Japanese guideline for childhood asthma

New onset bronchial asthma following oral propranolol for infantile hemangioma

Propranolol, a nonselective adrenergic beta-receptor blocker, is the first-line drug used for the treatment of infantile hemangiomas (IH). However, its use is contraindicated in patients with bronchial asthma. Nevertheless, studies assessing whether propranolol triggers asthma in infants and affects asthma control are limited. Here, we report the case of an infant with IH who developed asthma after starting propranolol. Asthma control was refractory to inhaled corticosteroids and leukotriene receptor antagonists, although it improved remarkably with discontinuation of propranolol. This report suggests that infants with a family history of allergic disorders should be monitored for asthma after propranolol administration.

Exhaled carbon monoxide levels in infants and toddlers with episodic asthma

Objective:

There are few lung function tests available to evaluate bronchial asthma in infants and toddlers. The objective of this study was to test the hypothesis that the measurement of exhaled carbon monoxide (eCO) levels is applicable to evaluate infants and toddlers with stable asthma and during acute asthma attack.

Methods:

A one-way valve breath sampling bag was developed to collect the exhaled air of infants and toddlers. A total of 483 infants (under 2 years) and toddlers (2-5 years) were studied; 355 had an established diagnosis of asthma (182 suffering mild asthma attacks and 173 without active asthmatic symptoms), 119 had upper respiratory infection (URI) including acute bronchitis, and 9 were healthy.

Results:

In infants and toddlers, eCO levels of those with asthma attacks [median (interquartile range) = 2.0 (2.0-3.25) ppm, n=182] were significantly higher than those of subjects with asymptomatic asthma [2.0 (1.0-2.0) ppm, n=173, P < 0.0001], URI [2.0 (1.0-3.0) ppm, n=119, P < 0.0001], and healthy children [1.0 (0.0-1.0) ppm, n=9, P < 0.0001]. In 75 children with asthma petit mal, eCO levels during asthma attacks [3.0 (2.0-4.0) ppm] significantly decreased after therapy [1.0 (1.0-2.0) ppm, P < 0.0001]. In infants and toddlers with an established diagnosis of asthma (n=355), eCO cut-off >2 ppm discriminated asthma attack from an asymptomatic state with a sensitivity of 95.6%, a specificity of 43.3%, and an area under the curve (AUC) of 0.71 (95% CI: 0.65-0.76, P < 0.0001). In 401 infants and toddlers with some respiratory symptoms, of which 285 cases were finally diagnosed as asthma [eCO level = 2.0 (2.0-3.0) ppm] and 116 cases were not asthma [eCO level = 2.0 (1.0-3.0) ppm, P < 0.0001], eCO cut-off >3 ppm supported the final diagnosis of asthma with a sensitivity of 38.9%, a specificity of 74.1%, and AUC of 0.63 (95% CI: 0.56-0.69, P < 0.0001).

Conclusion:

The measurement of eCO by a novel method is applicable to evaluate asthmatic activity and treatment responsiveness, and to diagnose asthma in infants and toddlers.

Effects of maintaining web-based diaries by caregivers on adherence to care regimens in preschoolers with asthma

BACKGROUND

The objective of this pilot study was to assess the effects of maintaining web-based diaries by the caregivers of preschoolers with asthma on the adherence to asthma care regimens, the recognition of asthma symptoms, and their perceived levels of parenting stress, quality of life, and family functioning.

DESIGN AND METHODS

The caregivers of preschoolers with asthma completed a 4-week web-based diary and received weekly emails that depicted their children's asthma symptoms. We compared asthma symptoms from before and after the intervention. We analyzed demographic data, such as the caregivers' age and education, and assessment scores from the Japanese Pediatric Asthma Control program (JPAC), Adherence with Asthma Management for Caregivers of Preschoolers (AAMCP), General Functioning subscale of the Family Assessment Device (GF-FAD), Parenting Stress Index Short Form (PSI-SF), and Quality of Life assessment scale for Caregivers of Asthmatic Children 24 (QOLCA-24).

RESULTS

A total of 45 participants were included in the analyses. The mean scores depicting asthma control were significantly improved postintervention (pre: 12.29 ± 2.65; post: 13.02 ± 2.01; t = -2.15, p = .037). Mean AAMCP scores postintervention (52.13 ± 6.25) were significantly greater than before (49.78 ± 7.20; t = -3.07; p = .004).

PRACTICE IMPLICATIONS

Adherence to asthma care and the recognition of asthma symptoms improved following the use of a web-based diary, making it a potential cost-effective intervention for asthma patients and their families.

The effect of short-term particular matter2.5 exposure on asthma attacks in asthma children in Fukuoka, Japan

We investigated whether asthma attacks in asthmatic children were caused by short-term exposure to particulate matter(PM)2.5. Methods Subjects were 411 patients who received inhalation therapy in National Fukuoka Hospital, from March to May 2013. All subjects were outpatients. We surveyed the air quality measurement results in the stations closest to the address of the patients. Data were used from the City of Fukuoka website data on air pollution. We carried out a case-crossover study and compared PM2.5 concentration between 7 days after asthma attack occurred and the day asthma attack occurred and 1, 2 and 3 days before asthma attack occurred. Results Highest hourly concentration of the day (OR 1.013, 95%CI 1.000-1.025) showed a significant association with 1 day before PM2.5 concentration statistically. And 0-1 year-old infants were more vulnerable to the highest concentration of 1 day before PM2.5 concentration(P &lt; 0.05). Average concentration of NO2 and O3 and asthma attack also showed a significant association. Conclusions Maximal daily PM2.5 concentrations within 24 hours prior to the attack affect asthma exacerbation. 0-1 year-old infants are particularly vulnerable to PM2.5 concentration. Asthma exacerbation is aggravated by NO2 and O3 concentration on the day of the asthma attack.

Montelukast Treatment of Acute Asthma Exacerbations in Children Aged 2 to 5 Years: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Although montelukast has an established role in the management of chronic asthma in children, its efficacy in acute asthma exacerbations (AAEs) in children aged 2 to 5 years is not fully known. This study aimed to evaluate the effectiveness and safety of montelukast for treating AAE in children aged 2 to 5 years in China.

METHODS

In total, 120 Chinese children with AAE, aged 2 to 5 years, were randomly divided into 2 groups, each with 60 patients. All patients received either montelukast or placebo along with standard therapy for acute asthma between January 2011 and December 2015. The outcome measurements included the difference in peak expiratory flow and lung function improvements, as well as adverse events.

RESULTS

A total of 117 patients completed the study. Montelukast showed no greater effectiveness than did placebo in increasing the peak expiratory flow during the period of hospital stay (P = 0.92 at day 2, P = 0.86 at day 3, and P = 0.82 at day 4) and at discharge (P = 0.84). Similarly, the forced expiratory volume in 1 second at discharge also did not show significant difference between the 2 groups (P = 0.80). In addition, no serious adverse events were found during the intervention period of the study.

CONCLUSIONS

The results of this study demonstrate no benefit of montelukast over placebo in the treatment of AAE in a cohort of 2- to 5-year-old children.

Long-term treatment in pediatric asthma: an update on chemical pharmacotherapy

INTRODUCTION

Asthma is the most common chronic disease in childhood, affecting approximately 10% of all children, and is the leading cause of hospitalization in developed countries. In this paper we aimed to review the evidence on chemical pharmacotherapy for long-term treatment of pediatric asthma, according to the latest updates. Area covered: Long-term treatment, essential for controlling symptoms and reducing future risks including exacerbations and decline in lung function, includes control agents such as inhaled corticosteroids, long-acting beta2-adrenergic agonists, and leukotriene modifiers. More recent strategies based on the use of a biological drug such as omalizumab, which is a monoclonal antibody directed against immunoglobulin E (IgE), can be considered in selected patients with severe asthma. Expert opinion: In the near future, the challenge of childhood asthma treatment will be to improve the chemical drugs that already exist as well as to carefully characterize the several different asthma subtypes, with special regard to children with severe disease. A better definition of patient features, made possible by the current advanced knowledge of the pathobiology of severe asthma, can ultimately allow the identification of specific phenotypes and endotypes of severe asthma, aimed to personalize pharmacological treatment.

Development and validation of asthma questionnaire for assessing and achieving best control in preschool-age children

BACKGROUND

Several patient-/caregiver-completed questionnaires have been utilized for the assessment of asthma control. However, due to the diversity in medical/social circumstances, they may not be optimal for use in all countries. The Japanese pediatric asthma guideline (JPGL) aims at higher levels of control compared with other international guidelines, based on a strong social demand for best care. We developed a new control test to help meet that demand.

METHODS

A 34-item working questionnaire was developed based on input from pediatric asthma specialists and the caregivers of preschool children with asthma. The questionnaire was administered to caregivers of 565 patients aged <6 years who had physician-diagnosed asthma or β2-agonist-responsive recurrent wheeze. Then, 6 questions for assessing JPGL-defined control levels were selected from the 34 questions by stepwise logistic regression methods using randomly selected questionnaires completed by two-thirds of the caregivers. We named that set of questions the Best Asthma Control Test for Preschoolers (Best ACT-P). Validation of Best ACT-P was performed using the remaining completed questionnaires.

RESULTS

The 6 questions asked about the frequency/severity of cold-induced wheeze, nighttime awakening, exercise-induced symptoms, and disruption of family life due to asthma in the past 4 weeks and hospitalization in the past 12 months. The 6-item logistic model showed good statistical fit, and the scores for the physicians' ratings of the asthma control differed significantly in the hypothetical direction.

CONCLUSIONS

Best ACT-P is a valid caregiver-completed questionnaire of asthma control in preschoolers in whom total control needs to be achieved.

Caregiver treatment satisfaction is improved together with children's asthma control: Prospective study for budesonide monotherapy in school-aged children with uncontrolled asthma symptoms

BACKGROUND

If asthmatic children cannot obtain sufficient control of their disease, not only do they suffer from asthma symptoms, but the daily life activities of their caregivers are also disrupted. We investigated the effectiveness of an inhaled corticosteroid (ICS) for symptom control in previously ICS-untreated school-aged asthmatic children as well as caregiver treatment satisfaction (CTS).

METHODS

A multicenter, open-label, single-arm study on 12-week ICS (budesonide Turbuhaler®) monotherapy was undertaken in subjects aged 5-15 years with bronchial asthma not treated with ICS during the previous 3 months. At 0, 4, 8, and 12 weeks after start of ICS administration, Japanese Pediatric Asthma Control Program (JPAC) scores, and CTS scores were summated and lung function measured. At weeks 0 and 12, questionnaires on caregiver anxiety were also assessed.

RESULTS

Seventy-five patients were enrolled, and 69 assessed. Ninety percent of subjects had been treated with asthma controller medication except ICS before study enrollment. JPAC score and CTS score were improved significantly at weeks 4, 8, and 12 (p < 0.001). With regard to CTS, more than half of caregivers showed a perfect score at weeks 8 and 12. There was a significant correlation between JPAC score and CTS score. Lung function and caregiver anxiety were also improved, and good compliance with treatment was observed during the intervention.

CONCLUSIONS

If treating ICS-untreated school-aged asthmatic children with uncontrolled symptoms, ICS monotherapy can improve CTS along with improving asthma control.

Nutritional status, adiposity and asthma severity and control in children

AIM

To investigate association between nutritional status, adiposity and asthma severity and control in children.

METHODS

We conducted a case control study at two teaching hospitals in Brazil. Cases were children (3-12 years) with persistent asthma and age-matched controls were those with intermittent asthma. Nutritional status was assessed by body mass index (BMI). Adiposity was assessed by sum of skinfolds and waist circumference (WC). Crude and adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated using conditional logistic regression or multinomial logistic regression as appropriate.

RESULTS

Two hundred sixty-eight cases and 126 controls were included. Obesity (>2 BMI z-score for age) was significantly associated with persistent asthma (adjusted OR 2.62; 95% CI 1.39-4.95). There was a significant linear relationship between BMI z-scores (≤1, >1 to ≤2, >2) and risk of having persistent asthma (P = 0.003 for linear trend). Children with WC >90th percentile had a higher risk of persistent asthma when compared with those with WC ≤90th percentile (adjusted OR 3.38; 95% CI 1.26-9.06). No significant difference was found in terms of nutritional status and adiposity between children whose asthma was controlled by inhaled corticosteroids and those requiring inhaled corticosteroids plus other medications for asthma control.

CONCLUSIONS

Obesity measured by BMI and increased abdominal adiposity are significantly associated with risk of persistent asthma but not type of controller medications.

Asthma Controller Medications for Children in Japan: Analysis of an Administrative Claims Database

Background. Treatment and management strategies for asthma in children are generally consistent internationally, but prescription of antiasthma drugs differs among countries. The objective of this study was to examine the prescribing patterns of antiasthma drugs, particularly controller medications, in children. Methods. A retrospective cohort study was performed in children with asthma using an administrative claims database in Japan. Results. A total of 1149 preschool-age and 3226 school-age children were identified. Leukotriene receptor antagonists were prescribed for about 80% of the children. Long-acting β-agonists were prescribed for 87.6% and 59.6% of preschool-age and school-age children, respectively, whereas prescriptions of inhaled corticosteroids had lower rates of 8.2% and 16.5%, respectively. In an examination of prescriptions at 1-month intervals, a relatively high number of children were prescribed bronchodilators without anti-inflammatory agents. Conclusion. Our findings suggest that asthma care for children in Japan can be improved through changes in drug prescriptions.

Polycyclic aromatic hydrocarbons and childhood asthma

Asthma is the most common chronic illness in children living in developed countries and the leading cause of childhood hospitalization and school absenteeism. Prevalence rates of asthma are increasing and show disparities across gender, geographic regions, and ethnic/racial groups. Common risk factors for developing childhood asthma include exposure to tobacco smoke, previous allergic reactions, a family history of asthma, allergic rhinitis or eczema, living in an urban environment, obesity and lack of physical exercise, severe lower respiratory tract infections, and male gender. Asthma exacerbation in children can be triggered by a variety of factors, including allergens (e.g., pollen, dust mites, and animal dander), viral and bacterial infections, exercise, and exposure to airway irritants. Recent studies have shown that exposure to polycyclic aromatic hydrocarbons (PAHs), a major component of fine particulate matter from combustion sources, is also associated with onset of asthma, and increasing asthmatic symptoms. In this paper, we review sources of childhood PAH exposure and the association between airborne PAH exposure and childhood asthma prevalence and exacerbation.

Prophylactic effectiveness of suplatast tosilate in children with asthma symptoms in the autumn: a pilot study

BACKGROUND

Exacerbations of bronchial asthma usually occur in the autumn. To our knowledge, however, the effectiveness of drugs for preventing exacerbations of asthma in the autumn has not been studied previously, except for leukotriene receptor antagonists and Omalizmab.

METHODS

This study compared the prophylactic effectiveness of suplatast tosilate with that of mequitazine in children with asthma symptoms, which is usually exacerbated in the autumn. The study group comprised 27 children aged 2 to 15 years who required treatment for asthmatic attacks during the past year and tested positive at least for mite allergen in the preceding autumn. The subjects were randomly assigned to receive either suplatast or mequitazine. The primary endpoint of this study was the number of days without symptoms during the 8 weeks of treatment. In addition, the Japanese Pediatric Asthma Control Program (JPAC) scores were also recorded every 2 weeks in each group.

RESULTS

Overall, 14 patients received suplatast, and 13 received mequitazine for 8 weeks from September through early October. During follow-up, the number of days without symptoms and the total JPAC scores did not differ significantly between the groups. However, as compared with weeks 1 to 2 of treatment, the mean number of days without symptoms during weeks 7 to 8 increased significantly in only the suplatast group (8.6 vs. 11.5 days; p = 0.004).

CONCLUSIONS

Our results suggest that short-term additional treatment with suplatast is useful for preventing asthma symptoms in children with asthma, which is usually exacerbated in the autumn.

Pediatric allergy and immunology in Japan

The Japanese Society of Pediatric Allergy and Clinical Immunology (JSPACI) was started in 1966 and currently has 3613 members as of August 1, 2012. The number of pediatricians specializing in allergies who have been certified by the Japanese Society of Allergology is 817. Among these, there are 125 training directors and training facilities for allergy and clinical immunology. The JSPACI first published an asthma guideline specific for children in 2000, and this has been revised every 3 yrs, contributing to better control of pediatric asthma. Food allergy management guidelines were first developed in 2005, which have helped to improve the care of food allergy patients. Among 514 pediatric training programs by the Japanese Society of Pediatrics, there are 312 facilities routinely performing oral food challenges. Among these, there were already 53 facilities performing oral immunotherapy at the end of 2011, treating 1400 cases of food allergy. The prevalence of pediatric allergic diseases has increased in Japan over the past 50 yrs. A number of International Study of Asthma and Allergies in Childhood surveys have been conducted in the past at specific times. The prevalence of wheezing among children aged 13-14 yrs in 2002 was 13.0%. Multi-year surveys found a 1.5- to 2-fold increase every 10 yrs until 2002. However, according to the latest data in 2012, asthma prevalence seems to have slightly decreased in Japan. Food allergy mainly associated with infantile atopic eczema among infants younger than 1 yr of age is the most common form as with other developed countries. The estimated food allergy prevalence based on data from several surveys is 5-10% among infants (0-6 yrs) and 1-2% among schoolchildren (6-15 yrs). A variety of patients suffering from primary deficiency syndrome have been actively analyzed. Previously, antibody defects and well-defined syndromes with immunodeficiency were analyzed, but recent research is focusing on not only acquired immune disorders but also on innate immune disorders. In contrast to the widespread use of oral immunotherapy, one immediate issue is to develop and reassess subcutaneous and sublingual immunotherapies for mite and Japanese cedar pollen antigens that have been disused in Japan since the 1990s.

Budesonide inhalation suspension versus montelukast in children aged 2 to 4 years with mild persistent asthma

BACKGROUND

Budesonide inhalation suspension (BIS) and montelukast provide acceptable asthma control, whereas overall measures favored BIS in children aged 2 to 8 years with mild persistent asthma.

OBJECTIVE

We compared BIS and montelukast over a 1-year period in children aged 2 to 4 years with asthma.

METHODS

Data were derived from a 52-week, open-label, randomized, active-controlled, multicenter study (NCT00641472). Children with mild asthma received either BIS 0.5 mg or montelukast 4 to 5 mg once daily. Patients were stepped up to twice-daily BIS or oral corticosteroids for mild or severe asthma worsening, respectively. Primary efficacy assessment was time to first additional asthma medication for exacerbation over 52 weeks.

RESULTS

Two hundred two patients, age 2 to 4 years, received BIS (n = 105) or montelukast (n = 97). No difference was observed between the BIS and montelukast groups in median time to first additional asthma medication over 52 weeks (183 vs 86 days). Statistically significant differences were observed in favor of BIS over montelukast in the percentage of patients requiring oral steroids at 52 weeks (21.9% vs 37.1%; P = .022), the rate (number/patient/year) of additional courses of medication (1.35 vs 2.30; P = .003), the rate of additional oral steroid therapy (0.44 vs 0.88; P = .008), and caregivers' ability to manage the patient's symptoms (P = .026). Both treatments were well tolerated.

CONCLUSION

BIS and montelukast provided acceptable asthma control in children aged 2 to 4 years with mild persistent asthma with no significant difference between treatments in the primary end point; however, several secondary outcomes showed statistically significant differences (and many had numerical differences) in favor of BIS over montelukast.

Inhibition of common cold-induced aggravation of childhood asthma by leukotriene receptor antagonists

BACKGROUND

Virus infection is an important risk factor for aggravation of childhood asthma. The objective of this study was to examine the effect of drugs on aggravation of asthma induced by a common cold.

METHODS

Asthma control was examined in a survey of 1,014 Japanese pediatric patients with bronchial asthma. The occurrence of common cold, asthma control, and drugs used for asthma control were investigated using a modified Childhood Asthma Control Test (C-ACT) for patients aged <4 years old and 4 to 11 years old, and an Asthma Control Test (ACT) for patients aged 12 to 15 years old.

RESULTS

The status of asthma control did not differ among the age groups. The prevalence of common cold and aggravation of asthma were significantly higher in patients aged <4 years old. Control of asthma following common cold-induced aggravation was significantly less effective in patients aged <4 years old compared to those aged ≥4 years old. In patients aged <4 years old with a common cold, asthma control was significantly more effective for those treated with leukotriene receptor antagonists (LTRAs) compared to treatment without LTRAs. Asthma control did not differ between patients who did or did not take inhaled corticosteroids or long-acting β2 stimulants.

CONCLUSIONS

These findings showed a high prevalence of common cold in younger patients with childhood asthma and indicated that common cold can induce aggravation of asthma. LTRAs are useful for long-term asthma control in very young patients who develop an asthma attack due to a common cold.

International consensus on (ICON) pediatric asthma

Asthma is the most common chronic lower respiratory disease in childhood throughout the world. Several guidelines and/or consensus documents are available to support medical decisions on pediatric asthma. Although there is no doubt that the use of common systematic approaches for management can considerably improve outcomes, dissemination and implementation of these are still major challenges. Consequently, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), recently formed by the EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus on (ICON) Pediatric Asthma. The purpose of this document is to highlight the key messages that are common to many of the existing guidelines, while critically reviewing and commenting on any differences, thus providing a concise reference. The principles of pediatric asthma management are generally accepted. Overall, the treatment goal is disease control. To achieve this, patients and their parents should be educated to optimally manage the disease, in collaboration with healthcare professionals. Identification and avoidance of triggers is also of significant importance. Assessment and monitoring should be performed regularly to re-evaluate and fine-tune treatment. Pharmacotherapy is the cornerstone of treatment. The optimal use of medication can, in most cases, help patients control symptoms and reduce the risk for future morbidity. The management of exacerbations is a major consideration, independent of chronic treatment. There is a trend toward considering phenotype-specific treatment choices; however, this goal has not yet been achieved.