Childhood asthma

Increasing in incidence.

Affects more than 5% of all people in the U.S. younger than 18 years making it the most common chronic illness of childhood.

It is one of the most racially and ethnically disparate of all health conditions: in the US the lifetime prevalence of childhood asthma is highest among Puerto Ricans,  23.6%), among blacks 18.1% and lowest among whites 9.5% and Mexican Americans 9.6%.

Severe and poorly controlled asthma disproportionately affects black children and asthma mortality is four times higher among Puerto Ricans and blacks as among whites.

Children with the highest asthma prevalence and death rate have the  poorest drug response.

Estimated to affect 14% of children globally.

An estimated 5.5 million children in the US have asthma.

Inflammatory disease.

Chronic inflammation is present in mild asthma that is persistent.

Early diagnosis and treatment is needed to prevent airway remodeling and irreversible obstruction.

Environmental exposure to micro-organsims inversely related to the manifestations of asthma, hay fever and atopic diseases.

Globally, outdoor air pollution is recognized as a major public health concern and it’s estimated to contribute almost 7%of the annual disability adjusted life years lost in 2016.
Air pollution exposure is causally linked to asthma exacerbation‘s in children.
Declines in nitrogen dioxide and particular matter less than 2.5 Micromilliliters may be associated with decreased childhood asthma incidence.

Allergan sensitization is related to the pathogenesis and pathophysiology of childhood asthma.

In populations with higher bacterial exposures the prevalence of asthma and atopy is lower than in populations with lower bacterial exposure.

Lower prevalence of asthma and atopy among children raised on a farm.

The nascent gut microbiota of infants is essential in establishing proper immune function and that disruptions to this community results in early dysfunction and subsequent development of asthma.

Children who live on farms have a greater exposure to microbial agents and this is associated with protection from development of asthma (Ege MJ et al).

Asthma More Likely in children exposed to infection in utero.

The more common colds and viral infections a woman experiences during pregnancy, the higher the risk her baby will have asthma.

In most children with asthma and atopy, onset occurs occurs early in life, reflecting a crucial role of in utero and early childhood environment.

Children who have early exposure to allergens, such as house dust and pet dander, have increased risks of allergic sensitization by age 5.

In atopic mothers, acute atopic symptoms during pregnancy are associated with increased risk of early atopic dermatitis and allergic rhinitis at 5 years.

Repeated common colds during pregnancy increases the risk of asthma at 5 years,

Genetics play a factor in both asthma and allergy

If both of a child’s parents have allergies, the child has a 75% chance of being allergic.

If one of the parents is allergic, or if a close relative has allergies, the child has a 30 to 40% chance of having some form of allergy.

If neither parent has allergy, the chance of developing allergy/asthma is only 10 to 15%.

Asthma is the most common potentially serious medical condition to complicate pregnancy.

Gastrointestinal reflux identified by esophageal pH monitoring often associated with respiratory symptoms, and occurs frequently in children without characteristic gastrointestinal symptoms.

Some children with acute asthma have a limited response to inhaled beta2= agonists and corticosteroids.

In children with poorly controlled asthma, utilizing inhaled corticopsteroids, without symptoms of GERD the use of proton pump inhibitors (lansoprazole), compared to placebo did not improve symptoms or lung function, but did increase adverse events (Writing Committee for the American Lung Association Asthma Clinical Research Centers).

Use of PPIs in children with poorly controlled asthma is not warranted.

Long term therapy should be considered for infants and young children who have had more than three episodes of wheezing in the previous year that lasted more than 1 day and impaired sleep and so have risk factors for the development of asthma.

Long term therapy should be considered for infants and young children who have had more than three episodes of wheezing in the previous year that lasted more than 1 day and impaired sleep and who have risk factors for the development of asthma.

Goals of therapy include normal pulmonary function, minimal or no chronic symptoms, no exacerbations, no limits to activities, minimal use of rescue medicines with minimal adverse therapeutic effects and prevention of structural airway changes due to inflammation.

The Pediatric Asthma Controller Trial (PACT) indicated 100 mcg of fluticasone by inhaled therapy twice daily is the most effective treatment for childhood asthma, but uncontrolled asthma occurred in more than 50% of children and 39% of children require oral corticosteroids during a 48 week period.

The Best Add-on Therapy Giving Effective Responses (BADGER) trial:randomly assigned 182 children with asthma uncontrolled with inhaled fluticasone 100 mcg twice daily to step up therapy with higher dose fluticasone, adding a long acting beta-agonist, or a leukotriene receptor antagonist-the addition of long acting beta agonist regimen was more likely to be the best response (Lemanske RF).

Vitamin D supplementation in pregnancy does not reduce the incidence of childhood asthma .

Studies of nebulized magnesium with albuterol did not improve results in children with refractory acute asthma.

High efficiency particulate air filter purifiers in the classroom reduce allergens and particle exposure and improve asthma symptom control in school-age children.

Among children with uncontrolled moderate to severe asthma, patients treated with dupilumab had fewer asthmatic exacerbations and better lung function asthma control than those who received placebo.

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