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Paediatric asthma

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S1 RELATIONSHIP OF ASTHMA, ATOPY AND ADIPOSITY IN PREPUBERTAL CHILDREN

1A Maitra, 2A Sherriff, 1AJ Henderson. 1University of Bristol, Bristol, UK, 2University of Glasgow, Glasgow, UK

Background: The prevalence of overweight and obesity in children has been increasing. Observational studies support a positive association between asthma and obesity, with a stronger effect in females. Longitudinal studies in adults have suggested that obesity precedes asthma. However, this has been challenged by observations in British school children. Methodological differences between studies have made it difficult to establish whether obesity is a primary cause or an intermediate variable in the development of asthma or atopy.

Objectives: Using repeated anthropometric measurements in early and mid-childhood, we investigated the associations of changes in body mass with asthma and atopy in a contemporary birth cohort of prepubertal children.

Methods and Study Population: The Avon Longitudinal Study of Parents and Children (ALSPAC) is a longitudinal birth cohort study of children born between 1 April 1991 and 31 December 1992 in Avon, UK. Anthropometric data were obtained from measurements at 4 and 7 years of age. Body mass index (BMI) z-score was calculated relative to UK 1990 references and in a subsample, the timing of adiposity rebound was categorised as very early (<61 months), early (61 months) and late (>61 months). We defined a BMI changer as a subject crossing centiles in either direction by greater than 1.64 standard deviations between 4 and 7 years. Asthma was defined as doctor-diagnosed asthma with current symptoms at 91 months and atopy was defined as a positive response to skin prick tests performed at 7 years.

Results: A total of 14 541 women were enrolled during pregnancy, resulting in 14 062 live births. Approximately 8000 children attended the annual research clinics (∼58%). Data on centile crossing, atopy and patent ductus arteriosus were available on 4465 and 4422 subjects, respectively (786 subjects for adiposity rebound). Girls who increased BMI by >1.64 SD and with early adiposity rebound had a higher prevalence of asthma/atopy and the converse was true for boys (see table).

Conclusion: Early adiposity rebound and upward centile crossing in prepubertal girls was associated with an increased prevalence of asthma and atopy. Conversely, boys with early adiposity rebound and upward centile crossing were protected from developing atopy and asthma.

Abstract S1 Table

S2 EXCLUSION OF COWS’ MILK UP TO AGE 4 MONTHS DOES NOT REDUCE THE RISK OF ASTHMA LATER IN LIFE

1S Hand, 2F Dunstan, 2M Burr, 3K Jones, 3S Rolf. 1Cwm Taf NHS Trust, South Glamorgan, UK, 2Cardiff University, Cardiff, UK, 3University of Wales Institute Cardiff, Cardiff, UK

The natural history of athma is still poorly understood. There are now many longitudinal studies that aim to determine this. Our study is one of the oldest such longitudinal studies and was originally a randomised controlled trial to determine if the restriction of cows’ milk in infants reduced the risk of wheezing in later life.

Between 1982 and 1984 in the South Wales valley areas of Merthyr and Aberdare, 527 pregnant women were recruited to the study if either she, her partner or older child had a history of asthma, eczema or hayfever. Of these, a total of 487 live births was eventually randomly assigned to receive no cows’ milk or cows’ milk products (intervention group 238 babies) for the first 4 months of life. Mothers in the intervention group were advised to restrict their daily milk intake to one half pint (284 ml) during the pregnancy and while breast feeding.

Babies were examined at 3, 6 and 12 months by the same paediatrician. Parents were given a questionnaire at age 7 years and the children were again examined. At age 15 years children were asked to fill a questionnaire. At age 23 years the subjects themselves were invited to attend clinic for examination and to fill a questionnaire.

If subjects answered “yes” to the question “Have you noticed a wheezing noise from your chest in the past 12 months?” at age 7, 15 or 23 years they were considered to have a positive history of asthma for the purpose of our statistical analysis.

Results: A total of 254 subjects provided information at ages 7, 15 and 23 years. Based on the original randomisation the results in the table show there was no significant difference between those who avoided cows’ milk and products for the first 4 months of life and those who did not.

Conclusion: Cows’ milk avoidance up to age 4 months does not reduce the risk of wheezing in later life.

Abstract S2 Table Percentage who answered “yes” to wheezing in past year at the stated ages up to age 23 years (n  =  254)

S3 CONFIDENTIAL ENQUIRY INTO PAEDIATRIC ASTHMA DEATHS IN THE EASTERN REGION OF THE UK BETWEEN 2000 AND 2005: CAN WE IDENTIFY THE RISK FACTORS?

K Anagnostou, A Saraswatula, S Nasser, R Iles. Addenbrookes Hospital, Cambridge, UK

Introduction: This study analysed data from all asthma deaths age up to 16 years between 2000 and 2005 that occurred in the eastern region.

Methods: All children within the eastern region with asthma stated in the death certificate as the main cause of death were identified. Hospital and GP records and postmortem reports were examined in detail to establish whether asthma was the cause of death within 6 months of the child’s death. Details of drug therapy, asthma severity, compliance with treatment, hospital admissions, hospital and GP appointments were collected.

Results: A total of 14 children (age range 8–16 years, seven male, seven female) died of asthma during the above 5-year period in the eastern region. According to records and BTS guidance, of the 14 children two children had mild asthma, three moderate asthma and eight were considered to be severe asthmatics (one child was not a known asthmatic). Only three children had a written management plan. Nine children died between April and August and were classified as seasonal deaths. Three of the eight children with severe asthma were solely managed in primary care and had never seen a hospital specialist. Six children had adverse psychosocial factors (domestic problems/learning difficulties) and three of these displayed poor compliance with medication and attending appointments. Eight children had a clinical history of atopy but only two of them had formal allergy assessment. and none of them had had postmortem measurement of tryptase—a useful marker for mast cell degranulation due to anaphylaxis.

Conclusions: Children with seasonal asthma appear to be at high risk as they are usually asymptomatic out of season, poorly compliant with prophylactic treatment and suddenly receive a large allergen load. Formal allergy assessment in children with an atopic history can be useful in preventing anaphylaxis/allergic asthma deaths. Adverse psychosocial factors can affect asthma control and put children at high risk of death. All children diagnosed with asthma should have a clear, written management plan. There should be a low threshold for referring children with severe/difficult to control asthma to a respiratory specialist.

Acknowledgements: The authors would like to thank the Confidential Asthma Enquiry Committee

S4 INCREASED REQUIREMENT FOR ORAL STEROIDS IN CHILDREN USING SEPARATE LONG-ACTING BETA AGONIST AND STEROID INHALERS

H Elkout, C Simpson, J McLay, PJ Helms. University of Aberdeen, Aberdeen, UK

Introduction: The evidence base for the management of childhood asthma is limited and the efficacy and safety of long-acting beta agonists (LABA) less secure than in adult asthma. We therefore assessed the prescribing patterns in primary care with a focus on LABA use and the need for courses of oral steroids (OCS).

Methods: Retrospective observational survey of all children aged 0–18 years from September 2001 to August 2006 prescribed asthma medication. Data from 46 Scottish general practices contributing to the practice team information database.

Results: 11 685 children received at least one prescription of anti-asthmatic medication in the study period. The overall use of OCS increased over the 5 years with the expected lowest levels in those only using short-acting beta agonists, with the highest levels in those using LABA and inhaled corticosteroids (ICS). Within this group OCS use was lower in 4 of the 5 years (p<0.001 χ2) for combination compared with separate devices. Only 157 children were prescribed LABA without ICS over the whole 5-year period (see table).

Conclusions: In children being treated for asthma, the use of combined ICS/LABA inhalers reduces the need for oral steroid rescues and by inference achieves better control than ICS/LABA in separate inhalers. Routinely acquired NHS data may usefully contribute to a better understanding of medicines efficacy and safety in the post-licensing period.

Abstract S4 Table Use of oral steroids (%) by asthma treatment category

S5 VALIDATION OF THE MINI AND STANDARDISED VERSIONS OF THE PAEDIATRIC ASTHMA QUALITY OF LIFE QUESTIONNAIRE

A Wing, J Upton, S Walker. Education for Health, Warwick, UK

One of the primary aims of managing asthma in children is to identify and assess the impact of symptoms on quality of life (QoL). The paediatric asthma quality of life questionnaire (PAQLQ) (Juniper et al, 1996) reliably measures the problems that children (7–17 years) with asthma experience, although it is time-consuming to complete and requires training in administration. Here we compare the validity of two new, simpler questionnaires, the MiniPAQLQ and the standardised PAQLQ with the original PAQLQ to provide new tools for measuring QoL in children.

Forty-two children with current symptoms of asthma (asthma control questionnaire (ACQ) score >1.5) aged 7–17 years were recruited from a hospital paediatric asthma clinic and a GP practice. Children were assessed at baseline and after 1, 5 and 9 weeks. At each visit, a trained interviewer administered the PAQLQ, the MiniPAQLQ and the standardised PAQLQ as well as other measures of asthma control, ACQ and the health utilities index (HUI). Validity, reliability and responsiveness were assessed by correlating MiniPAQLQ and standardised PAQLQ scores with the gold standard (PAQLQ) and the ACQ and HUI.

Correlations between overall and individual domain scores for the standardised PAQLQ, MiniPAQLQ and the original PAQLQ were strong (r  =  >0.80; all p<0.001) apart from the activities domain, which showed only a moderate (r  =  0.56) correlation. The standardised PAQLQ and the MiniPAQLQ showed comparable reliability (detecting asthma stability over time and different levels of impairment between children) (intraclass correlation coefficient (ICC) >0.89) apart from the activity domain of the MiniPAQLQ, which was lower (ICC 0.56). Both the standardised PAQLQ and the MiniPAQLQ were able to detect differences between stable, deteriorated and improved groups according to the PAQLQ score (all p<0.001). All three questionnaires showed moderate–strong negative correlations (because of reverse scoring system for ACQ) with the ACQ (PAQLQ r  =  −0.77, standardised PAQLQ r  =  −0.79, MiniPAQLQ r  =  −0.72; all p<0.001). There were only poor correlations between the three questionnaires and the HUI (r  =  0.0, 0.13 and 0.06, respectively; all p = ns).

In summary, the new standardised PAQLQ and MiniPAQLQ are valid and reliable instruments for measuring QoL in children. The fact that they are easier to adminisister and complete should facilitate their use in practice.

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