.The demonstration of cysteinyl leukotrienes in the nasopharyngeal secretions of infants and young children who wheeze prompted investigation of the role of leukotriene receptor antagonists in the treatment of virus-induced wheezing for young children with bronchiolitis and virus-induced wheezing.Montelukast, the only leukotriene receptor antagonist studied in young children, has been proven useful in increasing the number of symptom-free days and delaying the recurrence of wheeze in the month following a diagnosis of respiratory syncytial virus-induced wheezing in children aged 3-36 months. Subsequently, in children aged 2-5 years with frequent episodic asthma, primarily involving viral induced attacks in this age group, regular therapy with daily montelukast for 12 months reduced the rate of asthma exacerbations by 31% over placebo, delayed the time to the first exacerbation by 2 months, and lowered the need to prescribe inhaled corticosteroids as preventative therapy. Additionally, montelukast has been demonstrated to be efficacious as an acute episode modifier in children aged 2-14 years (85% children <6 years) with virus-induced wheezing where it was prescribed at the onset of a viral infection in children with an established pattern of viral induced episodes of wheeze in the preceding year. In this study, emergency department visits were reduced by 45%, visits to all health care practitioners were reduced by 23%, and time of preschool/school and parental time off work was reduced by 33% for children who took montelukast for a median of 10 days.At present, there is good evidence to support the use of bronchodilators in the acute treatment of virus- induced wheezing, and increasing evidence to support the use of leukotriene receptor antagonists, in particular montelukast, in the management of children with virus-induced wheezing.

Entry age into day care and later development of allergic disorders--results from the city of Leipzig cohort of the LISA study

The situation in early childhood is supposed to be a risk factor for later development of allergic diseases. The birth cohort from the LISA (Lifestyle-Immune System-Allergy) study gave us the opportunity to investigate the relationship between early childhood situation and the development of allergic diseases. This paper describes our findings regarding to the relationship between entry age into day care and obstructive bronchitis as well as allergic rhinitis and atopic eczema. Study was designed as a longitudinal birth cohort study. Children were examined by a physician at birth, 1/2 year, 1 year, 1 1/2 year, 2 years, 3 years and 4 years. Further information was collected using a structured questionnaire which was answered by the parents. Outcomes under investigation were atopic eczema, allergic rhinitis, wheezing (with and without cold), obstructive bronchitis and asthma (after 2nd year of life). Logistic regression analysis adjusted for infectious diseases of the mother during pregnancy, vaccination of the mother during pregnancy, antibiotics, prenatal smoking of the mother or other persons in the apartment and vaccination state showed an significant promoting effect of entry age into day care against obstructive bronchitis over the first three years of life (OR 1/2 year: 8.55; 95%CI: 2.93...24.97; OR 1st year: 4.96; 95% CI: 1.73...14.24; OR 2nd year: 3.06 95% CI: 1...9.37). A further significant effect was found for crowding against asthma in the fourth year of life (OR 25.7; 95%CI: 1.65...400.17). No significant effects were found between the other periods under investigation (1st year until 4th year of life). On the base of our findings we recommend an entry age into day care of more than six months to prevent effects shown.

Asthma therapy for children under 5 years of age

PURPOSE OF REVIEW

The evidence for effectiveness of currently used asthma medication for wheeze in young children is reviewed.

RECENT FINDINGS

The management of the infant and preschool child with wheezing is complicated by the uncertainty with respect to the aetiology. Difficulties in defining phenotypes and objective outcome parameters combined with the transient nature of symptoms which often resolve spontaneously have confounded many therapeutic studies. Recent studies on the effect of pharmacotherapy in wheezing infants have tried to define a more homogeneous phenotype as well as make a selection of patients that are likely to respond to the studied drug. In addition, these studies have used lung function parameters and nitric oxide as one of the outcome measurements. Studies on the nature of inflammation and the development of airway remodelling in infants and young children are done to further define phenotypes.

SUMMARY

Currently, there are no evidence-based guidelines and not even consensus statements on the right approach in pharmacological treatment of wheezing in infants and preschool children. The main issue still is the difficulty in coming to a correct diagnosis. Further studies are needed on the nature and the diagnostics of phenotypes and on the effect of early intervention.

[Wheezing in infants and toddlers: new insights]

Wheezing in infants and toddlers is a common symptom, and these patients are difficult to approach--both diagnostically and therapeutically. Congenital conditions causing wheezing disorders should not be missed and--not all wheezy bronchitis is or will become asthma. Results from longitudinal studies indicate that the term "asthma" includes different phenotypes: so-called transient early wheezing, non atopic wheezing and atopic wheezing (asthma). Transient early wheezing is generally accepted to define recurrent wheezing in non-atopic babies or toddlers and tends to disappear by the age of 3. The primary risk factor is reduced pulmonary function since birth. The most common cause for non-atopic wheezing is viral infection, most frequently caused by respiratory syncytial virus. Infection with respiratory syncytial virus is a risk factor for ongoing wheeze during childhood but resolves in most children by the age of 13. Asthma can start at any age and is determined by a more chronic condition, provoked by a number of triggers in addition to viruses, frequently associated with a family history of atopy, early allergic sensitization and concomitant atopic dermatitis. Only asthma seems to be a progressive disease; and there is evidence from long-term studies that if anti-inflammatory interventions are started late, it might be too late to alter the natural course of the disease with its decline in pulmonary function. On the other hand, there is no evidence that small children with non-atopic wheezy bronchitis would benefit from long-term therapy with anti-inflammatory treatment; in this group a therapeutic trial with bronchodilators is sufficient. The diagnostic and therapeutic challenges of diagnosing asthma in this age group are considerable and require a comprehensive approach.