Compliance with a dietary manipulation programme in families with infants prone to atopy

Adulthood asthma after wheezing in infancy: a questionnaire study at 27 years of age

BACKGROUND

Wheezing in early childhood is a heterogeneous condition, the longterm prognosis varying from total recovery to chronic asthma. Though short-term outcome has been actively studied, there is lack of data on long-term outcome until adulthood. The aim of the study was to evaluate the prevalence and risk factors of asthma at 26-29 years of age after early-life wheezing.

METHODS

At the median age of 27.3 years (range 26.3-28.6), a questionnaire was sent to 78 study subjects hospitalized for wheezing at <24 months of age, and 59 (76%) answered. Asthma, allergy and weight status were compared with selected controls followed up from birth and with non-selected population controls recruited for this adulthood study.

RESULTS

Doctor-diagnosed asthma was present in 20% of the former bronchiolitis patients, compared with 5% in the two control groups (OR 2.1, 95% CI 0.3-17.9 vs selected controls; OR 5.2, 95% CI 1.7-15.8 vs nonselected controls). The respective figures for current self-reported asthma were 41% and 7-10% (OR 11.4, 95% CI 2.3-56.1 vs selected controls; OR 12.2, 95% CI 4.4-33.7 vs nonselected controls). Current allergic rhinitis and current smoking were significantly associated with asthma, but current overweight or obesity was not. In multivariate analyses, early-life wheezing was an independent risk factor of adulthood asthma.

CONCLUSION

An increased asthma risk in early-life wheezers continues, even after many symptom-free years at school age, at least until 27 years of age.

Chronic enteropathy and feeding in children: an update

Enteropathy defines abnormalities of the small intestinal mucosa of various etiologies in which nutrition has a causal or a therapeutic role. Breast milk is the gold-standard feeding during infancy for optimal nutrition in health and the majority of diseases. Therapeutic formulae have decreased the need for enteral or parenteral support. Gastrointestinal infections are worldwide the most frequent cause of enteropathy by increasing mucosal permeability, local expression of costimulatory molecules allowing antigen penetration in the mucosa, and T-cell activation leading sometimes to disruption of oral tolerance. Concomitant malnutrition impairs not only the immunologic response but also the recovery of damaged mucosa with secondary intestinal and pancreatic enzymatic reductions. Optimal nutritional rehabilitation is the cornerstone of the management of persisting diarrhea. Celiac disease and cow's milk protein allergy are examples of chronic enteropathy. Multiple food allergies, even during breast-feeding, are increasingly reported due to an impaired development of oral tolerance. The dietary approach to allergic disease is currently evolving from passive allergen avoidance to active modulation of the immune system to (re)establish tolerance. The gastrointestinal flora provides maturational signals for the lymphoid tissue, improves balance of inflammatory cytokines, reduces bacterial invasiveness and dietary antigen load, and normalizes gut permeability. The clinical effects of nucleotides and zinc merit further clinical evaluation. Major attention has recently focused on the immune effects of dietary lipids in terms of possible prevention of allergic sensitization by downregulating inflammatory response and protecting the epithelial barrier and host-microbe interactions modifying the adherence of microbes to the mucosa.

Adherence to allergy prevention recommendations in children with a family history of asthma

Allergen avoidance has been a major component of most programs for primary prevention of asthma and allergic diseases in childhood. As a part of the Childhood Asthma Prevention Study, families were provided with written and oral information on measures considered to be helpful in the primary prevention of allergic disease in high-risk infants. Dietary measures included advice to breastfeed for 6 months or longer, to delay the introduction of solid foods until after the infant turned 6 months of age, and to delay giving allergenic foods (egg and peanut butter) until after 12 months of age. In the active group of the randomized controlled trial aimed at reducing house dust mite (HDM) allergen levels, parents were advised to use an HDM-impermeable study mattress cover and an acaricide, to avoid sheep skins, and not to use a pillow before 12 months of age. Families received regular visits from the research nurses at 1, 3, 6, 9 and 12 months and phone calls every 6 wk. Only 43.4% of mothers were breastfeeding by 6 months and less than 20% by 12 months. The introduction of solid foods before 6 months was common, 26% by 3 months and 96% by 6 months. Adherence to infant-feeding recommendations was significantly greater in women over 30 yr of age, women who did not smoke during pregnancy, and women who had a tertiary education. Adherence to HDM reduction measures was greater than to those for infant feeding. The presence of symptoms in the form of an itchy rash by 4 wk did not significantly increase adherence. Complete adherence to infant-feeding recommendations in this intervention study of high-risk infants was low despite the provision of written information and reinforcement at home visits. In considering allergy prevention advice offered during clinical care, the likelihood of adherence is a factor which needs to be evaluated in assessing any potential benefits of allergy prevention regimens.

Cost of illness of atopic dermatitis in children: a societal perspective

Childhood atopic dermatitis is a disorder with considerable social and financial costs. Consideration of these costs is increasingly important in view of the growing prevalence of atopic dermatitis, particularly in developed countries over recent decades. The family stress related to the care of children with moderate or severe atopic dermatitis is significantly greater than that of the care of children with type 1 diabetes mellitus. The factors contributing to family stress include sleep deprivation, loss of employment, time taken for care of atopic dermatitis and financial costs. The financial costs for the family and community include medical and hospital direct costs of treatments and indirect costs from loss of employment. There are many interventions utilised in the treatment of childhood atopic dermatitis which involve not only medical practitioners but nurses, pharmacists, dieticians, psychologists and purveyors of so-called alternative therapies such as naturopathy, aromatherapy and bioresonance, all of which contribute to the financial burdens on the parents and the community. It is possible that appropriate interventions directed to reducing trigger factors might produce worthwhile savings, although the cost benefit of these measures has not been demonstrated. In conclusion, atopic dermatitis should not be regarded as a minor skin disorder but as a condition which has the potential to be a major handicap with considerable personal, social and financial consequences both to the family and the community.

Maternal compliance with nutritional recommendations in an allergy preventive programme

AIMS

To assess maternal compliance with nutritional recommendations in an allergy preventive programme, and identify factors influencing compliance behaviour.

METHODS

Randomised double-blind intervention study on the effect of infant formulas with reduced allergenicity in healthy, term newborns at risk of atopy. Maternal compliance with dietary recommendations concerning milk and solid food feeding was categorised.

RESULTS

A total of 2252 newborns were randomised to one of four study formulas. The drop out rate during the first year of life was 13.5% (n = 304). The rates of high, medium, and low compliance to milk feeding during weeks 1-16 were 83.4%, 4.0%, and 7.5%; the corresponding rates to solid food feeding during weeks 1-24 were 60.0%, 12.1%, and 22.9%. In 5.1% of subjects no nutritional information was available. Low compliance was more frequent among non-German parents, parents with a low level of education, young mothers, smoking mothers, and those who weaned their infant before the age of 2 months.

CONCLUSIONS

Evaluation of allergy preventive programmes should take into account non-compliance for assessing the preventive effectiveness on study outcome.

Psychosocial factors and adherence to treatment advice in childhood atopic dermatitis

Poor adherence to maintenance treatment for atopic dermatitis and anxiety about using topical steroids are common features seen among children with atopic dermatitis and their mothers. No systematic study exploring factors associated with adherence to treatment advice on atopic dermatitis has been carried out to date. This study seeks to generate hypotheses regarding the relationship between a range of psychosocial factors and adherence to treatment advice on atopic dermatitis. An anonymous self-completed questionnaire containing adherence items, psychosocial items, some demographic items, and attitudes to steroid use was given to 258 mothers of atopic dermatitis follow-up patients who attended the National Children's Hospital, Tokyo. Responses from 205 families (80%) with complete data were then analyzed to explore the correlation between each factor and to build a structure equation model. The strongest predictor of adherence to skin-care treatment was a good doctor-patient (mother) relationship, followed by the severity of the disease as perceived by the mother. Surprisingly, the mother's anxiety about using topical steroids had no significant influence on reported use of topical steroids nor on adherence to skin-care treatment. This may have been overcome by the well-established doctor-patient (mother) relationship. Maternal personality, husband's cooperation, and social support were indirectly correlated with adherence via the doctor-patient relationship. Maternal self-efficacy of treatment was strengthened by good doctor-patient (mother) relationship.

Effect of an allergy prevention programme on incidence of atopic symptoms in infancy. A prospective study of 159 "high-risk" infants

A total of 105 "high-risk" infants born in 1988 were studied prospectively from birth to 18 months of age. The infants were recommended breastfeeding and/or hypoallergenic formula (Nutramigen or Profylac) combined with avoidance of solid foods during the first 6 months of life. All mothers had unrestricted diet. Avoidance of daily exposure to tobacco smoke, furred pets and dust-collecting materials in the bedroom were advised. This prevention group was compared with a control group consisting of 54 identically defined "high-risk" infants born in 1985 in the same area. All infants had either severe single atopic predisposition combined with cord blood IgE > or = 0.5 KU/l or biparental atopic predisposition. The control group had unrestricted diet and was not advised about environmental factors. Apart from the prevention programme and year of birth the prevention group and the control group were comparable. The parents were highly motivated and compliance was good. The rate of participation was 97%, and 85% followed the dietary measures strictly. The cumulative prevalence of atopic symptoms was significantly lower at 18 months in the prevention group (32%), as compared with the control group (74%) (p < 0.01), due to reduced prevalence of recurrent wheezing (13% versus 37%; p < 0.01), atopic dermatitis (14% versus 31%; p < 0.01), vomiting/diarrhoea (5% versus 20%; p < 0.01) and infantile colic (9% versus 24%; p < 0.01). The cumulative prevalence of food allergy was significantly lower in the prevention group (6% versus 17%; p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Diet in infancy and bronchial hyperreactivity later in childhood

Sixty-seven atopy-prone children (atopic family group, AFG) and 52 children with no family history of atopy (NAFG) were followed for 10 years. During infancy, the mothers of the newborn AFG children were advised to adjust their infants' diet, with a view toward minimizing the risk of atopy, and not to keep pets. Pulmonary function tests, methacholine inhalation challenge (MIC), and skin prick tests (SPT) were done in order to evaluate the bronchial reactivity and skin reactivity in the two groups. A pathological result in MIC was found in 20 (30%) of the AFG children and in 10 (19%) of the NAFG children. Such results of MIC were more common in the children with positive SPT results than in those without (67% vs. 24%). In regard to the diet consumed in infancy, MIC was pathological in 23% of children with and in 36% without prophylactic diet in infancy. For MIC, using the new, Spira electro 2 dosimeter equipment, the sensitivity was 75% and specificity 97%, but the predictive value for diagnosing bronchial asthma was only 25%. The important advantage of our method is that the degree of bronchial reactivity can be estimated by responses to increasing provocative doses. Our observations confirm that the new method is suitable for detecting bronchial asthma in clinical practice but it seems not to be optimal for epidemiological studies. We concluded that later bronchial hyperreactivity can not be diminished by avoiding home pets or providing a hypoallergenic diet during infancy.

Asthma, allergic rhinitis and atopic eczema in Finnish children and adolescents

The parents of 3649 Finnish children and adolescents were interviewed in 1980 to evaluate the prevalence of bronchial asthma, allergic rhinitis and atopic dermatitis. The same group was interviewed 6 years later to determine the incidence of new cases of bronchial asthma in the 1980s. Age- and sex-matched samples were taken from three areas, southern, eastern and northern Finland to allow assessment of possible regional differences in prevalences and incidences. The prevalences of atopic eczema, allergic rhinitis and asthma were 1.7%, 6.0% and 4.3%, respectively. These figures are similar to those found in previous studies in Scandinavia and Finland over 10 years ago. The prevalence of atopy was highest (6.4%) in southern Finland, which is the most urbanized area of our country. The prevalence of asthma was highest (3.3%) in northern Finland. This is still low when compared with the incidences in other European countries. THe prevalences of asthma and atopy were lowest in eastern Finland which is the most agrarian area. The incidence of asthma was 1.5 cases/1000 individuals/year, but regional differences were shown.

Atopy in children with and without a family history of atopy. I. Clinical manifestations, with special reference to diet in infancy

The influence of a family history of atopy on atopic morbidity, and relationships between diet in infancy and allergic manifestations at the ages of one and five years were prospectively studied in 91 children. A control group consisted of 72 children with no family history of atopy. At the age of one year, atopic manifestations were found in 19% of 163 children, in 23% of those with a family history of atopy and in 14% of those with no such history. Skin problems were more common in children with a family history of atopy (43%) than in the control children (19%). Of the children with a family history of atopy, 23% had prolonged rhinorrhoea during infancy. The corresponding figure in children with no family history of atopy was 10%. Prolonged rhinorrhoea during infancy correlated with parental smoking only in children with a family history of atopy (47% vs. 18%). At the age of five years, atopic disease was found in 17% of 128 children, 24% of those with a family history of atopy and 9% of those with no such history. Atopic eczema was more common in children with a family history of atopy, irrespective of the diet consumed during infancy. Atopic signs were found in about half of all the children with a family history of atopy. If atopy had been present in the family, the child usually exhibited the same manifestation. Onset of atopic manifestations was not prevented or delayed.

Atopy in children with and without a family history of atopy. II. Skin reactivity

The influence of prolongation of breast feeding and postponement of introduction of solid food during infancy on skin reactivity at the age of five years was studied. At least one positive skin prick test result was observed in 23% of the 70 children with a family history of atopy and in 17% of the 58 children with no such history. Of the 26 skin-test-positive children, 54% exhibited positive reactions to cat dander and 42% to birch pollen. Of the 6 children with asthma, 6 with rhinitis and 17 with eczema, skin reactivity was observed in 66%, 66% and 35%, respectively. Contact with a cat during the first three to four months of life did not correlate with skin test positivity at the age of five years. Skin test positivity to birch pollen was more common in children born in January to February, probably because they were at a vulnerable age in their first birch pollen season in May. No preventive effect by the diet consumed during infancy was seen on subsequent skin test results in relation to common allergens.