Luis Garcia-Marcos

Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach

There is poor agreement on definitions of different phenotypes of preschool wheezing disorders. The present Task Force proposes to use the terms episodic (viral) wheeze to describe children who wheeze intermittently and are well between episodes, and multiple-trigger wheeze for children who wheeze both during and outside discrete episodes. Investigations are only needed when in doubt about the diagnosis. Based on the limited evidence available, inhaled short-acting β2-agonists by metered-dose inhaler/spacer combination are recommended for symptomatic relief. Educating parents regarding causative factors and treatment is useful. Exposure to tobacco smoke should be avoided; allergen avoidance may be considered when sensitisation has been established. Maintenance treatment with inhaled corticosteroids is recommended for multiple-trigger wheeze; benefits are often small. Montelukast is recommended for the treatment of episodic (viral) wheeze and can be started when symptoms of a viral cold develop. Given the large overlap in phenotypes, and the fact that patients can move from one phenotype to another, inhaled corticosteroids and montelukast may be considered on a trial basis in almost any preschool child with recurrent wheeze, but should be discontinued if there is no clear clinical benefit. Large well-designed randomised controlled trials with clear descriptions of patients are needed to improve the present recommendations on the treatment of these common syndromes.

Effect of diet on asthma and allergic sensitisation in the International Study on Allergies and Asthma in Childhood (ISAAC) Phase Two

Background The increasing prevalence of asthma and allergy might be related to diet, particularly in Western countries. A study was undertaken to assess the association between dietary factors, asthma and allergy in a large international study including objective measurements of atopy. Methods Between 1995 and 2005, cross-sectional studies were performed in 29 centres in 20 countries. Parental questionnaires were used to collect information on allergic diseases and exposure factors and data from 50 004 randomly selected schoolchildren (8–12 years, 29 579 with skin prick testing) were analysed. Random effect models for meta-analysis were applied to calculate combined ORs. Results Fruit intake was associated with a low prevalence of current wheeze in affluent (ORadj 0.86, 95% CI 0.73 to 1.02) and non-affluent countries (ORadj 0.71, 95% CI 0.57 to 0.88). Consumption of fish in affluent countries (ORadj 0.85, 95% CI 0.74 to 0.97) and of cooked green vegetables in non-affluent countries (ORadj 0.78, 95% CI 0.65 to 0.95) was associated with a lower prevalence of current wheeze. Overall, more frequent consumption of fruit, vegetables and fish was associated with a lower lifetime prevalence of asthma, whereas high burger consumption was associated with higher lifetime asthma prevalence. None of the food items was associated with allergic sensitisation. Except for fruit juice and fruit consumption, no associations were found with atopic wheeze. Food selection according to the ‘Mediterranean diet’ was associated with a lower prevalence of current wheeze and asthma ever (ptrend=0.03). Conclusion Diet is associated with wheeze and asthma but not with allergic sensitisation in children. These results provide further evidence that adherence to the ‘Mediterranean diet’ may provide some protection against wheeze and asthma in childhood.

Stabilization of asthma prevalence among adolescents and increase among schoolchildren (ISAAC phases I and III) in Spain

Background:  Most studies show a steep increase in asthma prevalence in the last decades, although few studies had applied the same methodology. Recent reports point out the possibility that the epidemic has come to an end. We have studied the prevalence of asthma in a very large sample of children, repeating the study eight years apart.

Relationship of asthma and rhinoconjunctivitis with obesity, exercise and Mediterranean diet in Spanish schoolchildren

Background: Although several studies have investigated the influence of diet on asthma in schoolchildren, none of them has evaluated how obesity can modify this effect. A study was undertaken to evaluate the association of various foods and a Mediterranean diet with the prevalence of asthma and rhinoconjunctivitis, adjusting for obesity and exercise. Methods: A cross-sectional study was performed in 20 106 schoolchildren aged 6–7 years from eight Spanish cities. Using the ISAAC phase III questionnaire, parents reported chest and nose symptoms, food intake, weight, height and other factors, including exercise. A Mediterranean diet score was developed. A distinction was made between current occasional asthma (COA) and current severe asthma (CSA). Results: Independent of the amount of exercise, each Mediterranean score unit had a small but protective effect on CSA in girls (adjusted OR 0.90, 95% CI 0.82 to 0.98). Exercise was a protective factor for COA and rhinoconjunctivitis in girls and boys (the more exercise, the more protection). Obesity was a risk factor for CSA in girls (adjusted OR 2.35, 95% CI 1.51 to 3.64). Individually, a more frequent intake (1–2 times/week and ⩾3 times/week vs never/occasionally) of seafood (adjusted ORs 0.63 (95% CI 0.44 to 0.91) and 0.53 (95% CI 0.35 to 0.80)) and cereals (adjusted OR 0.56 (95% CI 0.30 to 1.02) and 0.39 (95% CI 0.23 to 0.68)) were protective factors for CSA, while fast food was a risk factor (adjusted ORs 1.64 (95% CI 1.28 to 2.10) and 2.26 (95% CI 1.09 to 4.68)). Seafood (adjusted ORs 0.74 (95% CI 0.60 to 0.92) and 0.67 (95% CI 0.53 to 0.85)) and fruit (adjusted ORs 0.76 (95% CI 0.60 to 0.97) and 0.71 (95% CI 0.57 to 0.88)) were protective factors for rhinoconjunctivitis. Conclusions: A Mediterranean diet has a potentially protective effect in girls aged 6–7 years with CSA. Obesity is a risk factor for this type of asthma only in girls.

Mediterranean Diet as a Protective Factor for Wheezing in Preschool Children

OBJECTIVE To test the hypothesis that the Mediterranean diet can be a protective factor for current wheezing in preschoolers. STUDY DESIGN Questionnaires were completed by parents of 1784 preschoolers (mean age, 4.08 +/- 0.8 years). Children were stratified according to whether they experienced wheezing (20.0%) or not in the previous year. A Mediterranean diet score was built according to the intake frequency of several foods. RESULTS Age, birth by cesarean section, low birth weight, exposure to livestock during pregnancy, antibiotic use in the first year of life, acetaminophen consumption in the previous 12 months, rhinoconjunctivitis, eczema, parental asthma and tobacco consumption, maternal educational level, maternal age, physical activity, cat at home, and Mediterranean diet were associated with current wheezing but not with obesity. In the multivariate analysis, eczema, rhinoconjunctivitis, paternal asthma, and acetaminophen consumption remained risk factors for current wheezing (adjusted odds ratio [aOR] = 2.35 [95% confidence interval (CI) = 1.2 to 4.8], 2.78 [95% CI =1.3 to 6.1], 3.89 [95% CI = 1.4 to 10.7], and 2.38 [95% CI = 1.2 to 4.6], respectively). Conversely, Mediterranean diet and older age remained protective factors (aOR = 0.54 [95% CI = 0.3 to 0.9] and 0.67 [95% CI = 0.5 to 0.9], respectively). CONCLUSIONS The Mediterranean diet is an independent protective factor for current wheezing in preschoolers, irrespective of obesity and physical activity.

Variaciones geográficas en la prevalencia de síntomas de asma en los niños y adolescentes españoles. International Study of Asthma and Allergies in Childhood (ISAAC) fase III España

Objetivo: Analizar las variaciones geograficas en la prevalencia de sintomas relacionados con el asma en ninos y adolescentes espanoles. Poblacion y metodos: Durante los anos 2001 y 2002, el International Study of Asthma and Allergies in Childhood (ISAAC) fase III estudio a 28.445 ninos de 6-7 anos de 10 areas (A Coruna, Asturias, Barcelona, Bilbao, Cartagena, Castellon, Madrid, Pamplona, San Sebastian y Valencia) y 31.257 adolescentes de 13-14 anos de 11 areas (las anteriores mas Valladolid) espanolas. Los sintomas de asma se recogieron en un cuestionario escrito completado por los padres de los ninos o por los propios adolescentes. Las variaciones geograficas de las prevalencias de los sintomas se analizaron con un modelo de regresion logistica y su correspondencia por edad mediante correlacion lineal. Resultados: La prevalencia de sibilancias recientes (ultimos 12 meses) vario entre el 7,1 y el 12,9% a los 6-7 anos, y entre el 7,1 y el 15,3% a los 13-14 anos. El riesgo mas elevado (odds ratio [OR] respecto al area de menor prevalencia) de presentar sibilancias recientes correspondio a los ninos de A Coruna (OR = 1,96; intervalo de confianza [IC] del 95%, 1,65-2,33) y Bilbao (OR = 1,83; IC del 95%, 1,54-2,18) y los adolescentes de A Coruna (OR = 2,38; IC del 95%, 2,04-2,79) y Asturias (OR = 2,37; IC del 95%, 2,03-2,77). Se comprobo una fuerte correlacion por edad en las prevalencias de sibilancias recientes de cada area geografica (r = 0,72). Conclusiones: En Espana existen, desde edades tempranas, variaciones geograficas notables en la prevalencia de sintomas de asma. Estos son mas frecuentes en los ninos y adolescentes que habitan en la fachada atlantica del pais.

International prevalence of recurrent wheezing during the first year of life: variability, treatment patterns and use of health resources

Background Recurrent wheezing (RW) during the first year of life is a major cause of respiratory morbidity worldwide, yet there are no studies on its prevalence at an international level. A study was undertaken to determine the prevalence of RW in infants during their first year of life in affluent and non-affluent localities. Methods This international population-based study was performed in random samples of infants aged 12–15 months from 17 centres in Latin America and Europe. It uses a validated questionnaire answered by parents at the primary care health clinics where infants attend for growth/development monitoring and/or vaccine administration. Results Among the 30 093 infants surveyed, 45.2% (95% CI 44.7% to 45.8%) had at least one episode of wheezing and 20.3% (95% CI 19.8% to 20.7%) had RW. The mean prevalence of RW in Latin American and European centres was 21.4% (95% CI 20.9% to 21.9%) and 15.0% (95% CI 14.0% to 15.9%), respectively (p<0.001). There was significant morbidity associated with RW in terms of severe episodes (59.4%), visits to the emergency department (71.1%) and hospital admissions (26.8%); 46.1% used inhaled corticosteroids. Conclusions The prevalence of RW in infants during the first year of life is high and varies between localities. A significant proportion of infants progress to a more severe condition which results in high use of health resources (visits to emergency department and hospitalisations). The prevalence of RW is lower and less severe in European than in Latin American centres, suggesting there is a higher risk for the disease in developing areas.

International study of wheezing in infants: risk factors in affluent and non-affluent countries during the first year of life

Garcia‐Marcos L, Mallol J, Solé D, Brand PLP and EISL group. International study of wheezing in infants: risk factors in affluent and non‐affluent countries during the first year of life.
Pediatr Allergy Immunol 2010: 21: 878–888.
© 2010 John Wiley & Sons A/S

Do fast foods cause asthma, rhinoconjunctivitis and eczema? Global findings from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three

Background Certain foods may increase or decrease the risk of developing asthma, rhinoconjunctivitis and eczema. We explored the impact of the intake of types of food on these diseases in Phase Three of the International Study of Asthma and Allergies in Childhood. Methods Written questionnaires on the symptom prevalence of asthma, rhinoconjunctivitis and eczema and types and frequency of food intake over the past 12 months were completed by 13–14-year-old adolescents and by the parents/guardians of 6–7-year-old children. Prevalence ORs were estimated using logistic regression, adjusting for confounders, and using a random (mixed) effects model. Results For adolescents and children, a potential protective effect on severe asthma was associated with consumption of fruit ≥3 times per week (OR 0.89, 95% CI 0.82 to 0.97; OR 0.86, 95% CI 0.76 to 0.97, respectively). An increased risk of severe asthma in adolescents and children was associated with the consumption of fast food ≥3 times per week (OR 1.39, 95% CI 1.30 to 1.49; OR 1.27, 95% CI 1.13 to 1.42, respectively), as well as an increased risk of severe rhinoconjunctivitis and severe eczema. Similar patterns for both ages were observed for regional analyses, and were consistent with gender and affluence categories and with current symptoms of all three conditions. Conclusions If the association between fast foods and the symptom prevalence of asthma, rhinoconjunctivitis and eczema is causal, then the findings have major public health significance owing to the rising consumption of fast foods globally.

Classification and pharmacological treatment of preschool wheezing: changes since 2008

Since the publication of the European Respiratory Society Task Force report in 2008, significant new evidence has become available on the classification and management of preschool wheezing disorders. In this report, an international consensus group reviews this new evidence and proposes some modifications to the recommendations made in 2008. Specifically, the consensus group acknowledges that wheeze patterns in young children vary over time and with treatment, rendering the distinction between episodic viral wheeze and multiple-trigger wheeze unclear in many patients. Inhaled corticosteroids remain first-line treatment for multiple-trigger wheeze, but may also be considered in patients with episodic viral wheeze with frequent or severe episodes, or when the clinician suspects that interval symptoms are being under reported. Any controller therapy should be viewed as a treatment trial, with scheduled close follow-up to monitor treatment effect. The group recommends discontinuing treatment if there is no benefit and taking favourable natural history into account when making decisions about long-term therapy. Oral corticosteroids are not indicated in mild-to-moderate acute wheeze episodes and should be reserved for severe exacerbations in hospitalised patients. Future research should focus on better clinical and genetic markers, as well as biomarkers, of disease severity. The distinction between episodic viral and multiple-trigger wheeze is unclear in many preschool children http://ow.ly/sKYZF