Increased airway responsiveness in children of low birth weight at school age: effect of topical corticosteroids

Inhaled Corticosteroids Alone and in Combination With Long-Acting β2 Receptor Agonists to Treat Reduced Lung Function in Preterm-Born Children: A Randomized Clinical Trial

Importance

Decreases in future lung function are a hallmark of preterm birth, but studies for management of decreased lung function are limited.

Objective

To determine whether 12 weeks of treatment with inhaled corticosteroids (ICS) alone or in combination with long-acting β2 agonists (LABA) improves spirometry and exercise capacity in school-aged preterm-born children who had percent predicted forced expiratory volume in 1 second (%FEV1) less than or equal to 85% compared with inhaled placebo treatment.

Design, Setting, and Participants

A double-blind, randomized, placebo-controlled trial was conducted to evaluate ICS and ICS/LABA against placebo. Preterm-born children (age, 7-12 years; gestation ≤34 weeks at birth) who did not have clinically significant congenital, cardiopulmonary, or neurodevelopmental abnormalities underwent spirometry, exercise testing, and measurement of fractional exhaled nitric oxide before and after treatment. A total of 144 preterm-born children at the Children's Hospital for Wales in Cardiff, UK, were identified and enrolled between July 1, 2017, and August 31, 2019.

Interventions

Each child was randomized to 1 of 3 cohorts: fluticasone propionate, 50 μg, with placebo; fluticasone propionate, 50 μg, with salmeterol, 25 μg; or placebo inhalers, all given as 2 puffs twice daily for 12 weeks. Children receiving preexisting ICS treatment underwent washout prior to randomization to ICS or ICS/LABA.

Main Outcomes and Measures

The primary outcome was between-group differences assessed by adjusted pretreatment and posttreatment differences of %FEV1 using analysis of covariance. Intention-to-treat analysis was conducted.

Results

Of 144 preterm-born children who were identified with %FEV1 less than or equal to 85%, 53 were randomized. Treatment allocation was 20 children receiving ICS (including 5 with prerandomization ICS), 19 children receiving ICS/LABA (including 4 with prerandomization ICS), and 14 children receiving placebo. The mean (SD) age of children was 10.8 (1.2) years, and 29 of the randomized children (55%) were female. The posttreatment %FEV1 was adjusted for sex, gestation, bronchopulmonary dysplasia, intrauterine growth restriction, pretreatment corticosteroid status, treatment group, and pretreatment values. Posttreatment adjusted means for %FEV1, using analysis of covariance, were 7.7% (95% CI, -0.27% to 15.72%; P = .16) higher in the ICS group and 14.1% (95% CI, 7.3% to 21.0%; P = .002) higher in the ICS/LABA group compared with the placebo group. Active treatment decreased the fractional exhaled nitric oxide and improved postexercise bronchodilator response but did not improve exercise capacity. One child developed cough when starting inhaler treatment; no other adverse events reported during the trial could be attributed to the inhaler treatment.

Conclusions and Relevance

The results of this randomized clinical trial suggest that combined ICS/LABA treatment is beneficial for prematurity-associated lung disease in children.

Trial Registration

EudraCT number: 2015-003712-20.

Outpatient Respiratory Management of Infants, Children, and Adolescents with Post-Prematurity Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline

Background: Premature birth affects millions of neonates each year, placing them at risk for respiratory disease due to prematurity. Bronchopulmonary dysplasia is the most common chronic lung disease of infancy, but recent data suggest that even premature infants who do not meet the strict definition of bronchopulmonary dysplasia can develop adverse pulmonary outcomes later in life. This post-prematurity respiratory disease (PPRD) manifests as chronic respiratory symptoms, including cough, recurrent wheezing, exercise limitation, and reduced pulmonary function. This document provides an evidence-based clinical practice guideline on the outpatient management of infants, children, and adolescents with PPRD. Methods: A multidisciplinary panel of experts posed questions regarding the outpatient management of PPRD. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. Results: The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Recommendations were developed for or against three common medical therapies and four diagnostic evaluations in the context of the outpatient management of PPRD. Conclusions: The panel developed recommendations for the outpatient management of patients with PPRD on the basis of limited evidence and expert opinion. Important areas for future research were identified.

Characterization of Negative Allosteric Modulators of the Calcium-Sensing Receptor for Repurposing as a Treatment of Asthma

Asthma is still an incurable disease, and there is a recognized need for novel small-molecule therapies for people with asthma, especially those poorly controlled by current treatments. We previously demonstrated that calcium-sensing receptor (CaSR) negative allosteric modulators (NAMs), calcilytics, uniquely suppress both airway hyperresponsiveness (AHR) and inflammation in human cells and murine asthma surrogates. Here we assess the feasibility of repurposing four CaSR NAMs, which were originally developed for oral therapy for osteoporosis and previously tested in the clinic as a novel, single, and comprehensive topical antiasthma therapy. We address the hypotheses, using murine asthma surrogates, that topically delivered CaSR NAMs 1) abolish AHR; 2) are unlikely to cause unwanted systemic effects; 3) are suitable for topical application; and 4) inhibit airway inflammation to the same degree as the current standard of care, inhaled corticosteroids, and, furthermore, inhibit airway remodeling. All four CaSR NAMs inhibited poly-L-arginine-induced AHR in naïve mice and suppressed both AHR and airway inflammation in a murine surrogate of acute asthma, confirming class specificity. Repeated exposure to inhaled CaSR NAMs did not alter blood pressure, heart rate, or serum calcium concentrations. Optimal candidates for repurposing were identified based on anti-AHR/inflammatory activities, pharmacokinetics/pharmacodynamics, formulation, and micronization studies. Whereas both inhaled CaSR NAMs and inhaled corticosteroids reduced airways inflammation, only the former prevented goblet cell hyperplasia in a chronic asthma model. We conclude that inhaled CaSR NAMs are likely a single, safe, and effective topical therapy for human asthma, abolishing AHR, suppressing airways inflammation, and abrogating some features of airway remodeling. SIGNIFICANCE STATEMENT: Calcium-sensing receptor (CaSR) negative allosteric modulators (NAMs) reduce airway smooth muscle hyperresponsiveness, reverse airway inflammation as efficiently as topical corticosteroids, and suppress airway remodeling in asthma surrogates. CaSR NAMs, which were initially developed for oral therapy of osteoporosis proved inefficacious for this indication despite being safe and well tolerated. Here we show that structurally unrelated CaSR NAMs are suitable for inhaled delivery and represent a one-stop, steroid-free approach to asthma control and prophylaxis.

Calcilytics: a non-steroidal replacement for inhaled steroid and SABA/LABA therapy of human asthma?

INTRODUCTION

Asthma afflicts more than 300 million people. Contemporary mainstay therapies (inhaled corticosteroids and bronchodilators), prescribed empirically, control symptoms resulting from airways obstruction tolerably well in many patients but it is less clear that they alter the natural history of progressive airways inflammation and remodeling resulting in severe, therapy-resistant obstruction in a significant minority (5-10%), causing lifelong symptoms and elevated risk of recurrent hospital admission and death. Furthermore, no current anti-asthma drug targets bronchial smooth muscle hyperresponsiveness, a critical contributor to airways obstruction and the fundamental physiological abnormality characterizing asthma. Recent monoclonal antibody (biological) therapies reduce obstruction and exacerbations in some, but not all treated patients to an unpredictable extent, but are further limited by administration logistics and cost.

AREAS COVERED

An overview of the cellular and molecular immunopathology of asthma, highlighting the need and logic for the development of a novel, non-steroidal, small molecule drug for topical delivery targeting bronchial smooth muscle hyperresponsiveness and airways inflammation, particularly corticosteroid-refractory inflammation.

EXPERT OPINION

This article elaborates evidence supporting the hypothesis that topically delivered, inhaled antagonists of the calcium-sensing receptor (CaSR) have the potential to meet these requirements, and the practicality of repurposing existing, small molecule CaSR antagonists (calcilytics) for this purpose.

Addressing the risk domain in the long-term management of pediatric asthma

There is growing concern regarding the long-term outcomes of early and poorly controlled childhood asthma, either of which can potentially lead to the development of severe asthma in adults and irrecoverable loss of lung function leading to chronic obstructive pulmonary disease. These outcomes of inadequately controlled asthma should prompt a change in practice to better and/or earlier identify children at risk of adverse respiratory outcomes of asthma, to monitor disease progression, and to design intervention strategies that could either prevent or reverse asthma progression in children. The careful follow-up of spirometry over time-in the form of lung function trajectories, the application of biomarkers to assist in the diagnosis of early asthma and medication selection for these patients, as well as methods to identify patients at risk of asthma attacks-can be used to develop individualized management strategies for children with asthma. It is now time for asthma specialists to communicate this information to patients, parents, and primary care physicians and to incorporate them into routine clinical assessments of children with asthma. In time, these concepts of risk management and prevention can be refined to provide a more comprehensive approach to asthma care so as to prevent adverse respiratory outcomes from poorly controlled childhood asthma.

Predicting Lung Health Trajectories for Survivors of Preterm Birth

Rates of preterm birth (<37 weeks of gestation) are increasing worldwide. Improved perinatal care has markedly increased survival of very (<32 weeks gestation) and extremely (<28 weeks gestation) preterm infants, however, long term respiratory sequalae are common among survivors. Importantly, individual's lung function trajectories are determined early in life and tend to track over the life course. Preterm infants are impacted by antenatal, postnatal and early life perturbations to normal lung growth and development, potentially resulting in significant shifts from the "normal" lung function trajectory. This review summarizes what is currently known about the long-term lung function trajectories in survivors of preterm birth. Further, this review highlights how antenatal, perinatal and early life factors are likely to contribute to individual lung health trajectories across the life course.

Persistent and progressive long-term lung disease in survivors of preterm birth

Preterm birth accounts for approximately 11% of births globally, with rates increasing across many countries. Concurrent advances in neonatal care have led to increased survival of infants of lower gestational age (GA). However, infants born <32 weeks of GA experience adverse respiratory outcomes, manifesting with increased respiratory symptoms, hospitalisation and health care utilisation into early childhood. The development of bronchopulmonary dysplasia (BPD) - the chronic lung disease of prematurity - further increases the risk of poor respiratory outcomes throughout childhood, into adolescence and adulthood. Indeed, survivors of preterm birth have shown increased respiratory symptoms, altered lung structure, persistent and even declining lung function throughout childhood. The mechanisms behind this persistent and sometimes progressive lung disease are unclear, and the implications place those born preterm at increased risk of respiratory morbidity into adulthood. This review aims to summarise what is known about the long-term pulmonary outcomes of contemporary preterm birth, examine the possible mechanisms of long-term respiratory morbidity in those born preterm and discuss addressing the unknowns and potentials for targeted treatments.

Management of Prematurity-Associated Wheeze and Its Association with Atopy

Introduction

Although preterm birth is associated with respiratory morbidity in childhood, the role of family history of atopy and whether appropriate treatment has been instituted is unclear. Thus we assessed (i) the prevalence of respiratory symptoms, particularly wheezing, in childhood; (ii) evaluated the role of family history of atopy and mode of delivery, and (iii) documented the drug usage, all in preterm-born children compared to term-born control children.

Methods

We conducted a cross-sectional population-based questionnaire study of 1–10 year-old preterm-born children (n = 13,361) and matched term-born controls (13,361). Data (n = 7,149) was analysed by gestational groups (24–32 weeks, 33–34 weeks, 35–36 weeks and 37–43 weeks) and by age, <5 years old or ≥ 5 years.

Main Results

Preterm born children aged <5 years (n = 2,111, term n = 1,402) had higher rates of wheeze-ever [odds ratio: 2.7 (95% confidence intervals 2.2, 3.3); 1.8 (1.5, 2.2); 1.5 (1.3, 1.8) respectively for the 24–32 weeks, 33–34 weeks, 35–36 weeks groups compared to term]. Similarly for the ≥5 year age group (n = 2,083, term n = 1,456) wheezing increased with increasing prematurity [odds ratios 3.3 (2.7, 4.1), 1.8 (1.5, 2.3) and 1.6 (1.3, 1.9) for the three preterm groups compared to term]. At both age groups, inhaler usage was greater in the lowest preterm group but prematurity-associated wheeze was independent of a family history of atopy.

Conclusions

Increasing prematurity was associated with increased respiratory symptoms, which were independent of a family history of atopy. Use of bronchodilators was also increased in the preterm groups but its efficacy needs careful evaluation.

Chronic lung disease of prematurity: long-term respiratory outcome

Chronic respiratory morbidity is a common adverse outcome of preterm birth, especially in infants who develop bronchopulmonary dysplasia (BPD), which is still a major cause of long-term lung dysfunction with a heavy burden on health care services and medical resources throughout childhood. The most severely affected patients remain symptomatic even in adulthood, and this may be influenced also by environmental variables (e.g. smoking), which can contribute to persistent obstruction of airflow. Of all obstructive lung diseases in humans, BPD has the earliest onset and probably lasts the longest. Since the prevention of BPD is an elusive goal, minimizing neonatal lung injury and closely monitoring survivors remain the best courses of action. This review describes the clinical and functional changes characteristic of the long-term pulmonary sequelae of preterm birth, focusing particularly on BPD.

Exercise-induced bronchoconstriction in school-age children born extremely preterm

BACKGROUND

School children born preterm often show airway hyperresponsiveness to methacholine or histamine. Less attention has been paid to their airway response to exercise, an important point because of the role of exercise in the child's daily life. The aim of this study was to describe the characteristics of, and potential determinants to, the airway response to exercise in children born extremely preterm.

METHODS

Forty-two nonasthmatic nonatopic children born before 32 wk gestation were compared with 27 healthy nonasthmatic nonatopic term children at age 7. Spirometry and respiratory impedance were measured at baseline and repeated after a single-step 6-min treadmill exercise in a climate-controlled room.

RESULTS

The preterm group showed significant broncho-constriction induced by exercise. Prematurity, but not low baseline lung function, neonatal oxygen supplementation, mechanical ventilation, chronic lung disease, or maternal smoking, was a determinant of exercise-induced bronchoconstriction.

CONCLUSION

Children born extremely preterm present significant exercise-induced airway obstruction at age 7. The response has different characteristics from that occurring in asthmatics and is likely to express airway noneosinophilic inflammation.

[Bronchopulmonary dysplasia and prematurity. Short-and long-term respiratory changes]

Bronchopulmonary dysplasia (BPD) is the most frequent chronic lung disease in premature children. With the inclusion of antenatal steroid therapy, surfactant use and novel mechanical ventilation strategies, survival of premature newborns has increased, whereupon the incidence of BPD has not only decreased but has also risen in extremely premature newborns. This has led to a high respiratory morbidity in the first 2-3 years of life, with numerous admissions to hospital and respiratory exacerbations mostly due to viral infections. Although there is a trend towards improvement, during school age and adolescence, respiratory symptoms may persist, due to changes in pulmonary function often showing a lower exercise capacity. Although BPD symptoms are similar to those of asthma, as there is limitation in airflow and bronchial hyperresponsiveness (BHR), pathophysiological mechanisms could be different in both diseases. On the other hand, isolated prematurity plays an important role in the child's respiratory pathology, proving that pulmonary function alterations in preterm children are present since the first months of life. A higher respiratory morbidity has also been observed in these children when compared to full-term newborns, not only during the first years of life but also subsequently. In this study, different aspects of chronic respiratory disease associated with prematurity will be analysed, drawing special attention to clinical symptoms, respiratory function changes, BHR and exercise capacity. All these aspects will be reviewed from early childhood until adolescence and young adult age. Similarities and differences between BPD and asthma will also be discussed.

Asthma

Asthma has been recognized as a disease since the earliest times. In the Corpus Hippocraticum, Hippocrates used the term “ασθμα” to indicate any form of breathing difficulty manifesting itself by panting. Aretaeus of Cappadocia, a well-known Greek physician (second century A.D.), is credited with providing the first detailed description of an asthma attack [13], and to Celsus it was a disease with wheezing and noisy, violent breathing. In the history of Rome, we find many members of the Julio-Claudian family affected with probable atopic respiratory disorders: Caesar Augustus suffered from bronchoconstriction, seasonal rhinitis as well as a highly pruritic skin disease. Claudius suffered from rhinoconjunctivitis and Britannicus was allergic to horse dander [529]. Maimonides (1136–1204) warned that to neglect treatment of asthma could prove fatal, whereas until the 19th century, European scholars defined it as “nervous asthma,” a term that was given to mean a defect of conductivity of the ninth pair of cranial nerves.

Airway function measurements and the long-term follow-up of survivors of preterm birth with and without chronic lung disease

This seventh paper in a review series on different aspects of chronic lung disease following preterm birth focuses on the current knowledge of respiratory symptoms, airway function, airway hyperresponsiveness, and exercise capacity from childhood to adulthood. This paper further considers the long-term implications of these studies for both future research and clinical practice.

Characteristics of asthma and airway hyper-responsiveness after premature birth

Asthma-like symptoms and airway hyper-responsiveness (AHR) are frequently reported in children subsequent to premature birth and bronchopulmonary dysplasia (BPD). There is limited knowledge on the mechanisms underlying these respiratory manifestations. Generally, childhood asthma and AHR is described within a context of inheritance, allergy and eosinophilic airway inflammation, and often in relation to cigarette exposures. We investigated these factors in relation to current asthma and AHR in a population-based cohort of 81 young people, born with gestational age < or = 28 wk or birth weight < or = 1000 g, and in a matched term-born control population. In the pre-term population, asthma and AHR were additionally studied in relation to neonatal respiratory morbidity. At follow up, more pre-term than control subjects had asthma. Forced expiratory volume in first second (FEV1) was reduced, AHR was substantially increased, and the level of the urinary leukotriene metabolite E4 (U-LTE4) was increased in the pre-term population compared to the term-born. In control subjects, asthma and AHR was associated with a pattern consistent with inheritance, allergy, airway inflammation, and cigarette exposures. In the pre-terms, asthma and AHR was either unrelated or less related to these factors. Instead, AHR was strongly related to a neonatal history of BPD and prolonged requirement for oxygen treatment. In conclusion, asthma and AHR subsequent to extremely premature birth differed from typical childhood asthma with respect to important features, and AHR was best explained by neonatal variables. These respiratory manifestations thus seem to represent a separate clinical entity.

Risk factors of bronchial hyperresponsiveness in children with wheezing-associated respiratory infection

The objectives of this study were to identify possible risk factors of bronchial hyperesponsiveness (BHR) in children up to 5 years of age with wheezing-associated respiratory infection (WARI), and to study the prevalence of BHR. Children up to 5 years of age with WARI were enrolled in the study. The parents or caregivers of children were asked about their demographic data and clinical histories. Physical examination and clinical score assessment were performed. Pulmonary function tests, i.e., tidal breathing flow volume (TBFV), were performed to measure tidal breathing parameters before and after salbutamol nebulization. If volume at peak tidal expiratory flow/expiratory tidal volume and time to peak expiratory flow/total expiratory time increased > or = 20%, or tidal expiratory flow at 25% of tidal volume/peak tidal expiratory flow increased > or = 20% after nebulization therapy, BHR was diagnosed. The number in the positive BHR group was used to calculate the prevalence of BHR, and clinical features were compared with those of the negative BHR group. Categorical data were analyzed for statistical significance (P < 0.05) by chi-square test or Fisher's exact test, or Student's t-test, as appropriate. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for those with statistical significance. One hundred and six wheezing children underwent pulmonary function tests before and after salbutamol nebulization. With the aforementioned criteria, 41 cases (38.7%) were diagnosed with BHR. History of reactive airway disease, (OR, 6.31; 95% CI, 1.68-25), maternal history of asthma (OR, 3.45; 95% CI, 1.34-9), breastfeeding less than 3 months (OR, 3.18; 95% CI, 1.26-8.12), and passive smoking (OR, 3; 95% CI, 1.15-7.62) were significant risk factors of BHR. The eosinophil count was significantly higher in the BHR (+) group particularly, in children 1-5 years of age (P < or = 0.01). Patchy infiltrates were more commonly found in patients with negative BHR but not statistically significant. In conclusion, a history of reactive airway disease, maternal history, breastfeeding less than 3 months, and passive smoking were significant risk factors for BHR.

Inhaled beclomethasone versus placebo for chronic asthma

BACKGROUND

Inhaled beclomethasone dipropionate (BDP) has been, together with inhaled budesonide, the mainstay of anti-inflammatory therapy for asthma for many years. A range of new prophylactic therapies for asthma is becoming available and BDP has been reformulated using a hydrofluoroalkane-134a (HFA) propellant which is free from chlorofluorocarbon (CFC).

OBJECTIVES

The objectives of this review were to: (1) Compare the efficacy of BDP with placebo with both CFC and HFA propellants in the treatment of chronic asthma. (2) Explore the possibility that a dose response relationship exists for BDP in the treatment of chronic asthma. (3) To provide the best estimate of the efficacy of BDP as a benchmark for evaluation of newer asthma therapies.

SEARCH STRATEGY

Electronic searches were current as of January 2003.

SELECTION CRITERIA

Randomised parallel group design trials for a minimum period of four weeks, in children and adults comparing CFC-BDP or HFA-BDP with placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data; authors were contacted to clarify missing information. We analysed data with RevMan Analyses 1.0.2.

MAIN RESULTS

60 studies recruiting 6542 participants met the inclusion criteria. CFC-BDP (57 studies): In non-oral steroid treated patients, at doses of 400 mcg/day or less CFC-BDP produced significant improvements from baseline in a number of efficacy measures compared with placebo, including forced expiratory volume in one second (FEV1) 360 ml (95% CI 260 to 460); FEV1 (% predicted) WMD 12.41% (95% CI 8.18 to 16.64) and morning peak expiratory flow rate (am PEF) WMD 35.95 L/min (95% CI 27.85 to 44.04). BDP also led to reductions in rescue beta-2 agonist use compared with placebo of -2.32 puffs/d (95% CI -2.55 to -2.09) and reduced the relative risk (RR) of trial withdrawal due to an asthma exacerbation 0.25 (95% CI 0.12 to 0.51). Subgroup analyses based on treatment duration provide support to the proposal that a treatment period of greater than four weeks is required to realise a fuller treatment effect. In oral steroid treated patients BDP led to significantly greater reductions in oral prednisolone use WMD -4.91 mg/d (95% CI -5.88 to -3.94 mg/d) and greater likelihood of withdrawing oral steroid treatment RR 8.02 (95% CI 3.23 to 19.92). HFA-BDP (3 studies): In non-oral steroid-treated patients, HFA-BDP was significantly more effective than placebo in improving FEV1, morning and evening PEF, FEF25 to 75%, reduced asthma symptoms and beta2-agonists daily consumption. Significant effects for such outcomes were apparent after six weeks of treatment. In oral steroid treated patients, HFA-BDP improved significantly FEV1 and am PEF. The summary estimates for these outcomes suggested a high level of heterogeneity, and divergent aims of the studies may contribute to the variation we observed. Limited data on adverse events were reported.

AUTHORS' CONCLUSIONS

This review has quantified the efficacy of CFC-BDP and HFA-BDP in the treatment of chronic asthma and strongly supports its use. Current asthma guidelines recommend titration of dose to individual patient response, but the published data provide little support for dose titration above 400 mcg/d in patients with mild to moderate asthma. There are insufficient data to draw any conclusions concerning dose-response in people with severe asthma.

Exhaled nitric oxide at school age in prematurely born infants with neonatal chronic lung disease

Prematurely born infants with neonatal chronic lung disease (CLD) have increased respiratory morbidity and bronchial obstruction at school age. To evaluate the possible inflammatory basis of lung function abnormalities, we studied 40 children, 7.5-9.6 years of age, born very prematurely (birth weights, 600-1,575 g) and 14 nonatopic term-born controls, using flow-volume spirometry and exhaled nitric oxide (eNO) measurements. In children born prematurely, eNO was significantly higher in atopics than in nonatopics (respective means, 14.8 vs. 6.3 ppb, P = 0.02). Nonatopic prematurely born infants did not differ significantly from controls (means, 6.3 vs. 6.4 ppb, P = ns). Of the 27 nonatopic children not on regular glucocorticoid inhalations, 9 had a history of CLD. Spirometry indicated bronchial obstruction and values that were significantly lower in prematurely born infants with or without CLD than in controls, and they were lower in the CLD than the non-CLD group. However, no significant differences were observed in eNO levels between CLD, non-CLD, and control groups (means, 6.8, 5.9, and 6.4 ppb, P = ns). In nonatopic schoolchildren born very prematurely and with a history of CLD, we found no evidence of airway inflammation associated with increased eNO concentrations. Neither were eNO levels associated with severity of chronic lung disease, as determined by conventional lung function tests. eNO levels were higher in atopic children born prematurely than in controls.

Effect of inhaled budesonide therapy on lung function in schoolchildren born preterm

We investigated the effect of inhaled glucocorticoid (GC) on bronchial obstruction and on bronchial lability in schoolchildren born preterm. Twenty-one children with bronchial obstruction, increased responsiveness to a beta2-agonist, and/or increased diurnal variation in peak expiratory flow (PEF) were selected for an open longitudinal study of the value of inhaled GC. None of these children had an earlier diagnosis of asthma or current GC treatment. Eighteen children with median (range) birth weight 1025 (640-1600) g and gestational age 28 (24-35) weeks, age at study 10.1 (7.7-13) years, were treated with inhaled budesonide in initially high (0.8 mg m(-2) day(-1) for 1 month) and subsequently lower dose (0.4 mg m(-2) day(-1) for 3 months). Daily symptom scores were recorded. Spirometric values were measured in the clinic at the beginning and end of each treatment period. At home, children used a data storage spirometer. After treatment with budesonide for 4 months, spirometric values in the clinic did not significantly change. The median forced expiratory volume in 1 sec (FEV1) was 74% of predicted both at entry and after budesonide treatment. However, the median number of > or = 20% diurnal change in PEF values at home decreased during treatment. According to the present study, inhaled budesonide for 4 months had no significant effect on basic lung function but may decrease bronchial lability in schoolchildren born preterm.

Prematurity at birth reduces the long-term risk of atopy

BACKGROUND

Antigen exposure in early life has long-lasting effects on atopic sensitization. Thus the predisposition to atopy of children born preterm can be assumed to differ from that of children born at term.

OBJECTIVE

The aim of this study was to evaluate the association between premature birth and atopy.

METHODS

At an outpatient clinic, we examined 2 groups of 10-year-old children, 72 who were born preterm (birth weight < 1500 g) and 65 who were born at term (birth weight > 2500 g). The atopy data were collected with a questionnaire, by performing skin prick testing, and by measuring the serum total IgE level, 3 allergen-specific IgE levels, the eosinophil cationic protein level, and the blood eosinophil level. The data on perinatal and neonatal events affecting the preterm children were collected from the hospital records.

RESULTS

By the age of 10 years, the children born preterm had significantly less atopy than the children born at term: 15% versus 31% of children in the 2 groups were defined as having had obvious atopy (P = .03, odds ratio 0.41, 95% CI 0.18-0.93). The mean value of total IgE level was significantly higher in the term group, 74 kU/L versus 41 kU/L (P = .02). By skin prick testing, the children born at term had positive reactions 2 to 3 times more often; 37% versus 17% of children in the groups had at least 1 positive reaction (P = .007).

CONCLUSION

Our data show that prematurity at birth is linked with a decreased long-term risk of atopic sensitization.

Inhaled steroids for episodic viral wheeze of childhood

BACKGROUND

Recurrent episodic wheeze in association with viral upper respiratory tract infection (URTI) is a specific clinical illness distinct from persistent atopic asthma.

OBJECTIVES

The objective of this review was to identify whether corticosteroid treatment, given episodically or daily, is beneficial to children with viral episodic wheeze.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of corticosteroid treatment versus placebo in children under 17 years of age who suffer from 'episodic viral wheeze', which is defined by wheeze in association with coryzal symptoms with minimal or no intercurrent lower respiratory tract symptoms.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed independently by two reviewers. Study authors were contacted for missing information. Studies were categorised according to whether treatment was given episodically or daily (maintenance). The primary outcome was episodes requiring oral corticosteroids. Secondary outcomes addressed episode severity, frequency and duration and parental treatment preference.

MAIN RESULTS

Five randomised controlled trials in children with a history of mild episodic viral wheeze were identified. Most of the children had previously required no or infrequent oral corticosteroids and had very infrequent hospital admissions. There were three studies of preschool children given episodic high dose inhaled corticosteroid (1.6 - 2.25 mg per day), two using a crossover and one a parallel design. The two studies of maintenance corticosteroid (400 micrograms per day) were parallel in design, one of pre-school children the other of children aged 7 -9 years. Results from the two cross-over studies of episodic high dose inhaled corticosteroids showed a reduced requirement for oral corticosteroids (Relative risk (RR)=0.53, 95% CI: 0.27, 1.04). In these 2 double blind studies, this treatment was preferred by the children's parents over placebo (RR=0.64, 95% CI: 0.48,0.87). Maintenance low dose inhaled corticosteroids did not show any clear reduction over placebo in the proportion of episodes requiring oral corticosteroids (N=2 trials, RR=0.82, 95%CI: 0.23,2.90) or in those requiring hospital admission (N=1 trial, RR=0.21, 95% CI: 0.01,4.11).

REVIEWER'S CONCLUSIONS

Episodic high dose inhaled corticosteroids provide a partially effective strategy for the treatment of mild episodic viral wheeze of childhood. There is no current evidence to favour maintenance low dose inhaled corticosteroids in the prevention and management of episodic mild viral induced wheeze.

Inhaled beclomethasone versus placebo for chronic asthma

BACKGROUND

Inhaled beclomethasone diproprionate (BDP) has been, together with inhaled budesonide, the mainstay of anti-inflammatory therapy for asthma for many years. A range of new prophylactic therapies for asthma is becoming available and BDP is now frequently used as the reference treatment against which these newer agents are being compared.

OBJECTIVES

The objectives of this review were to: a) Compare the efficacy of BDP with placebo in the treatment of chronic asthma. b) Explore the possibility that a dose response relationship exists for BDP in the treatment of chronic asthma. c) To provide the best estimate of the efficacy of BDP as a benchmark for evaluation of newer asthma therapies.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trial Register (1999) and reference lists of articles. We contacted trialists and Glaxo Wellcome for additional studies and searched abstracts of major respiratory society meetings (1997-1999).

SELECTION CRITERIA

Randomised trials in children and adults comparing BDP to placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data; authors were contacted to clarify missing information. Quantitative analyses where undertaken using Review Manager (Revman) 4.0.3 with Metaview 3.1.

MAIN RESULTS

52 studies were selected for inclusion (3459 subjects). The studies were generally of high methodological quality. In non-oral steroid treated patients, BDP produced significant improvements in a number of efficacy measures compared to placebo including FEV1 weighted mean difference (WMD) 340ml (95% CI 190-500ml); FEV1 (% predicted) WMD 6% (95% CI 0.4 to 11.5%) and morning PEFR WMD 50 L/min (95% CI 8 to 92 L/min). BDP also led to reductions in rescue beta2 agonist use compared to placebo WMD 1.75 puffs/d (95% CI 1.4 to 2.4 puffs/d) and reduced the likelihood of trial withdrawal due to asthma exacerbation relative risk (RR) 0.26 (95% CI 0.15 to 0.43). In oral steroid treated patients BDP led to significantly greater reductions in oral prednisolone use WMD 5 mg/d (95% CI 4 to 6 mg/d) and a higher likelihood of discontinuing oral prednisolone RR 0.54 (95% CI 0.43 to 0.67). There was little evidence for a clincially worthwhile dose response effect, but few studies recruited patients with more severe asthma.

REVIEWER'S CONCLUSIONS

This review has quantified the efficacy of BDP in the treatment of chronic asthma and strongly supports its use. Current asthma guidelines recommend titration of dose to individual patient response, but the published data provide little support for dose titration above 400 mcg/d in patients with mild to moderate asthma. There are insufficient data to draw any conclusions concerning dose-response in patients with severe disease.

Peripheral blood lymphocyte subpopulations in schoolchildren born very preterm

AIM

To investigate whether lymphocytes or serum inflammatory markers are associated with obstructive lung disease and bronchial lability in schoolchildren born very preterm.

METHOD

Lymphocyte subsets were studied in the peripheral venous blood of 29 such children (median age 8.8 years). Serum eosinophil cationic protein (ECP) and myeloperoxidase (MPO) concentrations and the association between them, lymphocyte subsets, and lung function were studied. Fourteen healthy children born at term, median age 9.1 years, served as controls. T lymphocytes (CD3), T lymphocyte subpopulations (CD4 and CD8), B lymphocytes (CD19), natural killer cells (CD16+56) and activation markers of T and B lymphocytes (CD23 and CD25) were determined using flow cytometry. Lung function was measured in all children both in the clinic and at home (Vitalograph Data Storage Spirometer).

RESULTS

Compared with the controls, schoolchildren born very preterm had significantly lower CD4(+) T cell percentages and CD4:CD8 ratios (p < 0.05 for both), whereas natural killer cell percentages and serum ECP values were significantly higher (p < 0. 05). The very preterm schoolchildren had significantly lower spirometric values than the control group (p < 0.05)-except forced vital capacity. When all the subjects were considered together, a weak, but significant, negative association was observed between the bronchial responsiveness in peak expiratory flow, after a beta(2) agonist during home monitoring, and the CD4(+) T cell percentage (r = -0.45; p = 0.008) and the CD4:CD8 ratio (r = -0.50; p = 0.003), indicating a relation between bronchial lability and imbalance of T cell subpopulations.

CONCLUSIONS

These results suggest that there is an inflammatory basis for lung function abnormalities in schoolchildren born very preterm.

Bronchial lability and responsiveness in school children born very preterm

We evaluated bronchial lability and responsiveness in 29 prematurely born children (birth weight < 1,250 g) 8 to 14 yr of age, 12 with histories of bronchopulmonary dysplasia (BPD). Flow-volume spirometry, a bronchodilator test, and histamine challenge at the office and home monitoring of peak expiratory flow (PEF) values twice daily for 4 wk with and without a beta2-agonist were performed with a novel device, the Vitalograph Data Storage Spirometer. The spirometric values at the office and the results of home monitoring were compared with those for a control group of children born at term. All spirometric values except FEV1/FVC were significantly lower in the BPD group than in the non-BPD group (p < 0.0001). Ten children (83%) in the BPD group and four (24%) in the non-BPD group had subnormal spirometric values at the office, indicating bronchial obstruction. Of the children with obstruction, 79% reported respiratory symptoms during the preceding year, and 57% had increased diurnal PEF variation and/or responded to administration of a beta2-agonist during home monitoring or at the office. The BPD children were significantly more responsive to histamine than the non-BPD children (p = 0.002). All spirometric values were significantly lower in both preterm groups than in the control group born at full term (p < 0.01). In conclusion, regardless of BPD, bronchial obstruction, bronchial lability, and increased bronchial responsiveness are common in prematurely born children of school age.

Chronic lung disease of prematurity: are we too cautious with steroids?

Encompassed by the term chronic lung disease (CLD) of prematurity is a sequence of pathophysiological processes ranging from acute inflammation and its resolution to remodelling and growth. There is good evidence for clinical and biological effects of parenteral corticosteroid therapy at each stage in the disease process. A number of questions remain to be resolved: can risk prediction be refined to permit trials of prevention; what is the minimum effective dosage regime; are topical corticosteroids effective; what are the long-term effects on lung growth and development and indeed, is the long-term prognosis of CLD affected by corticosteroid therapy? It is prudent to be cautious with steroids until these questions are answered.