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Bronchiolitis and Asthma in Infancy and Early Childhood S61 Who Smoked Or Had Asthma and Other Atopic Diseases

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Bronchiolitis and Asthma in Infancy and Early Childhood S61 Who Smoked Or Had Asthma and Other Atopic Diseases S60 Thorax 1996;51 (Suppl 2):S60-S64 Bronchiolitis and asthma in infancy and Thorax: first published as 10.1136/thx.51.Suppl_2.S60 on 1 August 1996. Downloaded from early childhood Simon Godfrey Institute of Pulmonology, Hadassah University Hospital, Hebrew University-Hadassah Medical School, Jerusalem, Israel Introductory article Asthma and wheezing in the first six years of life FD Martinez, AL Wright, LM Taussig, CJ Holberg, M Halonen, WJ Morgan and the Group Health Medical Associates Background. Many young children wheeze during respiratory infections, but the pathogenesis of these episodes and their relation to the development ofasthma later in life are not well understood. Methods. In a prospective study, we investigated the factors affecting wheezing before the age of three years and their relation to wheezing at six years of age. Of 1246 newborns in the Tucson, Arizona area enrolled between May 1980 and October 1984, follow-up data at both three and six years of age was available for 826. For these children, assessments in infancy included measurement of cord-serum IgE levels (measured in 750 children), pulmonary-function testing before any lower respiratory illness had occurred (125), measurement of serum IgE levels at nine months of age (672), and questionnaires completed by the children's parents when the children were one year old (800). Assessments at six years of age included measurement of serum IgE levels (in 460), pulmonary-function testing (526), and skin allergy testing (629). Results. At the age of six years, 425 children (51 5 percent) had never wheezed, http://thorax.bmj.com/ 164 (19.9 percent) had had at least one lower respiratory illness with wheezing during the first three years of life but had no wheezing at six years of age, 124 (15 0 percent) had no wheezing before the age of three years but had wheezing at the age of six years, and 113 (13 7 percent) had wheezing both before three years of age and at six years of age. The children who had wheezing before three years of age but not at the age of six had diminished airway function (length-adjusted maximal expiratory flow at functional residual capacity [Vmax FRC]) both before the age of one year and at the age of six years, were more likely than the other children to have mothers who smoked but not mothers with on September 30, 2021 by guest. Protected copyright. asthma, and did not have elevated serum IgE levels or skin-test reactivity. Children who started wheezing in early life and continued to wheeze at the age of six were more likely than the children who never wheezed to have mothers with a history ofasthma (P<0.001), to have elevated serum IgE levels (P<0*01), to have normal lung function in the first year of life, and to have elevated serum IgE levels (P<0*001) and diminished values for VmaxFRC (P<0.01) at six years of age. Conclusions. The majority of infants with wheezing have transient conditions associated with diminished airway function at birth and do not have increased risks of asthma or allergies later in life. In a substantial minority of infants, however, wheezing episodes are probably related to a predisposition to asthma. (N Engl J Med 1995;332:133-8) Probably the two most common questions which the have been many surveys which have attempted to follow parents of a wheezy infant ask their paediatrician are up wheezy infants in order to see what becomes of them "has he got asthma, doctor?" and "will he grow out of as they grow older. Over 40 years ago Boesen2 published it, doctor?" As we approach the end of the 20th century the results of a questionnaire sent to the parents of the honest answer to both questions is usually that we children who had been admitted to hospital several have no idea, but research of the kind described by years earlier with "chronic cough, prolonged expiration Martinez et al' is helping us to obtain a better under- and characteristic rales". Of particular interest in the standing of the problem. present context is that only 3-7% of infants who had been admitted under one year of age were considered Do infants who wheeze stop wheezing in early to be asthmatic in later childhood compared with 42% childhood? who were over three years old on admission, while a Interest in this subject goes back a long way and there family history of allergy was also much commoner in Bronchiolitis and asthma in infancy and early childhood S61 who smoked or had asthma and other atopic diseases. Table 1 Summary of findings in study of Martinez et al' Thus, there appears to be a difference in premorbid Thorax: first published as 10.1136/thx.51.Suppl_2.S60 on 1 August 1996. Downloaded from No. of Percentage lung function and in an association with atopic diseases infants of total between those who continue to wheeze and those who Total cohort studied 826 100-0 stop early. Another approach to this problem was used Never wheezed <6 years 425 51 5 Wheezy <3 years and stopped 164 19 9 by Young et al5 in Perth who studied a birth cohort of Wheeze >3 years only 124 15-0 children to see whether there were differences between Wheeze <3 years and continued 113 13-7 All wheezing >3 years 237 287 those who wheezed with viral bronchiolitis and those who did not. They also noted a trend for the infants who subsequently developed viral bronchiolitis in the first year of life to have lower values of VmaxFRC before their first respiratory illness. These children with the older group (55% versus 33%). More recent studies bronchiolitis also tended to stop wheezing by the end have reached similar conclusions - namely, that the of the first year (78%) and not to have positive skin younger the child when wheezing begins the less likely tests for allergy. Those who began to wheeze in their is it to continue. Most older studies were based on the second year of life did not have reduced lung function follow up of children admitted to hospital because of in early infancy but did have an increased incidence of wheezing and hence the population was clearly biased positive skin tests for allergy and a trend for a positive in favour of those who were sick enough to come to family history of asthma. Thus, there are obvious sim- hospital. A more informative approach has been the ilarities between the bronchiolitic infants of Young et study of cohorts of children who were selected before al5 and the wheezy infants of Martinez et al' who they ever began to wheeze. Thus, Sporik et al3 followed stopped wheezing in early childhood. However, some a cohort of 67 children from birth who were selected bronchiolitics continue to wheeze6 and, in studies of as potential wheezers because at least one parent had a lung function in such patients, we noticed that over half history of hay fever or asthma. By the age of 11 years had surprisingly low values of lung volume which we the lifetime prevalence of wheezing was 63% but, of the originally thought was related to problems of whole 21 who first wheezed when under two years of age, body plethysmography7 since we did not find this in only five (24%) were wheezing at the age of 11 years infants with cystic fibrosis or in normal infants. It now compared with 17 of 21 (81%) who first wheezed seems quite possible that these bronchiolitic infants had after the age of two years. Brooke et a14 undertook an small lung volumes even before their viral infection. unselected community based survey of a cohort of Thus, several studies now suggest that those infants preschool Leicestershire children and then followed 68 who wheeze very early in life may be predisposed to whose parents had reported that the child wheezed, 70 wheeze with viral bronchiolitis because their airways are who reported coughing, and 175 controls. Almost half narrower, while others wheeze because of a family or the wheezers and over half the coughers were symptom personal background of atopy. Older infants who begin free when reviewed an average of three years later. In to wheeze are also more likely to have the allergic http://thorax.bmj.com/ the study ofMartinez et all a birth cohort of 826 children background of asthmatic subjects but do not have re- was available for evaluation at both three and six years duced lung function as a predisposing factor.' of age (table 1). This cohort was not apparently selected on the basis of a parental predisposition to respiratory disease although it is common knowledge that many Do infants with proven viral bronchiolitis families move to the Tucson area for health reasons. Of develop asthma? the total cohort 51-5% had never wheezed by the age Another approach to the problem of the wheezy infant of six years and, of the 277 who first wheezed before has been to follow infants with viral bronchiolitis to see on September 30, 2021 by guest. Protected copyright. the age of three years, 164 (59%) had stopped wheezing whether or not they become asthmatic. This type of by six years of age. Given that the evaluation in the research has been plagued by ambiguous definitions of other studies was carried out at different ages,34 the bronchiolitis and by the inclusion of infants with re- trend for early wheezers to stop wheezing is similar in current wheezing and older infants who might well have all three studies.
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