Diagnosis and management of early asthma in preschool-aged children

Bacharier, Leonard B.; Guilbert, Theresa W.

doi:10.1016/j.jaci.2012.04.025

Cited by 94 publications

(106 citation statements)

References 71 publications

(67 reference statements)

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“…There is increasing recognition that asthma is a heterogeneous disease with multiple disease variants, which may have a similar clinical presentation, but differ in their etiology and pathogenesis (2,3). It is likely that these different asthma subgroups (sometimes referred to as asthma endotypes [3]) have different causative mechanisms, and may require different treatments.…”

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confidence: 99%

Challenges in Identifying Asthma Subgroups Using Unsupervised Statistical Learning Techniques

Prosperi

Şahiner

Belgrave

et al. 2013

Am J Respir Crit Care Med

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Rationale: Unsupervised statistical learning techniques, such as exploratory factor analysis (EFA) and hierarchical clustering (HC), have been used to identify asthma phenotypes, with partly consistent results. Some of the inconsistency is caused by the variable selection and demographic and clinical differences among study populations. Objectives: To investigate the effects of the choice of statistical method and different preparations of data on the clustering results; and to relate these to disease severity. Methods: Several variants of EFA and HC were applied and compared using various sets of variables and different encodings and transformations within a dataset of 383 children with asthma. Variables included lung function, inflammatory and allergy markers, family history, environmental exposures, and medications. Clusters and original variables were related to asthma severity (logistic regression and Bayesian network analysis). Measurements and Main Results: EFA identified five components (eigenvalues > 1) explaining 35% of the overall variance. Variations of the HC (as linkage-distance functions) did not affect the cluster inference; however, using different variable encodings and transformations did. The derived clusters predicted asthma severity less than the original variables. Prognostic factors of severity were medication usage, current symptoms, lung function, paternal asthma, body mass index, and age of asthma onset. Bayesian networks indicated conditional dependence among variables. Conclusions: The use of different unsupervised statistical learning methods and different variable sets and encodings can lead to multiple and inconsistent subgroupings of asthma, not necessarily correlated with severity. The search for asthma phenotypes needs more careful selection of markers, consistent across different study populations, and more cautious interpretation of results from unsupervised learning.

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mentioning

confidence: 99%

Challenges in Identifying Asthma Subgroups Using Unsupervised Statistical Learning Techniques

Prosperi

Şahiner

Belgrave

et al. 2013

Am J Respir Crit Care Med

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“…19 These diagnostic challenges are compounded by variations in the natural history of the early stage of asthma, which are not fully understood because early childhood wheezing and asthma are heterogeneous disorders with many phenotypic and variable expressions. 20 Many symptoms that support an asthma diagnosis in young children are not necessarily "asthma specific." For example, cough and wheezing may be seen in healthy children or are characteristic of other pediatric diseases.…”

Section: Why Is Diagnosing Preschool Children With Asthma So Difficult?mentioning

confidence: 99%

“…17,20 Clear, understandable, and culturally sensitive discussion between a clinician and their patient is a prerequisite for effective communication of symptoms during history taking. 29 However, young children provide a special challenge in communicating symptoms, primarily because it is the parent who must often interpret their child's descriptions of the symptoms or the physical signs they observe and describe these symptoms to the clinician.…”

Section: Take a Careful Historymentioning

confidence: 99%

“…The Asthma Predictive Index (API) was derived from data from the Tucson cohort and developed to help clinicians identify those children who will continue wheezing into older childhood. 20 The most impressive aspect of the API is its ability to determine the likelihood that young children with wheezing will develop asthma by school age. 15,44 The API includes risk factors such as frequent wheezing, parental history of asthma, and signs of personal atopy.…”

Section: Other Factors To Consider During History Takingmentioning

confidence: 99%

“…15,44 The API includes risk factors such as frequent wheezing, parental history of asthma, and signs of personal atopy. 5,48 The API was recently modified, replacing the clinical diagnosis of allergic rhinitis with evidence for allergic sensitization 20,49 (see Table 1). The mAPI has been described and endorsed by the Expert Panel Report 3, and although it is not prospectively validated, it might be a useful tool in identifying children who are more likely to have persistent wheezing and who might respond to inhaled corticosteroids.…”

Section: Other Factors To Consider During History Takingmentioning

confidence: 99%

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Asthma in Preschool Children: A Review of the Diagnostic Challenges

Cave

Atkinson

2014

The Journal of the American Board of Family Medicine

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Family physicians face many challenges when diagnosing asthma in preschool children. These diagnostic challenges are compounded by variations in the natural history of early stage asthma, which are not fully understood, since early childhood wheezing and asthma are heterogeneous disorders with many phenotypic and variable expressions. Since no standard definition for the type, severity, or frequency of symptoms exist for this age group, clear evidence-based recommendations are lacking. Without adequate guidance, family physicians are left to make diagnostic and treatment decisions, which can lead to undertreatment of asthmatics and overtreatment of transient wheezers. New guidelines that specifically address the challenges of diagnosing asthma in this particular age group (Global Initiative for Asthma, British Thoracic Society/Scottish Intercollegiate Guidelines Network) have recently been published, and researchers are actively seeking new methods and techniques through epidemiological studies to assist primary care clinicians in the diagnostic process. This review has wide application in primary care. By recognizing the diagnostic challenges and understanding the related best practices, family physicians will be better placed to treat, manage, and control asthma symptoms, resulting in lower morbidity rates and reduced health system costs, as well as enhancing the overall quality of life and well-being of the children affected. (J Am Board Fam Med 2014;27:538 -548.)

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Effect of Prenatal Supplementation With Vitamin D on Asthma or Recurrent Wheezing in Offspring by Age 3 Years

Litonjua

Carey

Laranjo

et al. 2016

JAMA

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382

394

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IMPORTANCE Asthma and wheezing begin early in life, and prenatal vitamin D deficiency has been variably associated with these disorders in offspring. OBJECTIVE To determine whether prenatal vitamin D (cholecalciferol) supplementation can prevent asthma or recurrent wheeze in early childhood. DESIGN, SETTING, AND PARTICIPANTS The Vitamin D Antenatal Asthma Reduction Trial was a randomized, double-blind, placebo-controlled trial conducted in 3 centers across the United States. Enrollment began in October 2009 and completed follow-up in January 2015. Eight hundred eighty-one pregnant women between the ages of 18 and 39 years at high risk of having children with asthma were randomized at 10 to 18 weeks' gestation. Five participants were deemed ineligible shortly after randomization and were discontinued. INTERVENTIONS Four hundred forty women were randomized to receive daily 4000 IU vitamin D plus a prenatal vitamin containing 400 IU vitamin D, and 436 women were randomized to receive a placebo plus a prenatal vitamin containing 400 IU vitamin D. MAIN OUTCOMES AND MEASURES Coprimary outcomes of (1) parental report of physician-diagnosed asthma or recurrent wheezing through 3 years of age and (2) third trimester maternal 25-hydroxyvitamin D levels. RESULTS Eight hundred ten infants were born in the study, and 806 were included in the analyses for the 3-year outcomes. Two hundred eighteen children developed asthma or recurrent wheeze: 98 of 405 (24.3%; 95% CI, 18.7%-28.5%) in the 4400-IU group vs 120 of 401 (30.4%, 95% CI, 25.7%-73.1%) in the 400-IU group (hazard ratio, 0.8; 95% CI, 0.6-1.0; P = .051). Of the women in the 4400-IU group whose blood levels were checked, 289 (74.9%) had 25-hydroxyvitamin D levels of 30 ng/mL or higher by the third trimester of pregnancy compared with 133 of 391 (34.0%) in the 400-IU group (difference, 40.9%; 95% CI, 34.2%-47.5%, P < .001). CONCLUSIONS AND RELEVANCE In pregnant women at risk of having a child with asthma, supplementation with 4400 IU/d of vitamin D compared with 400 IU/d significantly increased vitamin D levels in the women. The incidence of asthma and recurrent wheezing in their children at age 3 years was lower by 6.1%, but this did not meet statistical significance; however, the study may have been underpowered. Longer follow-up of the children is ongoing to determine whether the difference is clinically important.

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Diagnosis and management of early asthma in preschool-aged children

Cited by 94 publications

References 71 publications

Challenges in Identifying Asthma Subgroups Using Unsupervised Statistical Learning Techniques

Challenges in Identifying Asthma Subgroups Using Unsupervised Statistical Learning Techniques

Asthma in Preschool Children: A Review of the Diagnostic Challenges

Effect of Prenatal Supplementation With Vitamin D on Asthma or Recurrent Wheezing in Offspring by Age 3 Years

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