Gordon R. Bloomberg

Rationale: Maternal depression and prenatal and early life stress may influence childhood wheezing illnesses, potentially through effects on immune development. Objectives: To test the hypothesis that maternal stress and/or depression during pregnancy and early life are associated with recurrent wheezing and aeroallergen sensitivity and altered cytokine responses (enhanced type 2 or reduced virus-induced cytokine responses) from stimulated peripheral blood mononuclear cells at age 3 years. Methods: URECA (Urban Environment and Childhood Asthma) is a birth cohort at high risk for asthma (n = 560) in four inner cities. Maternal stress, depression, and childhood wheezing episodes were assessed by quarterly questionnaires beginning at birth. Logistic and linear regression techniques were used to examine the relation of maternal stress/depression to recurrent wheezing and peripheral blood mononuclear cell cytokine responses at age 3 years. Measurements and Main Results: Overall, 166 (36%) children had recurrent wheeze at age 3 years. Measures of maternal perceived stress at Years 2 and 3 were positively associated with recurrent wheeze (P < 0.05). Maternal depression (any year) was significantly associated with recurrent wheezing (P ≤ 0.01). These associations were also significant when considered in a longitudinal analysis of cumulative stress and depression (P ≤ 0.02). Neither stress nor depression was significantly related to aeroallergen sensitization or antiviral responses. Contrary to our original hypothesis, prenatal and Year 1 stress and depression had significant inverse associations with several type 2 cytokine responses. Conclusions: In urban children at high risk for asthma, maternal perceived stress and depression were significantly associated with recurrent wheezing but not increased atopy or reduced antiviral responses.

Summary: Background: Mouse models of atopic march suggest that systemic, skin‐derived thymic stromal lymphopoietin (TSLP) mediates progression from eczema to asthma.Objective: We investigated whether circulating TSLP is associated with eczema, allergic sensitization, or recurrent wheezing in young children.Methods: A prospective analysis of the relationship between plasma levels of TSLP to allergic sensitization and recurrent wheezing was conducted in the birth cohort from the Urban Environment and Childhood Asthma (URECA) study. Plasma TSLP levels were measured at 1, 2, and 3 years of age and analysed for correlation with clinical parameters in each of the three years. Only those children with consecutive samples for all three years were included in this analysis.Results: We detected TSLP in 33% of 236 children for whom plasma samples were available for all three years. Overall, a consistently significant association was not found between TSLP and eczema or allergic sensitization. With regard to recurrent wheezing, children with detectable TSLP at one year of age were significantly less likely to experience recurrent wheezing by 3 years compared with those children without detectable TSLP, but this was only seen in children without aeroallergen sensitization at 3 years (P < 0.01).Conclusions and Clinical Relevance: Contrary to our expectations, circulating TSLP was not significantly associated with eczema, allergen sensitization, or recurrent wheezing during the first three years of life. Early presence of circulating TSLP was significantly associated with reduced incidence of recurrent wheeze in those children not sensitized to aeroallergen. These findings suggest a possible underlying distinction between pathogenesis of developing atopic vs. non‐atopic recurrent wheeze.

Long recognizing that asthma, one of the most common chronic childhood diseases, is difficult to manage, the National Asthma Education Prevention Program developed clinical practice guidelines to assist health care providers, particularly those in the primary care setting. Yet, maintenance asthma care still fails to meet national standards. Therefore, in an attempt to improve and support asthma self-management behaviors for parents of children 5 to 12 years of age with persistent asthma, a novel nurse telephone coaching intervention was tested in a randomized, controlled trial. A detailed description of the intervention is provided along with parent satisfaction results, an overview of the training used to prepare the nurses, and a discussion of the challenges experienced and lessons learned.

The purpose of this review is to consider the collective influence of factors affecting recurrent wheezing in young children. Specific allergen sensitization, upper respiratory infections, genetic polymorphisms and environmental factors have collectively been reported in the prevalence of and induction of recurrent wheezing in young children. Two examples of environmental factors are diet and exposure to air pollution, both of which are potentially modifiable. Recent investigations provide evidence that a 'Mediterranean diet' and a diet that emphasizes polyunsaturated fatty acids during pregnancy and early infancy, as well as breastfeeding, may be protective for wheezing, and that exposure to traffic-related pollution may be an independent factor in the incidence of wheezing in young children. Recent studies of early childhood wheezing demonstrate a potentially protective effect of diet and exposure to air pollution as a significant risk factor. An evaluation of collective factors influencing the presence of disease may help to broaden the clinical assessment and give parents and physicians the opportunity to potentially modify circumstances that promote the incidence of recurrent wheezing in infants and preschool aged children.

The new guidelines for assessment of asthma control emphasize two domains: impairment and risk. Exacerbations of asthma are an important component of risk but have not received as much attention as the day-to-day symptoms that make up impairment. The purpose of this review is to report what has recently been learned about exacerbations. Exacerbations occur in the context of both controlled and uncontrolled asthma. Exacerbations are a strong independent risk factor of further exacerbations. This suggests that unrecognized factors may be involved in susceptibility to exacerbations in addition to more commonly recognized triggers such as viruses, allergens, and poorly controlled asthma. Such factors may be the result of genetic variation. Recent evidence now shows a residual effect on lung function from an exacerbation event. There are no current specific intervention measures to prevent exacerbations but attention to management practices continues to look at the role of the emergency department in improving care. The presence of exacerbations is considered a risk factor of the likelihood of further exacerbations and requires assessment of the triggers identified with history of exacerbations, host factors, atopic disposition, exposure to allergens, adherence to prescribed medications, and preventive measures to reduce future risk of such an event.

Recurrent wheezing is common in preschool-aged children, with 1 in 3 children experiencing at least 1 acute wheezing illness before the age of 3 years. These children represent a diverse group, with some going on to present with asthma at school age and others experiencing complete resolution of symptoms. The primary care physician is faced with a dilemma of when to recommend daily therapy. He or she must also answer parents' concerns, often expressed as, "Does my child have asthma?" and "Will my child have to take medication the rest of his or her life?" This article presents recent studies and recommendations that can guide the physician in approaching the child and the parent with rational management. The emphasis is on viewing recurrent wheezing as a continuum requiring a plan of monitoring that starts with the very first episode. Using background information from the parents and a history of the child's allergic disposition, one can discuss with parents the risks of developing asthma and, together with planned monitoring, prescribe appropriate management. The primary care physician can plan management by using the Asthma Predictive Index and employing specific questions for features present during the intervals between acute episodes. Together with close monitoring, the physician will have a compass that effectively directs rational management.

The incidence and morbidity of wheezing illnesses and childhood asthma is especially high in poor urban areas. This paper describes the study design, methods, and population of the Urban Environment and Childhood Asthma (URECA) study, which was established to investigate the immunologic causes of asthma among inner-city children.