Asthma in Premies More Likely To Resolve

There is a well observed and documented phenomenon of increased asthma risk particularly in ex-premies delivered before 30 weeks gestational age.  Parents may be alarmed by the "asthma" label, but that this study suggests that normal child growth and development may help resolve this form of early onset asthma.  Dr. Susarla

Parents of premature babies worry about many things, including an increased risk of asthma. But a large Danish study has found that asthma, common in premature babies, disappears as the children grow older. By the time they are adults, their risk of asthma is no greater than that of babies born full term.

Researchers combed birth and health data on 1.8 million people born from 1980 to 2009, checking for gestational age and neonatal respiratory problems.

The study, published in PLOS One, found that 27 percent of infants born earlier than 27 weeks required asthma medication during childhood, compared with 18 percent of those born at 28-31 weeks, 13 percent at 32-36 weeks, and 9 percent at full term.

But after controlling for socioeconomic status, maternal asthma, multiple birth and other factors, they found that by adolescence, the association had weakened, and by adulthood 2.4 percent of the former preemies required medication compared with 2.1 percent of those born full term, a clinically insignificant difference.

“There are more and more preemies,” said the lead author, Dr. Anne Louise Damgaard, a researcher at the University of Copenhagen, “and we don’t really know what happens to them as they get older. But up to age 31, their lungs are pretty healthy. It’s possible that the differences may become more evident as they age.”

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Preterm Birth May Raise Child's Asthma Risk, Study Suggests

Premie infants seem to have a higher risk for early childhood wheezing, which often follows a pattern consistent with asthma. Dr. Susarla

THURSDAY, March 13, 2014 (HealthDay News) -- A new study may add asthma to the list of downsides of being born too early.

Children who were born prematurely appear to be at higher risk for asthma and wheezing disorders, according to a new review.

Researchers led by Dr. Aziz Sheikh, of Brigham and Women's Hospital in Boston, looked at 30 studies focused on links between preterm birth -- defined as less than 37 weeks' gestation -- and asthma or wheezing disorders among more than 1.5 million children.

Their analysis found that preterm babies were 70 percent more likely than full-term infants to develop asthma or wheezing disorders later in childhood. Overall, close to 14 percent of "preemie" babies went on to develop asthma during childhood, compared to 8.3 percent of babies born at term.

The risk was even higher for very preterm babies, defined as children born at less than 32 weeks' gestation. These infants were about three times more likely than full-term babies to develop asthma or wheezing disorders later on.

"Worldwide, more than 11 percent of babies are born preterm," Sheikh said in a hospital news release.

"As asthma is a chronic condition, our findings underscore the need to improve our understanding of the mechanisms underlying the association between preterm birth and asthma or wheezing disorders in order to develop preventive and therapeutic interventions," he said.

Although the study found an association between premature birth and later asthma, it could not prove cause and effect. The findings were published in a recent issue of the journal PLoS Medicine.

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Having bronchiolitis in infancy, a wheezy illness associated with viral infections, seems to leave its footprint in the lungs for years to come including adulthood.  Dr Susarla

Infant Wheezing Episodes Impact Lungs Later

BARCELONA -- Children who suffer through a bout of bronchiolitis can end up with lungs early in adulthood that look like those of patients with chronic obstructive pulmonary disease (COPD), researchers reported here.

Thirty years after being hospitalized for bronchiolitis when they were younger than 2 years of age, 11% of the patients exhibited lung function that fell below the 0.7 FEV (forced expiratory volume in one second)/FCV (forced vital capacity) ratio that is threshold for the definition of COPD, said Katri Backman, MD, a researcher in pediatrics at Kuopio University Hospital in Finland.

"We found that [about] 30 years after first being hospitalized for bronchiolitis, many of these patients exhibited irreversible airway obstruction -- even though [they] were 28 to 31 years of age," Backman told MedPage Today. She reported her results in a late-breaking poster abstract session at the annual meeting of the European Respiratory Society.

"Irreversible airway obstruction is present 30 years after infantile bronchiolitis for more than 20% of former bronchiolitis patients, suggesting permanent structural changes in airways," Backman said.

Backman and colleagues determined that these patients' airways had been permanently damaged by performing lung function tests before and after administration of bronchodilating medications. But there were no differences in lung function among the bronchiolitis patients, compared with controls or with patients who had been hospitalized with pneumonia in childhood.

"The lack of effect among the bronchiolitis patients of these medicines leads us to believe that the disease has irreversibly damaged their lungs," she said.

In the study, Backman and colleagues identified 83 children hospitalized for bronchiolitis and 44 who were hospitalized for pneumonia at Kuopio University Hospital in 1981-82. All the children in the study were under 2 years of age. "All these children had viral infections in their lungs," she said. "What differentiates bronchiolitis and pneumonia is that the bronchiolitis children have their illness accompanied by this wheezing."

In 2010, the researchers tracked down 47 of the bronchiolitis patients and 22 of the pneumonia patients and compared them with controls who had avoided hospitals as youths. The researchers also recruited 138 healthy, matched controls. All the subjects then underwent multiple lung function tests, such as forced vital capacity, FEV1, the FVC-FEV-1ratio and the FVC/FEV1-ratio % of predicted (FEV%).

They found irreversible airway obstruction that could be considered COPD in five of the bronchiolitis patients (P=0.012); in one of the pneumonia patients (P=0.360), and in two of the controls. "I think that if we had more pneumonia patients, then that number would be statistically significant too. These are both serious diseases in infancy."

Irreversible airway obstruction -- defined as an FEV % of less than 88% -- was observed in 21% of bronchiolitis patients (P=0.001); in 9% of pneumonia patients (P=0.247), and in 4% of controls.

Backman said making comparisons between the bronchiolitis patients and pneumonia patients was difficult because there were few pneumonia patients.

"These findings are similar to what we are finding in our children," Guilia Cangiano, MD, resident in pediatrics at Sapienza University in Rome, told MedPage Today. "Our children have reached the age of 6 and we are seeing these kinds of long-term problems." She did not participate in Backman's study.

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Genetic Test Could Predict Lasting Asthma Symptoms

Asthma for many, is certainly a combination of genetic risk and environmental exposure.  Tests may be available in the future to help identify risk.  Dr. Susarla

Genetic Test Could Predict Which Kids Will Have Lasting Asthma Symptoms

Half of children with asthma will continue to suffer from the respiratory disorder as adults, and a new genetic test could reveal who remains at risk past childhood.

About one in 11 children suffers from asthma, according to the Centers for Disease Control (CDC), and although half will eventually grow out of the condition, a recent CDC survey found that medical costs of asthma and its complications add up to about $56 billion each year. Improved treatment of those most likely to live with their condition longer term, say experts, could help to lower some of these costs, which include treating complications and mismanaged symptoms.

Researchers report in the journal Lancet Respiratory Medicine that a new genetic test may be able to predict a child’s risk of having asthma into adulthood, and therefore help doctors figure out which children might need more intensive care in childhood to potentially lower their risk of longer term symptoms.

The new study piggy backs on so-called genome-wide association (GWAS) studies, which compare those affected by asthma to those who are not to isolate specific genetic markers that could be associated with the disease. In the 40-year long study, Duke University researchers developed a genetic risk score that was based on 15 variants gleaned from previous GWAS, and looked at how these scores matched up to physical symptoms of asthma over time among 880 participants. The genetic score reflected only individual participant’s asthma risk, independent of family history.

The kids with higher scores, which meant they were more likely to possess more of the genetic markers linked to asthma, were also more likely to have asthma symptoms as adults, based on a 38 year follow-up. Those with the higher genetic risk also tended to miss school or work or be hospitalized for their symptoms more often than those with lower genetic scores.

Family history of asthma, the researchers say, did not appear to correlate with a higher genetic risk of the disease; many of the participants with high genetic risk had no family history of asthma, and conversely, people with a strong family history of the disease showed low genetic risk. That suggests that many of the cases were caused by environmental factors such as exposure to pollution or other irritants that have been linked to respiratory problems.

That means that doctors may need to expand the criteria they use to assess asthma risk to include measures such as genetic factors, which may be more predictive of future disease than family history. “What we are discovering in GWAS and doing molecular studies of asthma, is giving us new information over and above the old fashioned way we used to evaluate the genetic risk for asthma and still are in the clinic, which is to take family histories,” says study author Dan Belsky, a postdoctoral Fellow at Duke University. “I think that we are seeing more and more genomic medicine as time goes on. It is really coming into play in cancer medicine. It is not yet there in the treatment of asthma, but I think it will be coming. This study shows some of what may be possible.”

Belsky says scientists are far from knowing which genetic factors are directly responsible for causing asthma, but GWAS are a first step toward narrowing down the field of likely candidates. Most experts believe that for conditions such as asthma, multiple genes may contribute to the disease’s symptoms, so panels such as the one discovered in the current study could help to triage patients and ultimately guide them toward the most effective treatments — both in childhood and in adulthood.

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Take your child's word for it on asthma, study finds

Many parents may be surprised by the subtlety of their child's asthma symptoms.  This frequently leads to underestimation of asthma severity.  Dr. Susarla

Take your child's word for it on asthma, study finds

SAN ANTONIO -- Children's perceptions of living with asthma may differ significantly from their caregivers' perceptions, which means both should be interviewed when they visit the doctor's office, a new study from UT Kids San Antonio and the Center for Airway Inflammation Research (cAIR) shows.

The study analyzed the agreement between 79 children and their caregivers on health-related quality-of-life questionnaires. The children ranged in age from 5 to 17. Fifty-three were classified as having acute asthma and 26 had refractory, or treatment-resistant, asthma.

Include children

"The take-home message is that children need to be included in the communication process with health care providers, and physicians need to elicit the child's perspective on their illness, health status, asthma symptoms and what is being done to treat their illness," said senior author Pamela Wood, M.D., Distinguished Teaching Professor of pediatrics in the School of Medicine at The University of Texas Health Science Center at San Antonio.

UT Kids is the clinical practice of the Department of Pediatrics. cAIR is a newly established research center at the Health Science Center's South Texas Research Facility that focuses on controlling and preventing acute and chronic airway diseases. The director is Joel Baseman, Ph.D.

Encouragement needed

Study lead author Margaret Burks, M.D., a 2013 graduate of the School of Medicine who is now an intern at Vanderbilt University, said children should be empowered to take control of their asthma. "Encouraging an environment where children can talk freely with their caregiver is important, and can start with allowing the child to participate in the office visit," Dr. Burks said. "It is important that children feel that their response to their disease is valued, not only by their physician but by their caregiver, as well."

Children were asked to rate their own limitations on activity, while caregivers were asked to rate the effect that the children's limitations had on family activities. "Overall, children viewed themselves as less impaired, in comparison to how caregivers viewed the limitations that the asthma placed on the family," Dr. Wood said.

Overcome barriers

Parents may not want to acknowledge a lack of communication when they go to a doctor's office. "I think there is often a concern in the minds of caregivers about how they appear to the physician," Dr. Burks said. "Caregivers may not want to seem out of touch with their child's day-to-day health, and, in such fear, they may dominate the conversation at the office visit. Our study demonstrates that it is helpful to gain insight from both the caregiver and the child."

Describing life with asthma to a health care provider can be an inexact science, to be sure. "There is no gold standard," Dr. Wood said. "We can't use a thermometer to measure quality of life."

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Impulse Oscillometry Offers Hope of Early Diagnosis of Asthma

Impulse oscillometry is an advanced lung function testing method that allows early asthma diagnosis and better prediction in loss of asthma control.  Dr Susarla

Impulse Oscillometry Offers Hope of Early Diagnosis of Asthma

A study led by researchers at NIAID suggests that impulse oscillometry (IOS), a non-invasive method for measuring lung function, is more effective in detecting asthma in children than spirometry, the commonly used method. The results appear in the August 2011 issue of Pediatric Pulmonology.

Background

A child uses an IOS machine to measure lung function. Credit: NIAID

Jason¹ was only 3 years old when he first arrived at the Pediatric Allergy Clinic at the National Institutes of Health (NIH), in Bethesda, Maryland. He had a history of severe allergic reactions to food and suffered from chronic atopic dermatitis, also called eczema. Recently, he had developed recurrent coughing and wheezing. His doctor suspected asthma and prescribed daily use of inhaled corticosteroids.

Before adding another drug to Jason’s daily regimen, his parents wanted conclusive proof that he had asthma. The standard test used to diagnose asthma, called spirometry, requires that a person exhale vigorously into a machine for 10 to 15 seconds. As a result, younger children and some adults with physical impairment may not be able to use the test. Because of Jason’s age, he would have to wait two to three years before he could take a lung function test to confirm his doctor’s diagnosis.

“A challenge for clinicians is how to make an accurate diagnosis in cases when the patient is not capable of performing the test required for that diagnosis,” said Hirsh D. Komarow, M.D., of the NIAID Laboratory of Allergic Diseases.

New Technology

IOS is a newer method of measuring lung function that has gradually been gaining acceptance by clinicians. The IOS machine works by producing small-pressure oscillations (vibrations) that are applied at the mouth and transmitted into the lungs. Measuring how the respiratory system responds to these impulses during natural breathing provides an indirect analysis of lung function. Unlike spirometry, IOS is non-invasive and easy-to-perform and requires minimal assistance from the patient.

“IOS offers several advantages over spirometry in the evaluation of young children in clinical practice,” said Dr. Komarow, “We sought to answer the question: Are the test results obtained from IOS as accurate as those produced by spirometry.”

Study Results and Significance

Dr. Komarow’s study compared results from lung function tests measured by IOS and by spirometry in 117 children who already were receiving medical care at the NIH Pediatric Allergy Clinic.

“The data were conclusive,” said Dean Metcalfe, M.D., chief of the Laboratory of Allergic Diseases, “In these children, IOS was not only more sensitive than spirometry, it was more specific in identifying children with asthma.”

This is a promising advance in asthma care. Asthma is a chronic lung disease that affects more than 22 million people in the United States, including nearly 7 million children under age 6. Early diagnosis of asthma promises several benefits: parents are able to more closely monitor their child for respiratory symptoms that may worsen asthma; doctors can track the course of the disease over a longer time period to better predict its outcome; and there are studies that indicate that beginning asthma treatment at a younger age improves long-term control of the illness.

Dr. Komarow examined Jason using IOS and in moments confirmed that Jason had asthma.

“I was pleased that Jason could be evaluated with IOS at the clinic,” said Dr. Komarow, “We made an objective diagnosis and he is receiving appropriate treatment to manage his asthma. This would not have been possible without IOS.”

Read article here.

Adding to the state of asthma research in children, there appear to be specific genes that confer risk of wheezing in children possibly portending risk of asthma as well.  Dr. Susarla

Genetic Variants and Wheezing Put Kids At Risk For Asthma

Almost every toddler will sniffle through a cold by the time they are three, but if they wheeze while they’re sick, they may be at higher risk of developing asthma.

Previous research found that wheezing-related illnesses can increase a child’s risk for developing asthma, and other studies connected certain genetic factors to this heightened tendency to wheeze. In a new study published in the New England Journal of Medicine, researchers connected the two and found that 90% of three-year-olds with a combination of specific genes and a particular wheezing illness were diagnosed with asthma by the age of 6.

The scientists focused on a region of chromosome 17, known as 17q21 that has been associated with an elevated risk of asthma early in life. Two genes in the region likely increase this risk — ORMDL3 and GSDMB. Variants of these genes, which are relatively common, seemed to confer higher risk of wheezing when children were infected with the rhinovirus, which is responsible for the common cold. About half of the infants in the study had one copy of the variant, while a quarter had both copies, which significantly increased their likelihood of wheezing and developing asthma.

The researchers included children from two separate study groups, all of whom came from families with a history of allergies or asthma. The first group included 200 children toddlers with at least one, and possibly two parents who had allergies or asthma while the second group consisted of Danish toddlers whose mothers were diagnosed with asthma. Among children without the high-risk genetic variants for asthma, 40% who wheezed when they caught a cold before age three developed asthma by age six, compared to 60% who had one copy of the variant and wheezed, and 90% of those who had two copies and also wheezed.

“We found that the interaction between this specific wheezing illness and a gene or genes on a region of chromosome 17 determines childhood asthma risk. The combination of genetic predisposition and the child’s response to this infection has a huge effect,” said study author Carole Ober, a Blum-Riese Professor of Human Genetics at the University of Chicago in a statement.

Overall, the children with the genetic and wheezing illness combination were almost four times as likely to develop asthma compared to kids who did not have the genetic variation or did not wheeze, suggesting that wheezing might be a relatively easy marker for identifying toddlers who might be at highest risk of developing asthma later.

The biological mechanisms underlying the connection are not well understood, but to get a better idea of what’s going on, the researchers collected blood from 100 healthy adults and exposed their immune cells to human rhinovirus. Infection with the cold virus seemed to make the asthma-related genes on chromosome 17 more active, possibly leading to more wheezing.

If the results are confirmed, then doctors and parents could be more alert to early signs of wheezing, and consider testing for the presence of the genetic variants that could increase the risk of asthma. Such early intervention could help to limit exposure to asthma triggers, such as cigarette smoke, bisphenol A and other potential irritants, and hopefully reduce the severest symptoms as well.

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Asthma Patients Often Depressed

Adjustment to a chronic disease can be difficult.    This study suggests that patients with asthma should be closely monitored for depressive symptoms.  Every effort should be made to reduce the impact of asthma on daily life.

Asthma Patients Often Depressed

ANAHEIM, Calif. -- Depression and asthma appear to go hand in hand, even in patients whose asthma is relatively mild and who report generally good health, a researcher said here.

Analysis of some 13,000 participants in the Cooper Institute Longitudinal Study indicated that a diagnosis of asthma was a risk factor for reports of significant current depressive symptoms with an odds ratio of 1.41 (95% CI 1.16 to 1.65, P<0.001) after adjusting for asthma severity and self-assessment of overall health status.

Asthma and a previous history of depression also were significantly associated, with an odds ratio of 1.65 (95% CI 1.40 to 1.90,P<0.001), Tim Trojan, MD, of the University of Texas Southwestern Medical Center in Dallas, told attendees at the American College of Allergy, Asthma, and Immunology annual meeting.

Associations between asthma and depression have been reported before, Trojan explained, but those studies could not rule out the possibility that patients were simply sad about feeling sick with asthma.

Consequently, he and his colleagues utilized records from the Cooper Institute Longitudinal Study, begun in 1970 by the institute's founder, Kenneth Cooper, MD, the aerobics advocate. The database has unusually detailed information on patients including spirometry values, scores on the Center for Epidemiologic Studies Depression Scale (CES-D), medical history, body mass index, and lifestyle factors such as smoking and drinking status, as well as standard demographics.

Trojan and colleagues analyzed data on 12,944 study participants, including 1,169 with a diagnosis of asthma. Of these, only 187 were on controller medications, suggesting that the sample mostly included people with relatively mild asthma.

About 81% of the overall sample indicated that their health status was good or excellent, as opposed to fair or poor. Current depressive symptoms (CES-D scores of 10 or higher) were present in 11% and a past history of depression in 14%.

Bivariate analyses indicated that the risk of depressive symptoms was significantly increased, not only by a diagnosis of asthma, but also by female gender, hypertension, and current smoking. It was significantly decreased in nonwhites, those with more than a high school education, age older than 50, and current drinking.

Multivariate analysis produced the odds ratio 0f 1.40 for depressive symptoms with an asthma diagnosis. When expressed as an r² correlation coefficient, the value of 0.119 suggested that the relationship was only modest at best, Trojan said.

But a classification analysis based on the association correctly categorized 89.5% of study participants, he said.

The same held true for the association between asthma and depression history. The r² correlation coefficient was 0.110, but the classification analysis categorized 85.7% of participants correctly, Trojan said.

He noted that the study had a number of limitations including the fact that some of the data such as depression history and smoking and drinking status were self-reported, and the Cooper Institute database consists of people who are "mostly white and mostly healthy." Trojan added that they are probably relatively affluent as well, although income data are not collected.

Nevertheless, he said, the study findings "mean that your mild asthmatic ... who doesn't look or feel all that bad still has a significant risk, or could have a significant risk, of having depressive symptoms and should be evaluated for this."

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Discovery May Lead to New Asthma Treatment

This promising research focuses on a unique step in the pathway that leads to asthma exacerbations. Dr. Susarla

Scientists Focus on Factors Behind Asthma Attacks

Findings could pave way to reducing 2 major airway symptoms, researchers say

THURSDAY, Sept. 20 (HealthDay News) -- Blocking two particular biological processes might help provide relief to people with asthma, according to a new study.

The University of California, San Francisco-led team found that a specific calcium-activated chloride channel called TMEM16A plays a role in the severity of asthma. The channel regulates airway secretions and smooth-muscle contraction: the major factors that lead to an asthma attack.

"Maybe if we could inhibit both of these processes by blocking this one channel, then we could affect the two symptoms of asthma," study senior author Jason Rock, an assistant professor at the UCSF anatomy department, said in a university news release.

People with asthma have a higher-than-normal number of mucus-producing cells in the lining of the airway tubes that lead to the lungs, and they also have an abnormal amount of smooth muscle surrounding the airway tubes. The slightest stimulus can cause the tubes to contract.

"The overabundance of mucus plugging the airways combined with hyper-contractility of the smooth muscle -- when the tubes get really small -- make it difficult to move air in or out," Rock explained. "A lot of people equate that with breathing through a straw."

In laboratory tests, the researchers identified three chemicals that inhibited the activity of TMEM16A and led to reduced mucus production and smooth muscle contraction.

The study was published Sept. 17 in the journal Proceedings of the National Academy of Sciences.

The next step is to test the safety and effectiveness of these chemical blockers in animals, the researchers say. If that goes well, human clinical trials could follow.

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Height Reduction in Children Using Inhaled Steroids

This is not as surprising as some might think.  For many children, the benefits of therapy which include preventing life threatening asthma attacks outweigh any risk.  However, confirming a diagnosis of asthma is key.  It's important to know that if your child is taking inhaled steroids that he/she in fact really needs them or is on the correct dose.  Dr. Susarla

Height Reduction in Children Using

Asthma Inhalers

Children using steroid inhalers tend to be slightly, 

about half inch, shorter than their peers when they 

reach adulthood, a new study says.

• EnlargeAccording to estimates, about 9 million children in the United States have asthma. Inhaled corticosteroids are the most effective drug to treat asthma symptoms. Previous research has shown that inhaled corticosteroids lower the chances of asthma attacks, wheezing and improve lung function in infants and preschoolers.

"This [study results] was surprising because in previous studies, we found that the slower growth would be temporary, not affecting adult height. But none of those studies followed patients from the time they entered the study until they had reached adult height," said Robert C. Strunk, MD, Professor of Pediatrics at Washington University School of Medicine in St. Louis.

The present study involved around 1,000 children suffering from asthma. The participants were aged between 5 and 12 years old and were randomly divided into three groups; group one received inhaled corticosteroid asthma medication (budesonide), the second group received inhaled medication without steroids (nedocromil) and the third group was given a placebo. All participants were given albuterol, a drug for relief of acute asthma symptoms, and oral corticosteroids as needed for asthma symptoms.

Participants' height and weight was measured at regular interval until they reached adulthood. More than 900 participants were followed until they reached 18 years old, for girls, and 20 years old, for boys.

Researchers found that participants who used budesonide were half inch shorter than those who used either nedocromil or a placebo. They also found that the slowest growth in height occurred when the children started using budesonide between the ages of five and 11.

 "We found it made no difference if they were boys or girls or how long they had had asthma, or any other of these factors. We also looked at the height of the parents, and that didn't have any impact, either," Strunk said.

Benefits of the corticosteroids versus half an inch of height

Strunk said that pediatric asthma specialists at St. Louis Children's Hospital monitored the participants' growth and maintained records of growth curve. He said that the "half-inch of lowered adult height must be balanced against the well-established benefit of inhaled corticosteroids in controlling persistent asthma. We will use the lowest effective dose to control symptoms to minimize concerns about effects on adult height."

"The loss of height compared to expected height was not dramatic in this study [and] without inhaled steroids, some of these persistent, asthmatic children may well have suffered considerable morbidity [illness], which was prevented by the inhaled steroids," Dr. Len Horovitz, a pulmonary specialist at Lenox Hill Hospital in New York City, HealthDay reports.

Read more here.