Wheezing Episodes Research Articles

A meta-analysis of montelukast for recurrent wheeze in preschool children

There is conflicting evidence of the effectiveness of montelukast in preschool wheeze. A recent Cochrane review focused on its use in viral-induced wheeze; however, such subgroups are unlikely to exist in real life and change with time, recently highlighted in an international consensus report. We have therefore sought to investigate the effectiveness of montelukast in all children with preschool wheeze (viral-induced and multiple-trigger wheeze). The PubMed, Cochrane Library, Ovid Medline and Ovid EMBASE were screened for randomised controlled trials (RCTs), examining the efficacy of montelukast compared with placebo in children with the recurrent preschool wheeze. The primary endpoint examined was frequency of wheezing episodes. Five trials containing 3960 patients with a preschool wheezing disorder were analysed. Meta-analyses of studies of intermittent montelukast showed no benefit in preventing episodes of wheeze (mean difference (MD) 0.07, 95% confidence interval (CI) −0.14 to 0.29; mean for montelukast 2.68 vs placebo 2.54 (p = 0.5)), reducing unscheduled medical attendances (MD −0.13, 95% CI −0.33 to 0.07; mean for montelukast 1.62 vs placebo 1.78 (p = 0.21)) and reducing oral corticosteroids (MD −0.06, 95% CI −0.16 to 0.02; mean for montelukast 0.35 vs placebo 0.36 (p = 0.25)). The pooled results of the continuous regimen showed no significant difference in the number of wheezing episodes between the montelukast and placebo groups (MD −0.40, 95% CI −1.00 to 0.19; mean for montelukast 2.05 vs placebo 2.37 (p = 0.18)).Conclusions: This review highlights that the currently available evidence does not support the use of montelukast in preschool children with recurrent wheeze. We recommend further studies to investigate if a ‘montelukast responder’ phenotype exists, and how these can be easily identified in the clinical setting.What is Known:• Current guidelines recommend montelukast use in preschool children with recurrent wheeze.• A recent Cochrane review has found montelukast to be ineffective at reducing courses of oral corticosteroids for viral-induced wheeze.What is New:• This meta-analysis has examined all children with preschool wheeze and found that montelukast was not effective at preventing wheezing episodes or reducing unscheduled medical attendances.• A specific montelukast responder phenotype may exist, but such patients should be sought in larger multicentre RCTs.

Current and future management of the young child with early onset wheezing.

In this review, we discuss current thinking in relation to available guidelines for the care of preschool-aged children with recurrent wheezing, while highlighting the gaps in our knowledge and discussing changes that could occur over the next 5 years. The Asthma Predictive Index as well as allergen-specific IgE, peripheral eosinophil count and exhaled nitric oxide are perhaps underutilized sources of information that can assist in predicting progression to asthma and response to therapies. Inhaled corticosteroids and leukotriene receptor antagonists decrease impairment and exacerbation frequency in wheezing children but are not disease modifying. Macrolides may be useful during acute wheezing episodes for preventing progression to more severe symptoms. Monoclonal antibodies targeting IgE and TH2 cytokines have been successful in trials of adults and older children with asthma, but trials in younger children are needed. Establishing the phenotype and endotype of young wheezing children can be useful for prognostication of future asthma risk as well as for selection of the most appropriate treatment. Primary asthma prevention strategies are needed during the critical developmental window in early life prior to the onset of irrecoverable loss of lung function.

Management of preschool recurrent wheezing and asthma: a phenotype-based approach.

The purpose of this review is to summarize the recent evidence on the management of preschool children with wheezing and asthma, and to propose a phenotype-based approach to the management of these children. Recent studies have begun to identify populations of preschool children that are likely to benefit from inhaled corticosteroids (ICS) therapy and defined ICS regimens: daily ICS in preschool children with persistent asthma, and pre-emptive high-dose intermittent ICS among preschool children with intermittent disease reduce the risk of exacerbation. In addition, among preschool children with mild persistent asthma, the presence of aeroallergen sensitivity and/or blood eosinophil counts of 300/μL or greater are predictors of good response to daily ICS therapy. Other studies identified intermittent azithromycin as a therapy to prevent, and potentially to treat, acute exacerbations.The uncertainty of the role of oral corticosteroids (OCS) as a therapy for acute exacerbations continues, as a recent meta-analysis showed that OCS did not prevent hospitalizations or urgent visits, and did not reduce the need for additional courses of OCS. Whereas previous epidemiologic studies suggested acetaminophen may increase risk of exacerbations, a clinical trial clearly demonstrated acetaminophen use, compared to ibuprofen use,does not increase exacerbation risk among preschool children with mild-persistent asthma. Recent studies have shown potential for phenotypic-driven therapies for the management of preschool children with asthma. Targeting airway bacteria has emerged as a promising therapeutic approach, but its effect on antibiotic resistance still needs to be investigated. Finally, more studies are required to evaluate if oral corticosteroids provide any benefits for acute episodic wheeze.

A young child with a history of wheeze

The parents of a 3-year old boy are anxious about their son who has recurring episodes of wheezing. They are frustrated that no one seems to be able to give them answers to their questions and would like a referral to a specialist. Does their son have asthma and what is the prognosis; how can the recurrent wheezing be managed and can the risk of asthma be reduced; are there lifestyle changes that could improve the environment and avoid triggers? Communication and support from the family practice team were essential. Listening to the parents’ concerns, explaining the diagnostic uncertainty, being realistic about what drug treatments could achieve, and providing practical advice on inhaler use and trigger avoidance reassured the parents that there was a strategy for managing their son’s wheeze. The specialist referral was postponed.

Factors predicting persistence of early wheezing through childhood and adolescence: a systematic review of the literature.

BackgroundFor the early identification of persistent asthma symptoms among young children with recurrent wheezing, it would be helpful to identify all available studies that have identified at least one factor for predicting the persistence of early wheezing. The objective of the present study was to perform a systematic review of all studies that have identified factors that predict the persistence of symptoms among young patients with recurring wheezing.MethodsA systematic review of relevant studies was conducted through searching in MEDLINE, EMBASE, CINHAL, and SCOPUS databases up to June 2016. Studies that identified predictors of persistence of wheezing illness among young children with recurrent wheezing were retrieved. Two independent reviewers screened the literature and extracted relevant data.ResultsThe literature search returned 649 references, 619 of which were excluded due to their irrelevance. Five additional studies were identified from reference lists, and 35 studies were finally included in the review. Among all the identified predictors, the most frequently identified ones were the following: family asthma or atopy; personal history of atopic diseases; allergic sensitization early in life; and frequency, clinical pattern, or severity of wheezing/symptoms.ConclusionParental asthma (especially maternal), parental allergy, eczema, allergic rhinitis, persistent wheezing, wheeze without colds, exercise-induced wheeze, severe wheezing episodes, allergic sensitization (especially polysensitization), eosinophils (blood or eosinophil cationic protein in nasal sample), and fraction of exhaled nitric oxide were risk factors predicting persistence of early wheezing through school age. All of them are included in conventional algorithms, for example, Asthma Predictive Index and its modifications, for predicting future asthma.

Viral aetiology of wheezing in children under five.

Background & objectives:Wheezing is a common problem in children under five with acute respiratory infections (ARIs). Viruses are known to be responsible for a considerable proportion of ARIs in children. This study was undertaken to know the viral aetiology of wheezing among the children less than five years of age, admitted to a tertiary care hospital in eastern India.Methods:Seventy five children, under the age of five years admitted with wheezing, were included in the study. Throat and nasal swabs were collected, and real-time multiplex polymerase chain reaction (PCR) assay was used to screen for influenza 1 and 2, respiratory syncytial virus (RSV), parainfluenza virus (PIV) 1, 2, 3 and 4, rhinovirus, human meta-pneumovirus, bocavirus (HBoV), Coronavirus, adenovirus, Enterovirus and Parechovirus.Results:The total viral detection rate was 28.57 per cent. Viral RNA markers were detected from children diagnosed to be having pneumonia (3 cases), bronchiolitis (9 cases), episodic wheeze (2 cases) and multitrigger wheeze (6 cases). RSV was the most common virus (35%) followed by PIV1, 2 and 3 (20%), HBoV (10%) and rhinovirus (5%). However, mixed infection was observed in 30 per cent of cases.Interpretation & conclusions:The study reported the presence of respiratory viral agents in 28.57 per cent of children with wheezing; RSV and PIV were most common, accounting to 55 per cent of the total cases. Mixed infection was reported in 30 per cent of cases. Seasonal variation in the occurrence of these viruses was also noted. Further studies need to be done with a large sample and longer follow up period to verify these findings.

First episode of preschool wheeze requiring hospitalization:a prospective study on the chance of recurrence and associated factors.

Although wheezing is very common in preschoolers, epidemiologic studies in Thailand are quite limited. The likelihood of having a second wheezing episode following the first attack remains unclearly established. This study aims to investigate the incidence of recurrent wheezing in preschool children presenting with first wheezing episode and identify the associated factors. The study is an observational prospective study conducted at the inpatient pediatric department. Patients admitted with first episode of wheezing were followed up as an outpatient approximately one week after hospital discharge and subsequently followed up by telephone 3-monthly with a structured questionnaire seeking information concerning recurrent wheezing, defined as having a second wheezing episode requiring bronchodilator within a 1-year period. The total of 97 patients, aged 6 months to 5 years, were recruited from June 2014 to November 2015. Thirty-five patients were excluded because of inaccessibility for telephone follow-up. Amongst the remaining 62 patients, twenty-eight (45.2%) had recurrent wheezing within one year. The mean lapse duration was 4.7 ± 3.7 months after the first episode. Having an allergic sensitization to aeroallergen was a risk factor for recurrent wheezing (OR 2.48, 95%CI 1.81-3.4). Although not statistically significant, having an allergic sensitization to food seems to be another related factor (OR 2.36, 95%CI 1.75-3.18). The recurrent rate of wheezing was 45%, which was considerably significant. Allergic sensitization to aeroallergen might increase the risk. These patients should be followed up, especially within the first year after their first wheezing episode.

A longitudinal assessment of circulating YKL-40 levels in preschool children with wheeze.

The chitinase-like protein YKL-40 (CHI3L1) is elevated in the circulation of adults and schoolchildren with chronic severe asthma. It is unknown whether YKL-40 is altered in younger, preschool children with wheeze, acute or chronic. We therefore examined YKL-40 in preschool children during an acute episode of wheeze and during remission, in comparison with healthy controls. Blood was obtained from 128 children (aged 6-44 months) at the emergency department during an acute episode of wheeze, and at two follow-up visits (approximately 3 months and 1 year later), as well as from 100 age-matched healthy controls on one occasion. Plasma YKL-40 levels were examined in relation to CHI3L1 rs4950928 genotype and clinical characteristics including Asthma Predictive Index, medication use, time spent with respiratory symptoms, atopic status, and blood leukocytes. Children with wheeze had higher median YKL-40 levels at the acute visit (14.7 (11.5-22.6) ng/ml, p < 0.001) and 3-month follow-up (15.9 (11.5-20.2), p < 0.001) compared to the 1-year follow-up (11.9 (9.5-17.3)). YKL-40 levels in healthy controls (13.6 (11.0-17.0)) tended to be lower than those during acute wheeze (p = 0.07) and 3-month follow-up (p = 0.04), but were no different at the 1-year follow-up. CHI3L1 rs4950928 affected YKL-40 in all subjects, with highest levels present in those with the CC genotype (p < 0.001). Genotype frequency was similar in the two subject groups. YKL-40 levels showed a positive correlation with blood neutrophil counts but no consistent relationships with clinical characteristics of relevance to continuous wheeze. YKL-40 levels were elevated during acute wheeze in preschool children, a finding which may be related to current neutrophilic inflammation, but YKL-40 was not associated with characteristics of persistent wheeze in this young cohort.

Airway tone dysfunction among pre-schoolers with positive asthma predictive index: A case–control study

ObjectiveTo measure lung function by impulse oscillometry (IOS) and spirometry in recurrent wheezer pre-schoolers according to their asthma predictive index (API) condition. MethodsWe performed a case–control study enrolling all pre-schoolers with recurrent wheezing episodes (>3 episodes confirmed by physician) who presented at a paediatric pulmonology clinic. The population was divided according to stringent API criteria into positive or negative. ResultsIn the nine-month period, 109 pre-schoolers were enrolled. After excluding one patient (due to lung function technique problems) 108 pre-schoolers (56 males, age range from 24 to 72 months) completed the study; 50 belong to positive API and 58 to negative API group. There were no differences in demographics between groups. More use of ICS was found in those with positive API than with negative API (62% vs. 12%, respectively, p=0.001). No differences in basal lung function and post-bronchodilator response to salbutamol (by IOS or spirometry) were found between positive and negative API pre-schoolers. However, those positive API pre-schoolers with ICS had significantly higher central basal airway resistance (RA at 20Hz) and higher post-BD response (% change in FEF25–75 and in FEV0.5) than those positive API without ICS. ConclusionRecurrent wheezer pre-schoolers with positive API and ICS used may have airway dysfunction. More studies are needed to confirm this finding.

Rhinovirus-specific antibody responses in preschool children with acute wheeze reflect severity of respiratory symptoms.

Some children with rhinovirus (RV) infections wheeze, but it is unknown whether this is due to more virulent strains of virus or differences in host immune responses. The aim of this study was to investigate the RV species-specific antibody responses measured at a follow-up visit in preschool children in relation to reported time with respiratory symptoms and the presence of different RV species during an acute episode of wheeze. Nasopharyngeal swabs and blood samples were taken among 120 preschool children (<4 years of age) at an acute episode of wheeze and at a follow-up visit (median 11 weeks later). Nested PCR was used to detect different RV strains, and serum levels of IgG1 against purified recombinant VP1 proteins from representatives of the three RV species (RV-A, RV-B, and RV-C) were measured by ELISA. Rhinovirus was detected in 74% (n = 80/108) of the children at the acute visit, and RV-C was the most common subtype (n = 59/80, 74%). An increase in RV-specific IgG1 was seen in 61% (n = 73) of the children at follow-up, most frequently against RV-A (n = 61/73, 86%) irrespective of the RV strains detected by PCR. Increases in RV-specific IgG1 against RV-A or against RV-A and RV-C were significantly associated with more respiratory symptoms (p = 0.03, p = 0.007). Antibody response to recombinant RV VP1 proteins was associated with longer time with respiratory symptoms.

Lack of association between viral load and severity of acute bronchiolitis in infants.

ABSTRACTObjective: To investigate the correlation between respiratory syncytial viral load and length of hospitalization in infants with acute wheezing episodes. Methods: This was a two-year, cross-sectional study of infants ≤ 12 months of age with bronchiolitis at the time of admission to a tertiary hospital. For the identification of respiratory viruses, nasopharyngeal secretions were collected. Samples were analyzed (throughout the study period) by direct immunofluorescence and (in the second year of the study) by quantitative real-time PCR. We screened for three human viruses: rhinovirus, respiratory syncytial virus, and metapneumovirus. Results: Of 110 samples evaluated by direct immunofluorescence, 56 (50.9%) were positive for a single virus, and 16 (14.5%) were positive for two or more viruses. Among those 72 samples, the most prevalent virus was respiratory syncytial virus, followed by influenza. Of 56 samples evaluated by quantitative real-time PCR, 24 (42.8%) were positive for a single virus, and 1 (1.7%) was positive for two viruses. Among those 25 samples, the most prevalent virus was again respiratory syncytial virus, followed by human rhinovirus. Coinfection did not influence the length of the hospital stay or other outcome s. In addition, there was no association between respiratory syncytial virus load and the length of hospitalization. Conclusions: Neither coinfection nor respiratory syncytial viral load appears to influence the outcomes of acute bronchiolitis in infants.

Country of Birth and Variations in Asthma and Wheezing Prevalence, and Emergency Department Utilization in Children: A NHANES Study.

Asthma prevalence and asthma-related healthcare utilization differ across racial/ethnic groups and geographical areas. This study builds on previous research to examine the relationship between country of birth and asthma prevalence and healthcare utilization using a national data set. The National Health and Nutrition Examination Survey (NHANES) Demographic and Questionnaire Files from 2007 to 2012 were used for this study. We used SPSS complex sampling design to estimate the association between country of birth and asthma prevalence, wheezing and emergency department (ED) use. The sample size was 8272 children and adolescents between the ages of 5 and 19years old. US-born children had more reported episodes of wheezing (p=0.024) 95% CI 1.06; 2.54. There was no association between country of birth and asthma and ED use. US-born children and adolescents compared to foreign-born children and adolescents are more likely to have episodes of wheezing.

Stability and predictiveness of multiple trigger and episodic viral wheeze in preschoolers.

In 2008, the European Respiratory Society Task Force proposed the terms multiple-trigger wheeze (MTW) and episodic (viral) wheeze (EVW) for children with wheezing episodes. We determined MTW and EVW prevalence, their 24-month stability and predictiveness for asthma. In total, 565 preschoolers (1-, 2- and 3-year-olds) in primary care with respiratory symptoms were followed until the age of 6years when asthma was diagnosed. MTW status and EVW status were determined using questionnaire data collected at baseline and after one and 2years. We distinguished 3 phenotypes and determined their 24-month stability, also accounting for treatment with inhaled corticosteroids (ICS). Logistic regression was used to analyse the phenotypes' associations with asthma. Two hundred and eighty-one children had complete information. MTW and EVW were stable in 10 of 281 (3.6%) and 24 of 281 (8.5%), respectively. The odds of developing asthma for children with stable MTW and stable EVW were 14.4 (1.7-119) and 3.6 (1.2-11.3) times greater than those for children free of wheeze (for at least 1year). ICS was associated with increased stability of MTW and EVW. Stable multiple-trigger and stable episodic viral wheeze are relatively uncommon. However, 1- to 3-year-olds with stable MTW are at much increased risk of asthma.

Omalizumab (anti-IgE) therapy in the asthma–COPD overlap syndrome (ACOS) and its effects on circulating cytokine levels

Context: The term “asthma–chronic obstructive pulmonary disease (COPD) overlap syndrome” (ACOS) has been applied to the condition, in which a person has clinical features of both asthma and COPD.Methods: The patients (N = 10) were presented to our clinic with low lung function, limited reversibility of airway obstruction, hyperinflation, abnormal body composition, dyspnea and episodic wheezing. Based on the clinical and laboratory findings, the patients were diagnosed with ACOS. Patients’ serum IL-2 (sIL-2), sIL-4 sIL-6, sIL-10, sIL-17, sTNF-α and sIFN-γ levels were investigated as an apoptotic marker and a marker for inflammation.Results: Having undergone omalizumab treatment and a long-term (12 months) later, patients had a decreased IgE, fractional exhaled nitric oxide concentrations (FENO), eosinophil, neutrophils, macrophages, eosinophil cationic peptide (ECP) and sIL-4 levels.Conclusion: To our knowledge, this is the first documentation of omalizumab use in ACOS. We demonstrated decreased IL-4, allergic pulmonary symptoms (dyspnea, wheezing, bronchial hyper responsiveness) and migraine attacks in the patients.

Efficacy of oral corticosteroids in the treatment of acute wheezing episodes in asthmatic preschoolers: Systematic review with meta-analysis.

Systemic corticosteroids (SCS) are used for treat preschoolers with acute asthma or wheezing exacerbations, with conflicting results. To evaluate the effectiveness of oral corticosteroids (OCS) compared to placebo in preschoolers presenting with acute asthma/wheezing exacerbations. Five electronic databases were searched for all placebo-controlled, randomized clinical trials of OCS in children <6 years of age presenting with recurrent wheezing/asthma exacerbations of any severity. Primary outcomes were hospitalizations, unscheduled emergency department (ED) visits in following month, need of additional OCS courses, and length of stay (ED or hospital). Eleven studies met inclusion criteria (n = 1,733); four were conducted on an outpatient basis, five in inpatients, and two in the ED. Significant heterogeneity was found when pooling all studies, and thus analysis was stratified by trial setting. Among the outpatient studies, children who received OCS had a higher hospitalization rate (RR: 2.15 [95%CI = 1.08-4.29], I(2) = 0%) compared to those to received placebo. Among the ED studies, children who received OCS had a lower risk of hospitalization (RR: 0.58 [0.37-0.92], I(2) = 0%). Among the inpatient studies, children who received OCS needed fewer additional OCS courses than those on placebo (RR: 0.57 [0.40-0.81], I(2) = 0%). Treatment with OCS in the ED or hospital may be beneficial in toddlers and preschoolers with frequent asthma/wheezing exacerbations. However, more studies are needed before OCS can be broadly recommended for this age group. Future trials should be carefully designed to avoid bias and according to our findings regarding administration setting. Pediatr Pulmonol. 2016;51:868-876. © 2016 Wiley Periodicals, Inc.

Pediatric Asthma and Viral Infection

Respiratory viral infections, particularly respiratory syncytial virus (RSV) and rhinovirus, are the most importance risk factors for the onset of wheezing in infants and small children. Bronchiolitis is the most common acute respiratory infection in children under 1 year of age, and the most common cause of hospitalization in this age group. RSV accounts for approximately 70% of all these cases, followed by rhinovirus, adenovirus, metapneumovirus and bocavirus. The association between bronchiolitis caused by RSV and the development of recurrent wheezing and/or asthma was first described more than 40 years ago, but it is still unclear whether bronchiolitis causes chronic respiratory symptoms, or if it is a marker for children with a genetic predisposition for developing asthma in the medium or long term. In any case, sufficient evidence is available to corroborate the existence of this association, which is particularly strong when the causative agent of bronchiolitis is rhinovirus.The pathogenic role of respiratory viruses as triggers for exacerbations in asthmatic patients has not been fully characterized. However, it is clear that respiratory viruses, and in particular rhinovirus, are the most common causes of exacerbation in children, and some type of respiratory virus has been identified in over 90% of children hospitalized for an episode of wheezing. Changes in the immune response to viral infections in genetically predisposed individuals are very likely to be the main factors involved in the association between viral infection and asthma.

Risk Factors for Asthma at Age 7 to 8 in Early Childhood Wheezers: Results from a Japanese Asthma Cohort Study

Previous studies have demonstrated that a proportion of children with wheezing episodes in early childhood do not have asthma at school age. We sought to determine the risk factors for asthma at school age among early childhood wheezers in a Japanese asthma cohort study. A total of 632 children aged 0 to 3 with recurrent wheezing episodes were recruited in 2004 to 2006. Information including family history, environmental factors, wheezing symptoms and treatment were collected by annual questionnaires. Among the 545 children with adequate baseline information, we analyzed the 433 children followed up at 7 to 8 years old. Asthma at 7 to 8 years old was defined as having wheeze or the regular use of asthma controller medication in the past 12 months. Of the analyzed 433 children, 299 (69.1%) were boys and 350 (80.8%) children were on treatment of inhaled corticosteroids (ICS) or leukotriene receptor antagonists at recruitment. At 7 to 8 years of age, 276 (63.7%) had asthma. Multivariate regression analysis showed that low birth weight, personal history of atopic dermatitis and food allergy at baseline, parental allergic rhinitis or pollinosis, the use of ICS at baseline were significantly associated with asthma at age 7 to 8 (each p<0.05). Predisposition to atopy was a significant risk factor for asthma at school age in early childhood wheezers, similar to previous studies. Children with the early use of ICS had a high risk of asthma at school age in our study population, probably due to the initial severity.

Factors associated with the time to the first wheezing episode in infants: a cross-sectional study from the International Study of Wheezing in Infants (EISL).

Male gender, asthmatic heredity, perinatal tobacco smoke exposure and respiratory infections have been associated with wheeze in the first years of life, among other risk factors. However, information about what factors modify the time to the first episode of wheeze in infants is lacking. The present study analyses which factors are associated with shorter time to the first episode of wheeze in infants. Parents of 11- to 24-month-old children were surveyed when attending their health-care centres for a control visit. They answered a questionnaire including the age in months when a first wheeze episode (if any) had occurred (outcome variable). The study was performed in 14 centres in Latin America (LA) and in 8 centres in Europe (EU) (at least 1,000 infants per centre). Factors known to be associated with wheezing in the cohort were included in a survival analysis (Cox proportional hazards model). Summary hazard ratios adjusted for all risk factors (aHR) were calculated using the meta-analysis approach with random effects. A total of 15,067 infants had experienced wheezing at least once, out of 35,049 surveyed. Male gender in LA (aHR 1.05, 95% confidence interval (CI) 1.00–1.10, P=0.047), parental asthma in LA and EU (aHR 1.05, 95% CI 1.00–1.11, P=0.037), infant eczema in EU (aHR 1.25, 95% CI 1.12–1.39, P<0.001) and having a cold during the first 3 months in LA and EU (aHR 1.97, 95% CI 1.90–2.04, P<0.001), in LA (aHR 1.98, 95% CI 1.90–2.06, P<0.001) and in EU (aHR 1.91, 95% CI 1.75–2.09, P<0.001) were associated with a shorter period of time to the first episode. Breast feeding for at least 3 months was associated with a longer period, only in LA (aHR 0.91, 95% CI 0.86–0.96, P<0.001). Cold symptoms during the first 3 months is the most consistent factor shortening the time to the first episode of wheezing; breast feeding for ⩾3 months delays it only in LA, whereas eczema shortens it only in EU. Avoiding a common cold in the first months of life could be a good strategy to delay the first wheeze episode; however, cohort studies will help to elucidate this association.

Occupational Exposure and Co-Occurrence of Work-Related Skin and Respiratory Disorder in Cleaner: A Case Report

BACKGROUND: Despite the connection between skin and respiratory system in occupational disease is growing area of research interest, there is still a limited evidence for the effects of both airborne and skin exposures together with skin and respiratory outcomes.CASE PRESENTATION: This report describes a 32-years old female with no previous history of atopy, asthma or skin disorders working as an office cleaner for three years. About two years after entering the actual workplace she developed episodic wheezing, shortening of breath and chest tightness. At the same time, she noticed eczematous lesions on the skin of both hands. She reported work-relatedness of both respiratory and skin symptoms, i.e. the symptoms improved during weekends and holidays and worsened when she returned to work. The patient was referred to Institute for Occupational Health of R. Macedonia for assessment of possible occupational asthma (OA) and occupational contact dermatitis (OCD). Diagnosis of asthma was confirmed by standard diagnostic procedure, while the diagnosis of sensitizer-induced OA was established by positive result of serial peak expiratory flow rate (PEFR) measurements at and away from work. Diagnosis of allergic OCD was confirmed by positive patch test to formaldehyde. The management of both diseases included complete removal from the harmful workplace exposure, as well as pharmacological treatment according to the actual recommendations.CONCLUSIONS: This case report represents a description of a co-occurrence of work-related skin and respiratory symptoms in a female working as an office cleaner. Formaldehyde is found to be a causative factor of allergic OCD, and it also may be a causative factor of sensitive-induced OA in the same patient, but other occupational sensitizers cannot be excluded.

Asma y virus en el niño

Respiratory viral infections, particularly respiratory syncytial virus (RSV) and rhinovirus, are the most importance risk factors for the onset of wheezing in infants and small children. Bronchiolitis is the most common acute respiratory infection in children under 1year of age, and the most common cause of hospitalization in this age group. RSV accounts for approximately 70% of all these cases, followed by rhinovirus, adenovirus, metapneumovirus and bocavirus. The association between bronchiolitis caused by RSV and the development of recurrent wheezing and/or asthma was first described more than 40years ago, but it is still unclear whether bronchiolitis causes chronic respiratory symptoms, or if it is a marker for children with a genetic predisposition for developing asthma in the medium or long term. In any case, sufficient evidence is available to corroborate the existence of this association, which is particularly strong when the causative agent of bronchiolitis is rhinovirus.The pathogenic role of respiratory viruses as triggers for exacerbations in asthmatic patients has not been fully characterized. However, it is clear that respiratory viruses, and in particular rhinovirus, are the most common causes of exacerbation in children, and some type of respiratory virus has been identified in over 90% of children hospitalized for an episode of wheezing. Changes in the immune response to viral infections in genetically predisposed individuals are very likely to be the main factors involved in the association between viral infection and asthma.