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Cough and Phlegm in Young Adults

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Cough and Phlegm in Young Adults 890 BRITISH MEDICAL JOURNAL VOLUME 296 26 MARCH 1988 Asthma as a link between chest illness in childhood and chronic cough and phlegm in young adults D P STRACHAN, H R ANDERSON, J M BLAND, C PECKHAM Abstract pollution.5 The effect was greater when the same cohort was contacted again at the age of 25' and persisted at 36, although no The link between chest illnesses in childhood to 7 and the age significant effect on peak expiratory flow rate was found.7 In another of and in the winter at 23 prevalence cough phlegm reported age small longitudinal study "catarrhal" children had more respiratory was in a cohort of 10 557 British children born in one investigated symptoms in early middle age than their peers but lung function was week in 1958 child (national development study). Both pneumonia similar.8 and asthma or bronchitis to 7 were associated with a wheezy age Prospective studies of wheezy children in Melbourne led to excess in the significant prevalence of chronic cough and phlegm reassessment of the nature of childhood "bronchitis" and indicated at 23 after for current This excess was age controlling smoking. that asthma and bronchitis with wheezing may be regarded as part attributable to the association of and at largely cough phlegm age of the same syndrome.9-'2 Although many wheezy children sub- 23 with a of asthma or bronchitis from 16. history wheezy age sequently become free of symptoms,9'1 those who do not are at When adjustment was made forrecent wheezing, current cigarette increased risk of cough and phlegm in their early 20s.'2 This and to consumption, previous smoking habit, passive exposure suggested an alternative explanation of the link between childhood smoke the relative odds of or or in cough phlegm, both, subjects and adult respiratory disease: that they are connected through with a history of childhood chest illness was 1 11 (95% confidence persistence of the wheezing tendency. II interval to When 097 1.27). analysed separately asthma, wheezy The follow up to age 23 of a second British cohort, born in 1958 and to 7 did not bronchitis, pneumonia up age significantly (the national child development study), offered the opportunity to increase the prevalence of either cough or phlegm. re-examine the relation between respiratory disease in childhood The for the observed between chest explanation continuity and symptoms of chronic bronchitis in young adults. Information illness in childhood and in later life lie respiratory symptoms may on asthma and wheezy bronchitis, which was not reported for the more in the time course of functional disturbances related to 1946 cohort, allowed respiratory problems that were associated with asthma than in the of structural persistence lung damage. a wheezing tendency to be distinguished from those that were not. Introduction Methods Deaths from disease in and in respiratory infancy middle age show We obtained data from the national child development study, which is a similar patterns with respect to social class, urban or rural area, and follow up study of all children born in Britain during one week in March region of residence. 2 A similar relation was found between 1958; these children formed the study population for the perinatal mortality respiratory symptoms in children of primary school age and survey.'4 The children were examined at the ages of 7, 11, and 16; the mortality from bronchitis in adults.3 These observations led to the methods used have been discussed in detail elsewhere.'I'7 In 1981, when the theory that chronic respiratory disease in adults may have its origins subjects were 23, an attempt was made to trace and interview all those who 18 in childhood and, more specifically, that early episodes of lower were resident in the United Kingdom. At the follow up at age 7 the parents were interviewed health visitors and asked the Has respiratory illness may be causally related to chronic bronchitis in by following questions: child ever had attacks of asthma? Has child ever had attacks middle your your of age.'3 bronchitis with wheezing? Has your child ever had pneumonia? If so, at Because the recall of respiratory problems in childhood is likely what age did the first attack occur? to be influenced by current symptoms experienced by adult In 1981, when the age of the cohort was 23, the subjects themselves were respondents4 the case for respiratory disease in childhood con- given a 90 minute interview by staff from a commercial market research tinuing into later life has rested heavily on the follow up of British organisation. The following questions, including four derived from the children born in 1946 (the national survey of health and develop- Medical Research Council's questionnaire on respiratory symptoms,'9 were ment). Colley et al found that a history oflower respiratory infection asked: Since your 16th birthday have you had an attack ofasthma or wheezy (bronchitis, bronchopneumonia, or pneumonia) obtained from bronchitis? If so, have you had an attack in the past 12 months? Do you first in the in the winter? Do parents when their child was 2 was associated with a higher usually cough thing morning you usually cough during the day or at night in the winter? Do you usually bring up any phlegm of the winter at age of the prevalence cough during 20, independent from your chest first thing in the morning in the winter? Do you usually social and to subject's smoking habits, paternal class, exposure air bring up any phlegm from the chest during the day or at night in the winter? The interview did not include questions on the duration of cough and phlegm, which are used to define chronic bronchitis in older adults.2' Further questions were asked about current and past cigarette smoking and the presence of other smokers in the home. Department of Community Medicine, Medical School, University of In the analysis no distinction was made between asthma and wheezy EH8 9AG Edinburgh bronchitis in the first seven years of life as these conditions were not D P STRACHAN, MRCP, MRCGP, Wellcome research training fellow in clinical distinguished in the questionnaire given to the young adults. As one of the epidemiology principal associations ofrespiratory symptoms is with cigarette smoking this Department of Clinical Epidemiology and Social Medicine, St George's was controlled for in the analysis; in cross tabulations the cohort was divided Hospital Medical School, London into smokers and non-smokers according to smoking habit at age 23, and the H R ANDERSON, MD, FFCM, professor sample was then stratified into those who did and did not report attacks of J M BLAND, PHD, senior lecturer in medical statistics asthma or wheezy bronchitis from age 16. Multiple logistic regression models were used to control more rigorously for the effects of active and Department of Paediatric Epidemiology, Institute of Child Health, London passive smoking and recent wheezing episodes. The generalised linear C PECKHAM, MD, FFCM, professor interactive modelling statistical package2' was used to fit separate models Correspondence to: Dr D P Strachan, Department of Epidemiology, London with the outcome variable being, in turn, cough or phlegm, or both; cough School of Hygiene and Tropical Medicine, London WC1E 7HT. alone; and phlegm alone. For subjects who smoked these models included the daily cigarette consumption (0-9, 10-19, 20-29, 30 and over), and for BRITISH MEDICAL JOURNAL VOLUME 296 26 MARCH 1988 891 non-smokers the models included whether they had ever smoked a cigarette, subdivided according to whether they had recent wheeze the association was cigar, or pipe at any time; whether they had ever smoked regularly (at least reduced, confirming that recent asthma or wheezy bronchitis might partially one cigarette a day for a year or more); and whether they were currently explain the relation between chest illness in childhood and respiratory living with a smoker. The effect of recent wheezing episodes was controlled symptoms in young adults. for in the regression analysis with three categories: no asthma or wheezy Table IV shows the effect of recent wheezing episodes on the relations bronchitis from age 16; asthma or wheezy bronchitis from age 16 but not in between cough and phlegm at age 23 and pneumonia, asthma, and wheezy the past year at age 23; and asthma or wheezy bronchitis in the past year at bronchitis in childhood analysed by multiple logistic regression. When 23. The effects of any chest illness, asthma or wheezy bronchitis alone, and recent asthma or wheezy bronchitis was excluded (controlling only for active pneumonia alone by age 7 were investigated in separate models. and passive smoking) the association between chest illness in childhood and adult respiratory symptoms was highly significant overall and for cough and phlegm separately. The effect of pneumonia in childhood on respiratory Results symptoms in young adults was less than that ofasthma or wheezy bronchitis; because the numbers of children with pneumonia were fairly small the We obtained information on respiratory symptoms and smoking habits at confidence intervals were wide and included unity. age 23 and on chest illnesses in childhood for 6268 non-smokers and 4289 When a history of asthma or wheezy bronchitis from age 16 was included smokers, comprising 72% of the 14 571 children who had been available for in the models the effects of chest illness in childhood were no longer follow up at age 7 and for whom data on respiratory illness were available and significant at the 5% level but still showed the same trend, with cough and 63% ofthe 16 883 survivors in the perinatal mortality survey. Comparison of phlegm being more common among subjects with a history of pneumonia, responders and non-responders in earlier studies of the cohort has shown asthma, or wheezy bronchitis in childhood.
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