PEDIATRICS Vol. 108 No. 4 October 2001, p. e69
ELECTRONIC ARTICLE:
Onset and Persistence of Childhood Asthma: Predictors From
Infancy
Received Sep 6, 2000; accepted May 4, 2001.
,
From the * National Jewish Medical and Research Center, Denver,
Colorado; Objective. In a prospective study of
children with a family history of asthma, asthma onset by 3 years of
age was found previously to be positively associated with variables
from the first year of life, including elevated total immunoglobulin E
(IgE), frequent respiratory infections, and parenting difficulties. We
followed this cohort of genetically at-risk children to investigate the relationship between factors assessed in infancy and asthma, allergy, and psychological status at school age.
Methods. A cohort of 150 children who were at risk for
developing asthma were identified prenatally on the basis of the
mothers' having asthma. For 28 children, the father had asthma as
well, putting them at bilateral genetic risk. Families primarily were
middle and upper middle class Caucasians. Parents came to the clinic during the third trimester of pregnancy for assessments of medical and
psychosocial functioning. A home visit took place when the infant was 3 weeks old, when parenting risk was assessed before the onset of any
asthma symptoms. Parenting difficulties included problems with infant
caregiving as well as components of maternal functioning, such as
postpartum depression and inadequate marital support. Blood was drawn
for serum IgE at 6 months of age. Parents and offspring subsequently
came to the clinic multiple times, with the last clinic visit during
the child's sixth year. Follow-up at age 6 involved a clinic visit for
allergy and psychosocial evaluations, consisting of interviews and a
behavior questionnaire. Seventy-seven children received the allergy and
psychosocial evaluation, 26 received the psychosocial evaluation in the
clinic, and 30 families received telephone interviews and mailed in
questionnaires. Additional monitoring of families by telephone and mail
was maintained over the next 2 years, until the children were 8, to
ensure accurate characterization of the course of illness.
Comprehensive medical records were obtained and reviewed for all health
care contacts. Children were designated as having asthma when there was
documentation in medical records of physician-diagnosed asthma,
observed wheezing, and/or prescription of asthma medications during the
time period when the child was between 6 and 8 years of age. Parental
reports of the occurrence of asthma corroborated the medical record
data.
Results. Data regarding asthma status were available for
145 children through 8 years of age. Forty (28%) of the children
manifested asthma between 6 and 8 years of age. Among variables
previously reported to predict asthma onset by age 3, 3 proved to have
significant univariate relationships with asthma between ages 6 and 8:
elevated IgE levels measured when the children were 6 months of age,
global ratings of parenting difficulties measured when infants were 3 weeks old, and higher numbers of respiratory infections in the first
year of life. Among these offspring of mothers with asthma, paternal
asthma showed a significant association with asthma between ages 6 and
8. Eczema in the first year was not significantly related to later
asthma. Multiple logistic regression showed that the model that best
predicted asthma at ages 6 to 8 from infancy variables included 2 main
effects. The adjusted odds ratio for 6-month IgE was 2.15 (1.51, 3.05)
and for parenting difficulties was 2.07 (1.15, 3.71). Although
socioeconomic status (SES) was not associated with asthma at ages 6 to
8, families of lower SES were more likely to be rated as having
parenting difficulties early in the child's life. The mothers of lower
SES breastfed for a shorter period of time and were more likely to
smoke during their infant's first year. There were more respiratory
infections during the first year of life among infants whose mother was
rated as having more parenting difficulties. Mothers who reported
smoking breastfed their infants for a shorter length of time. Male
gender was significantly associated with higher IgE levels when infants
were 6 months of age. Laboratory testing was completed for 77 children
at age 6. Total serum IgE levels were significantly higher for the
children with asthma between ages 6 and 8. Skin-prick testing showed
that the children with asthma had significantly more positive skin test
reactions than did the children without asthma. Psychosocial interview
data at 6 years of age were available for 103 families, and behavioral
questionnaires were available for 133 families. On the basis of 6-year
interviews, children with asthma were rated as being at greater
psychological risk than were the children without asthma. Mothers'
Child Behavior Checklist (CBCL) ratings of their children's behavior
indicated higher internalizing scores for the children with asthma as
compared with the children without asthma. Like the 6-month IgE, 6-year
IgE was higher for boys. IgE levels measured at 6 months of age were
significantly correlated with 6-year IgE levels. Parenting difficulties
measured at 3 weeks were significantly correlated with 6-year measures
of maternal depression, CBCL Internalizing score, and Child
Psychological Risk (CPR) score. There also were significant
correlations among the psychosocial variables assessed when the
children were 6 years of age; maternal depression was significantly
associated with child CBCL Internalizing score and CPR score, and the
last 2 also were significantly correlated. Multiple logistic regression
showed that 2 concurrently measured variables entered the model showing the strongest associations with asthma at ages 6 to 8. The adjusted odds ratio for CPR score was 3.21 (1.29-7.96) and for 6-year IgE was
1.71 (1.04-2.80).
Conclusions. This study of the natural history of
childhood asthma focused on the development of asthma into the
school-age years in a genetically at-risk group of children. The
relationships between biological and psychosocial variables in the
first year and school-age asthma support the formulation of asthma as
beginning early in life, with the developing immune system interacting
with environmental influences. The data provide support for the
possible contribution of psychosocial factors to asthma onset and
persistence into childhood.
Colorado Allergy and Asthma Centers, Littleton, Colorado;
and § Mayo Clinic, Rochester, Minnesota.
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