Asthma prevention: Breast is best?

Whilst breastfeeding has been considered to exert a preventative effect on the development of allergic disease, several recent publications have challenged this view, particularly with respect to the long-term outcomes for asthma. There are many other beneficial effects of breastfeeding apart from the possibility of allergy prevention. The suggestion that breastfeeding may increase the development of allergic disease raises concerns about the appropriate steps to take for primary prevention of allergy. It is concluded that breastfeeding can still be recommended for the beneficial effects in reducing atopic disease in childhood in addition to the other demonstrated benefits, and that there are unresolved questions concerning the few studies that suggest the possibility of increased allergic disease in later life.     

Asthma — The changing face of drug therapy

Until the recent introduction of long acting p2-agonists and the leukotriene antagonists, the drug treatment of asthma had remained largely unchanged for a quarter century. Recent studies have demonstrated the efficacy of the long acting pjagonists in the management of asthma in children and highlighted their value as an adjunct to inhaled corticosteroids. The leukotriene antagonists are an important new class of drug therapy which target a specific area of asthma pathogenesis. Whilst they have been shown to be effective for asthma, their exact role in the clinical situation remains to be established. Recent guidelines have emphasised the important role of inflammation in persistent asthma and recommended the early institution of anti-inflammatory treatment. Many patients remain uncontrolled despite high doses of anti-inflammatory agents including oral corticosteroids. Recent experience with other immunomodulatory agents such as cyclosporin, methotrexate and intravenous immunoglobulin has highlighed their potential as steroid sparing agents. With improved understanding of asthma pathogenesis the potential for specific targeted therapies has become evident. Monoclonal antibodies to IgE and certain cytokines are being investigated as possible treatments for asthma. Similarly, preliminary studies of selective phosphodiesterase inhibitors in asthmatic individuals have been encouraging. Other potential therapies include platelet-activating factor receptor antagonists, tryptase inhibitors and prostaglandin E analogs. The continued development of such targetea1 treatments should ensure a greater diversity of therapeutic options for the management of asthma in the new millennium.     

Asthma und Allergie Genetische Prädisposition und Umweltfaktoren

Genetic disposition and environmental factors determine the development of asthma and other allergic diseases. Genetic disposition can be viewed as a complex combination of changes in a number of genes involved in various diseases causing mechanisms. Using a number of different approaches candidate genes for the development of asthma and allergy have been identified and polymorphisms in those genes have been detected. While numerous studies reported associations between polymorphisms and asthma and allergy related phenotypes the functional background of those associations are not jet clear. Variations in the signaling pathway of IL-4 and IL-13 highlight the complexity of gene-gene interactions. Furthermore, it can be speculated that gene-environment interactions might determine the development of asthma and allergy as effects of exposure to bacterial lipopolysaccharide (LPS) are influenced by genetic variants of the LPS-receptor CD14. In addition, successful therapy of asthma symptoms is also dependant on the genetic background of the patient. Discussion. While the role of genetic factors in the development, expression and therapy of asthma and other allergic diseases starts to unfold in the context of recent studies numerous questions still remain.     

What is New in the Management of Childhood Asthma?

Asthma still causes considerable morbidity and mortality globally and minimal improvement has been seen in key outcomes over the last decade despite increasing treatment costs. This review summarizes recent advances in the management of asthma in children and adolescents. It focuses on the need for personalized treatment plans based on heterogenous asthma pathophysiology, the use of the terminology ‘asthma attack’ over exacerbation to instill widespread understanding of severity, and the need for every attack to trigger a structured review and focused strategy. The authors discuss difficulties in diagnosing asthma, accuracy and use of Fractional exhaled nitric oxide both as second line test and as a method to monitor treatment adherence or guide the choice of pharmacotherapy. The authors discuss acute and long-term management of asthma. Asthma treatment goals are to minimize symptom burden, prevent attacks and (where possible) reduce risk and impact of progressive pathophysiology and adverse outcomes. The authors discuss pharmacological management; optimal use of short acting β₂ agonists, long acting muscarinic antagonist (tiotropium), use of which is relatively new in pediatrics, allergen specific immunotherapy, biological monoclonal antibody treatment, azalide antibiotic azithromycin, and the use of vitamin D. They also discuss electronic monitoring and adherence devices, direct observation of therapy via mobile device, temperature controlled laminar airflow device, and the importance of considering when symptoms may actually result from dysfunctional breathing rather than asthma.     

Umweltinduzierte frühe Prägung von Asthma und Epigenetik

The term “early programming” describes the mechanisms by which specific environmental exposures during critical periods of early development have a long-term impact on a child’s disease risks in later life. Moreover, this effect is passed on across generations even after discontinuation of the exposure. Understanding these mechanisms offers the potential of targeted therapeutic reprogramming in order to prevent asthma. Programming of diseases is caused by epigenetic mechanisms. These are heritable gene modifications that leave the DNA sequence untouched but can nonetheless be transferred to the next generation. The influence of prenatal exposures during pregnancy, such as nutrition, immune stimulatory substances or tobacco smoke on a child’s risk for asthma has been highlighted in epidemiologic studies. Only recently, it was shown for the first time that exposure to nutrients or exhaust fumes in utero leads to epigenetic changes and is directly associated with asthma risk in children. This risk was transmitted across two generations. The potential of this new insight into epigenetically mediated early programming of asthma offers novel opportunities for the development of pre-symptomatic preventive strategies.     

Asthma and Medicines – Long-Term Side-Effects,Monitoring and Dose Titration

Asthma is a major pediatric respiratory morbidity requiring long-term management. A thorough knowledge of long-term medication side-effects in children is, thus, essential for every physician dealing with childhood asthma. Establishing diagnosis and initiating treatment is just a beginning of the journey. Ongoing monitoring is an essential component of comprehensive asthma management programme. Monitoring includes not only assessment of asthma control but also checking for adherence to treatment, technique of inhaler device use, associated co-morbities, if any, and potential environmental exposure. Various tools – both subjective and objective - are available for assessment of asthma control. However, evidence for their optimum use in different settings and patient groups is lacking and monitoring has to be customized depending on available resources and individual patient characteristics. Patient education is an important component of long-term asthma therapy. The ultimate aim is to achieve optimum asthma control i.e., achieve and maintain control of clinical symptoms, decrease future risk to patients (risk of exacerbations, progressive loss of lung function and development of fixed airflow obstruction, adverse effects of medications) and enabling the child to lead a life without restrictions, at lowest possible dose of drugs. This article reviews the side-effects of medications used for long-term management of asthma and discusses current literature on asthma monitoring and dose titration in pediatric population to help the asthma therapist not only prescribe the drugs rationally but also help the family make right choices for treatment.     

Asthma symptoms in early childhood – what happens then?

Aim: To study the outcome in early adulthood for children with early asthma symptoms and to analyse the factors associated with current asthma. Methods: In a prospective study, we have re-investigated 89/101 children who were hospitalized before the age of two years due to wheezing. The children were investigated using a questionnaire and allergy and bronchial hyper-responsiveness tests at the age of 17-20 years and compared with age-matched controls. Results: In the cohort, 43% had had asthma symptoms in the preceding 12 months compared with 15% in the control group. The strongest risk factors for asthma were current allergy, bronchial hyper-responsiveness and female gender. Female gender and passive smoking in infancy were independent infantile risk factors. In addition to female gender, two pathways led to current asthma: an allergic pathway from family atopy via the development of allergy and another pathway from early passive smoking via hyper-responsiveness and active smoking.

Conclusion: In children with early wheezing disorder, current allergy, bronchial hyper-responsiveness and female gender were the strongest risk factors for asthma in early adulthood, while female gender and passive smoking in infancy were independent infantile risk factors. The effects of early passive smoking persist longer than previously reported.     

Does a Written Asthma Action Plan Reduce Unscheduled Doctor Visits in Children?

The aim of this study was to evaluate the impact of a written asthma action plan (WAAP) on reducing unscheduled doctor visits, asthma control and quality of life in children with all severities of asthma. This was a randomised controlled, single-blinded study whereby 80 children with asthma were randomly assigned to be either provided a WAAP or verbally counseled . The number of asthmatic exacerbations requiring unscheduled doctor visits, asthma control and quality of life were monitored over 9 mo. At the end of the study, there was no significant difference in the number of unscheduled doctor visits between the 2 groups (p?=?0.352). There was no significant difference in asthma control or quality of life between both groups. Hence, the WAAP did not reduce unscheduled doctor visits, nor improve asthma control or quality of life in children with all severities of asthma.