Asthma from childhood to adulthood Ernst Eber

Asthma from childhood to adulthood

Ernst Eber

Respiratory and Allergic

Disease Division, Paediatric

Department, Medical University

of Graz, Austria

300 million people suffer from asthma worldwide

No data available

Prevalence of asthma

ISAAC Lancet 1998

Martinez FD Pediatr Pulmonol 1997 based on: N Engl J Med 1995

Wheezing in preschool children

Wheezing in preschool children

Landau LI Pediatr Pulmonol 1996

• Different phenotypes of childhood

asthma

- Virus associated wheeze

- Post-bronchiolitis wheeze

- Atopy associated wheeze

• Asthma in more than 50% begins <3

years

Asthma is not one disease

„... there is a belief among general

practitioners and paediatricians that

children grow out of asthma.“

Issues in Adolescent Asthma.Thorax 1996; 51 (Supplement 1)

Childhood asthma

„... it is often not the asthma that is

outgrown but the paediatrician.“

Outcome of asthma and wheezing in the first 6 years of life

Morgan WJ et al. Am J Respir Crit Care Med 2005

Outcome of asthma and wheezing in the first 6 years of life

Morgan WJ et al. Am J Respir Crit Care Med 2005

„... our study strongly suggests that

both lung function characteristics in

early infancy and events occurring

during the first 6 years of life

determine the expression of asthma

and the level of lung function that

will be achieved during childhood

and into early adult life.“

The Melbourne Asthma Study: 1964-1999

Phelan PD et al. J Allergy Clin Immunol 2002

• 1964: Children at age 7 yrs with a history

of wheezing randomly selected; further

group selected from the same birth cohort

at age 10

• Subjects followed prospectively at 7-yr

intervals; last review 1999 (average age

42 yrs)

• 87% of the original cohort participated in

the 1999 review


Oswald H et al. Pediatr Pulmonol 1997



• The majority of children who had only a few

episodes of wheezing associated with symptoms

of a respiratory infection had a benign course,

with many ceasing to wheeze by adult life. Most

who continued with symptoms into adult life were

little troubled by them.

• Children with asthma mostly continued with

significant wheezing into adult life, and the more

troubled they were in childhood, the more likely

symptoms continued.



• There was a loss in lung function by the age of 14

years in those with severe asthma, the loss did

not progress in adult life.

• There was no significant loss of lung function in

those with milder symptoms.

A longitudinal, population-based cohort study of childhood asthma followed to

adulthood

Sears MR et al. N Engl J Med 2003

14.5%

15.0%12.4%9.5%21.2%27.4%


adulthood



adulthood


• More than 1 in 4 children had wheezing that

persisted from childhood to adulthood or that

relapsed after remission.

• The factors predicting persistence or relapse were

sensitization to HDM, AHR, female sex, smoking,

and early age at onset.

• These findings, together with persistently low lung

function, suggest that outcomes in adult asthma

may be determined primarily in early childhood.

A clinical index to define risk of asthma in young children with recurrent wheezing

Castro-Rodriguez JA et al. Am J Respir Crit Care Med 2000

Risk factors for onset of asthma

A 12-year prospective follow-up study

Porsbjerg C et al. Chest 2006

The presence of AHR and concomitant atopic

manifestations in childhood increase the risk

of developing asthma in adulthood, and

should be recognized as markers of

prognostic significance, whereas the absence

of these manifestations predicts a very low

risk of future asthma.


Airway inflammation and airway remodelling

are present in children and adolescents with

clinical remission of their asthma.

(Eosinophils, T cells, mast cells and IL-5 in bronchial

biopsy tissue; eosinophils in BALF; eosinophils, ECP,

TNF-α and GM-CSF in induced sputum; FeNO; BR to

AMP and MCh)

van den Toorn et al. Am J Respir Crit Care Med 2000 & 2001; Warke et al. Eur Respir J 2002; Obase et al. Allergy 2003

Childhood factors associated with asthma remission after 30 years follow up

Vonk JM et al. Thorax 2004

Cohort of 119 allergic asthmatic children

visit 1: 5-14 yrs, visit 2: 21-33 yrs, visit 3: 32-42 yrs

Clinical remission: no asthma symptoms, no use

of ICS

Complete remission: no asthma symptoms, no use

of ICS, normal lung function, no BHR

Childhood factors associated with asthma remission after 30 years follow up

Vonk JM et al. Thorax 2004

Complete remission at visit 3: 22%

Clinical remission at visit 3:30%

Both complete and clinical remission were

associated with a higher lung function level in

childhood and a higher subsequent increase in

FEV1.


Summary I

In the vast majority of cases asthma has its

onset in childhood.

In a proportion of asthmatic children,

asthma remits in adolescence or early

adulthood and the severity of asthma tracks

significantly with age.


Summary II

Complete remission of childhood asthma

may be the exception rather than the rule.

Patients with asthma in clinical

remission should be monitored with

periodic assessment of lung function,

bronchial responsiveness, and other

markers of inflammation.

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Asthma from childhood to adulthood Ernst Eber

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