Elsevier

The Lancet

Volume 372, Issue 9643, 20–26 September 2008, Pages 1100-1106
The Lancet

Review
Early identification of atopy in the prediction of persistent asthma in children

https://doi.org/10.1016/S0140-6736(08)61451-8Get rights and content

Summary

The long-term solution to the asthma epidemic is thought to be prevention, and not treatment of established disease. Atopic asthma arises from gene–environment interactions, which mainly take place during a short period in prenatal and postnatal development. These interactions are not completely understood, and hence primary prevention remains an elusive goal. We argue that primary-care physicians, paediatricians, and specialists lack knowledge of the role of atopy in early life in the development of persistent asthma in children. In this review, we discuss how early identification of children at high risk is feasible on the basis of available technology and important for potential benefits to the children. Identification of an asthmatic child's atopic status in early life has practical clinical and prognostic implications, and sets the basis for future preventative strategies.

Section snippets

Asthma-related phenotypes in childhood

International research over the past 20 years has established gene–environment interactions as the basis of the most common form of asthma, atopic asthma.1 Current treatment strategies do not alter the long-term prospects for children with asthma, despite controlling symptoms and improving quality of life,2 therefore implying that a different approach is necessary.

Several epidemiologically distinct wheezing phenotypes have been identified in childhood,3 the most common being: transient

The role of the environment: a differential response to allergen and bacterial products

A recent prospective cohort study30 assessed postnatal development of lung function in children at high risk of persistent asthma raised in conventional household environments in the UK (control) versus those raised under strict environmental control to reduce exposure to indoor allergens and airborne irritants. Although controlled environments did not improve sensitisation rates, children living in these environments had better lung function at 3 years of age than children in the control

Respiratory viral infections: direct and atopy-dependent roles in asthma development

Most wheezing episodes in the first few years of life are due to viral infection. Acute lower respiratory infections, including bronchiolitis, resulting from rhinoviruses and respiratory syncytial virus, account for most admissions to hospital of children younger than 3 years.20, 38 The mechanisms underlying wheeze-promoting effects of these infections are only partly understood, but are associated with the spread of infections to the lower airways and subsequent intensification, possibly

Early identification of children at risk of persistent asthma: new clinical indicators

Several attempts have been made to produce models or clinical indicators of risk of persistent asthma at young age.32, 72, 73 These models have used asthma risk factors identified in epidemiological studies including: parental history of asthma and atopy; history of wheeze; presence of other atopic conditions, such as eczema, rhinoconjunctivitis, or food allergy; increased serum concentrations of IgE; and in-vitro cytokine production. Although children identified with these models have a high

Potential benefits of early identification of children at high risk of persistent asthma

A substantial proportion of children who develop persistent asthma are not identified until their disease has already consolidated; thus, any potential benefits of early intervention are not achieved. But are these potential benefits real or imagined? One argument supporting the existence of real benefits is the Hawthorne effect, which is seen in the control group of intervention studies and in observational studies—notably, the improved disease outcomes (relative to the community) that are

Search strategy and selection criteria

The Medline search engine was used to find articles in the PubMed database, with the search terms “childhood asthma”, “allergic sensitisation”, “longitudinal cohort studies”, and “asthma risk factors”. In addition to this search, we looked for articles relevant to the Review. We did not use any selection or rejection criteria.

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