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Summary Background Diagnosing atopic dermatitis (AD) in infants is challenging. Objectives To determine the incidence and persistence of eczema and AD in infants using the UK Working Party (UKWP) and Hanifin and Rajka (H&R) criteria. Methods A cohort of 1834 infants was examined clinically at 3, 6 and 12 months of age. AD was diagnosed by UKWP (3, 6 and 12 months) and H&R (12 months) criteria. Logistic regression models were used to assess the relationship between AD and eczema. Results Eczema was observed in 628 (34·2%) infants (n = 240, n = 359 and n = 329 at 3, 6 and 12 months, respectively), with AD diagnosed in 212 (33·7%) infants with any eczema and in 64/78 (82%) infants with eczema at all three visits. The odds of AD were lower with first presentation of eczema at 6 [odds ratio (OR) 0·33, 95% confidence interval (CI) 0·22–0·48] or 12 months (OR 0·49, 95% CI 0·32–0·74) than at 3 months, and higher in infants with eczema at three (OR 23·1, 95% CI 12·3–43·6) or two (OR 6·5, 95% CI 4·3–9·9) visits vs. one visit only. At 12 months, 156/329 (47·4%) fulfilled the UKWP and/or H&R criteria; 27 (8%) fulfilled the UKWP criteria only and 65 (20%) only the H&R criteria. Of the 129 infants who fulfilled the H&R criteria, 44 (34·1%) did not meet the itch criterion. Conclusions Used in combination and at multiple timepoints, the UKWP and H&R criteria for AD may be useful in clinical research but may have limited value in most other clinical settings.

Background Loss-of-function mutations in the skin barrier gene filaggrin (FLG) increase the risk of atopic dermatitis (AD), but their role in skin barrier function, dry skin and eczema in infancy is unclear. Objectives To determine the role of FLG mutations in impaired skin barrier function, dry skin, eczema and AD at 3 months of age and throughout infancy. Methods FLG mutations were analysed in 1836 infants in the Scandinavian population-based PreventADALL study. Transepidermal water loss (TEWL), dry skin, eczema and AD were assessed at 3, 6 and 12 months of age. Results FLG mutations were observed in 166 (9%) infants. At 3 months, carrying FLG mutations was not associated with impaired skin barrier function (TEWL > 11 center dot 3 g m(-2) h(-1)) or dry skin, but was associated with eczema [odds ratio (OR) 2 center dot 89, 95% confidence interval (CI) 1 center dot 95-4 center dot 28; P < 0 center dot 001]. At 6 months, mutation carriers had significantly higher TEWL than nonmutation carriers [mean 9 center dot 68 (95% CI 8 center dot 69-10 center dot 68) vs. 8 center dot 24 (95% CI 7 center dot 97-8 center dot 15), P < 0 center dot 01], and at 3 and 6 months mutation carriers had an increased risk of dry skin on the trunk (OR 1 center dot 87, 95% CI 1 center dot 25-2 center dot 80; P = 0 center dot 002 and OR 2 center dot 44, 95% CI 1 center dot 51-3 center dot 95; P < 0 center dot 001) or extensor limb surfaces (OR 1 center dot 52, 95% CI 1 center dot 04-2 center dot 22; P = 0 center dot 028 and OR 1 center dot 74, 95% CI 1 center dot 17-2 center dot 57; P = 0 center dot 005). FLG mutations were associated with eczema and AD in infancy. Conclusions FLG mutations were not associated with impaired skin barrier function or dry skin in general at 3 months of age, but increased the risk for eczema, and for dry skin on the trunk and extensor limb surfaces at 3 and 6 months.

Background Prenatal exposure to perfluoralkyl substances (PFASs) has been reported to be associated with immunosuppression in early childhood, but with contradictory findings related to atopic and lung diseases. Aim We aimed to determine if prenatal exposure to PFASs is associated with asthma or other allergic diseases or respiratory tract infections in childhood. Methods Nineteen PFASs were measured in cord blood available from 641 infants in the Environment and Childhood Asthma (ECA) prospective birth cohort study. The six most abundant PFASs were perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), perfluorooctanesulfonamide (PFOSA), perfluorohexane sulfonic acid (PFHxS), perfluorononanoic acid (PFNA), and perfluoroundecanoic acid (PFUnDA). Health outcomes were assessed at two and ten years of age, and included reported obstructive airways disease (wheeze by 10 years; asthma by 2 and 10 years; reduced lung function at birth; allergic rhinitis by 10 years), atopic dermatitis (AD) by 2 and 10 years, allergic sensitization by 10 years, and episodes of common respiratory tract infections (common cold by 2 years, lower respiratory tract infections (LRTI) by 10 years). The associations between exposure and health outcomes were examined using logistic and Poisson regression. Results The number of reported airways infections were significantly associated with cord blood concentrations of PFAS; common colds by two years with PFUnDA (β = 0.11 (0.08–0.14)) and LRTIs from 0 to 10 years of age with PFOS (β = 0.50 (0.42–0.57)), PFOA (β = 0.28 (0.22–0.35)), PFOSA (β = 0.10 (0.06–0.14)), PFNA (β = 0.09 (0.03–0.14)) and PFUnDA (β = 0.18 (0.13–0.23)) concentrations. Neither reduced lung function at birth, asthma, allergic rhinitis, AD nor allergic sensitization were significantly associated with any of the PFASs. Conclusion Although prenatal exposure to PFASs was not associated with atopic or lung manifestations by 10 years of age, several PFASs were associated with an increased number of respiratory tract infections in the first 10 years of life, suggesting immunosuppressive effects of PFASs.

MeDALL (Mechanisms of the Development of ALLergy; EU FP7-CP-IP; Project No: 261357; 2010-2015) has proposed an innovative approach to develop early indicators for the prediction, diagnosis, prevention and targets for therapy. MeDALL has linked epidemiological, clinical and basic research using a stepwise, large-scale and integrative approach: MeDALL data of precisely phenotyped children followed in 14 birth cohorts spread across Europe were combined with systems biology (omics, IgE measurement using microarrays) and environmental data. Multimorbidity in the same child is more common than expected by chance alone, suggesting that these diseases share causal mechanisms irrespective of IgE sensitization. IgE sensitization should be considered differently in monosensitized and polysensitized individuals. Allergic multimorbidities and IgE polysensitization are often associated with the persistence or severity of allergic diseases. Environmental exposures are relevant for the development of allergy-related diseases. To complement the population-based studies in children, MeDALL included mechanistic experimental animal studies and in vitro studies in humans. The integration of multimorbidities and polysensitization has resulted in a new classification framework of allergic diseases that could help to improve the understanding of genetic and epigenetic mechanisms of allergy as well as to better manage allergic diseases. Ethics and gender were considered. MeDALL has deployed translational activities within the EU agenda.

SummaryBackground Epidemiological data and the effect of sun exposure on atopic eczema (AE) suggest that vitamin D (vitD) may be involved in the pathogenesis. Objectives To investigate if vitD levels were associated with the presence or severity of AE in the first 2 years of life in children living in south-east Norway. Methods Infants, recruited to a clinical trial on acute bronchiolitis (n = 404) and from the general population (n = 240), were examined at 1–13 months (first visit) and at 2 years of age (second visit). Caregivers were interviewed using a structured questionnaire. AE was diagnosed clinically, based on well-established criteria. Disease severity was assessed using the SCORing Atopic Dermatitis index. Blood samples were taken for vitD measurements, using liquid chromatography–tandem mass spectrometry and for common filaggrin mutation analyses. Complete data on AE and vitD were available in 596 and 449 children at the first and second visit, respectively. Results Atopic eczema was diagnosed in 67 children (11%) at the first visit and in 103 children (23%) at the second. Mean vitD levels were 58·2 nmol L−1 at the first visit and 66·9 nmol L−1 at the second. Using vitD level tertiles in multivariate regression analysis, there was no association between vitD levels and AE at either visit, regardless of filaggrin mutation. In children without AE at the first visit, vitD levels did not predict AE at the second. Conclusions In this cohort of young children in Norway, we found no association between vitD levels and the presence or severity of AE.

Introduction: Exposure to perfluoroalkyl substances (PFASs) has been inconsistently associated with asthma, allergic diseases and airways infections in early childhood. The aim of the study was, therefore, to investigate the effect of childhood exposure to PFASs on asthma and allergy related outcomes and on airways infections before and during puberty using the prospective birth cohort Environment and Childhood Asthma (ECA) Study. Aspects of gender, exposure period and study design (cross-sectional and longitudinal) were also taken into consideration. Material and methods: Included in the study was 378 participants with PFAS measurements at age 10 years and follow-up data at ages 10 years (cross sectional data) and 16 years (longitudinal data). Eight PFASs with at least 70% of measurements above the limit of quantification (LOQ) in the child’s serum were included in the present study: perfluoroheptanoate (PFHpA), perfluorooctanoate (PFOA), perfluourononanoate (PFNA), perfluorodecanoate (PFDA), perfluoroundecanoate (PFUnDA), perfluorohexane sulfonate (PFHxS), perfluoroheptane sulfonate (PFHpS) and perfluorooctane sulfonate (PFOS). The PFAS levels were converted into interquartile range (IQR). In addition, perfluorooctane sulfonamide (PFOSA) detected in 60% of the samples, was recoded into “not detected /detected”. Binomial, multinomial and linear regression were used, followed by Bonferroni adjustment to correct for multiple comparisons. Sensitivity analyses evaluating the effect of extreme PFAS values and gender were performed. Results: In the cross sectional data at 10 years a positive statistically significant association was seen between PFHpA and asthma in girls. In the longitudinal data, PFNA, PFDA and PFUnDA were inversely associated with atopic dermatitis (AD) in girls and with PFHxS in all participants and in boys. Further, PFNA and PFHpS were positively associated with rhinitis in girls and with PFOA in all participants. There seems to be a suggestive pattern of increased risk of allergic sensitisation in all participants and a decreased risk in boys, but due to different results in main and sensitivity analyses these findings should be interpreted with caution. No associations were found between PFASs and lung function. For airways infections and longitudinal data, PFDA was inversely associated with common cold, while positive association was found for PFHpA, PFOA, PFHpS and PFOS and lower respiratory tract infections (LRTI). Discussion and conclusion: Our results lend further support for an immunosuppressive effect of PFASs on AD and LRTI. Gender seems to be important for some exposure-health associations. No clear pattern in exposure-health associations was observed with regard to exposure period or study design, with the exception of asthma where significant findings have mostly been reported in cross-sectional studies. Keywords: Perfluoroalkyl substances, Asthma, airways infections, Allergic diseases, Immunosuppression, Immunotoxicity, Childhood, Puberty

Allergic Rhinitis and its Impact on Asthma (ARIA) has evolved from a guideline by using the best approach to integrated care pathways using mobile technology in patients with allergic rhinitis (AR) and asthma multimorbidity. The proposed next phase of ARIA is change management, with the aim of providing an active and healthy life to patients with rhinitis and to those with asthma multimorbidity across the lifecycle irrespective of their sex or socioeconomic status to reduce health and social inequities incurred by the disease. ARIA has followed the 8-step model of Kotter to assess and implement the effect of rhinitis on asthma multimorbidity and to propose multimorbid guidelines. A second change management strategy is proposed by ARIA Phase 4 to increase self-medication and shared decision making in rhinitis and asthma multimorbidity. An innovation of ARIA has been the development and validation of information technology evidence-based tools (Mobile Airways Sentinel Network [MASK]) that can inform patient decisions on the basis of a self-care plan proposed by the health care professional., EAACI -European Academy of Allergy and Clinical Immunology(undefined), info:eu-repo/semantics/acceptedVersion

SummaryBackground Early life risk factors are previously described for childhood asthma, but less is known related to asthma in adolescence. We aimed to investigate early risk factors (before 2 years) for pubertal asthma and secondarily for pubertal asthma phenotypes based upon allergic comorbidities. Methods Based on data from 550 adolescents in the prospective birth cohort ‘Environment and Childhood Asthma’ study, subjects were categorized by recurrent bronchial obstruction (rBO) 0–2 years, asthma 2–10 years, and pubertal asthma from 10 to 16 years including incident asthma in puberty and asthma in remission from 10 to 16 years or as never rBO/asthma 0–16 years. Asthma in puberty was further classified based on the comorbidities atopic dermatitis and allergic rhinitis (AR) from 10 to 16 years. Twenty-three common asthma risk factors identified by 2 years of age, including frequency and persistence of bronchial obstruction (severity score), were analysed by weighted logistic regression for each phenotype. Results In adjusted models, the risk of pubertal asthma increased significantly with higher severity score, parental rhinitis, being the firstborn child, and familial stress around birth. Pubertal asthma in remission was significantly associated with severity score and number of lower respiratory tract infections and inversely associated with breastfeeding beyond 4 months. Pubertal incident asthma was more common among firstborn children. All asthma phenotypes with allergic diseases were significantly associated with severity score, whereas familial perinatal stress increased the risk of asthma only. Asthma combined with AR was associated with parental asthma and being firstborn, whereas the risk of asthma with both atopic dermatitis and AR increased with higher paternal education, atopic dermatitis, being firstborn, and familial perinatal stress. Conclusion and clinical relevance Important early risk factors for pubertal asthma were early airways obstruction, parental rhinitis, being the firstborn child, and perinatal familial stress.

BACKGROUND Peanut allergy necessitates dietary restrictions, preferably individualized by determining reactivity threshold through an oral food challenge (OFC). However, risk of systemic reactions often precludes OFC in children with severe peanut allergy. OBJECTIVE We aimed to determine whether clinical and/or immunological characteristics were associated with reactivity threshold in children with anaphylaxis to peanut and secondarily, to investigate whether these characteristics were associated with severity of the allergic reaction during OFC. METHODS A double-blinded placebo-controlled food challenge (DBPCFC) with peanut was performed in 96 5- to 15-year-old children with a history of severe allergic reactions to peanut and/or sensitization to peanut (skin prick test [SPT] ≥3 mm or specific immunoglobulin E [s-IgE] ≥0.35 kUA/L). Investigations preceding the DBPCFC included a structured interview, SPT, lung function measurements, serological immunology assessment (IgE, IgG and IgG4 ), basophil activation test (BAT) and conjunctival allergen provocation test (CAPT). International standards were used to define anaphylaxis and grade the allergic reaction during OFC. RESULTS During DBPCFC, all 96 children (median age 9.3, range 5.1-15.2) reacted with anaphylaxis (moderate objective symptoms from at least two organ systems). Basophil activation (CD63+ basophils ≥15%), peanut SPT and the ratio of peanut s-IgE/total IgE were significantly associated with reactivity threshold and lowest observed adverse events level (LOAEL) (all P < .04). Basophil activation best predicted very low threshold level (

Google Trends (GT) searches trends of specific queries in Google and reflects the real-life epidemiology of allergic rhinitis. We compared Google Trends terms related to allergy and rhinitis in all European Union countries, Norway and Switzerland from January 1, 2011 to December 20, 2016. The aim was to assess whether the same terms could be used to report the seasonal variations of allergic diseases. Using the Google Trend 5-year graph, an annual and clear seasonality of queries was found in all countries apart from Cyprus, Estonia, Latvia, Lithuania and Malta. Different terms were found to demonstrate seasonality depending on the country - namely: "hay fever"; "allergy"; and "pollen" - showing cultural differences. A single set of terms cannot be used across all European countries, but allergy seasonality can be compared across Europe providing the above three terms are used. Using longitudinal data in different countries and multiple terms, we identified an awareness-related spike of searches (December 2016). This article is protected by copyright. All rights reserved.

SummaryBackground Sensitization to food allergens and food allergic reactions are mostly caused by ingesting the allergen, but can also occur from exposure via the respiratory tract or the skin. Little is known about exposure to food allergens in the home environment. Objective The objective of this study was firstly to describe the frequency of detection of allergens from fish, egg, milk, and peanut in mattress dust collected from homes of 13-year-old adolescents and secondly to identify home characteristics associated with the presence of food allergen contamination in dust. Methods Food allergens were measured by dot blot analysis in mattress dust from 143 homes in Oslo, Norway. We analysed associations between home characteristics (collected by parental questionnaires and study technicians) and food allergens by multivariate regression models. Results Fish allergen was detected in 46%, peanut in 41%, milk in 39%, and egg allergen in 22% of the mattress dust samples; only three samples contained none of these allergens. All four food allergens were more frequently detected in mattresses in small dwellings (

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

To cite this article: Bousquet J, Heinzerling L, Bachert C, Papadopoulos NG, Bousquet PJ, Burney PG, Canonica GW, Carlsen KH, Cox L, Haahtela T, Lodrup Carlsen KC, Price D, Samolinski B, Simons FER, Wickman M, Annesi-Maesano I, Baena-Cagnani CE, Bergmann KC, Bindslev-Jensen C, Casale TB, Chiriac A, Cruz AA, Dubakiene R, Durham SR, Fokkens WJ, Gerth-van-Wijk R, Kalayci O, Kowalski ML, Mari A, Mullol J, Nazamova-Baranova L, O'Hehir RE, Ohta K, Panzner P, Passalacqua G, Ring J, Rogala B, Romano A, Ryan D, Schmid-Grendelmeier P, Todo-Bom A, Valenta R, Woehrl S, Yusuf OM, Zuberbier T, Demoly P. Practical guide to skin prick tests in allergy to aeroallergens. Allergy 2011; DOI: 10.1111/j.1398-9995.2011.02728.x ABSTRACT: This pocket guide is the result of a consensus reached between members of the Global Allergy and Asthma European Network (GA(2) LEN) and Allergic Rhinitis and its Impact on Asthma (ARIA). The aim of the current pocket guide is to offer a comprehensive set of recommendations on the use of skin prick tests in allergic rhinitis-conjunctivitis and asthma in daily practice. This pocket guide is meant to give simple answers to the most frequent questions raised by practitioners in Europe, including 'practicing allergists', general practitioners and any other physicians with special interest in the management of allergic diseases. It is not a long or detailed scientific review of the topic. However, the recommendations in this pocket guide were compiled following an in-depth review of existing guidelines and publications, including the 1993 European Academy of Allergy and Clinical Immunology position paper, the 2001 ARIA document and the ARIA update 2008 (prepared in collaboration with GA(2) LEN). The recommendations cover skin test methodology and interpretation, allergen extracts to be used, as well as indications in a variety of settings including paediatrics and developing countries.

Educational aims Aid understanding of the complexity of linking clinical disease presentation of asthma with underlying mechanisms Outline possible advantages of improving this understanding Summary The lung is a highly complex organ that can only be understood by integrating the many aspects of its structure. There is increasing interest in defining childhood asthma phenotypes, following decades of research into understanding mechanisms of asthma development and their genetic background without significant breakthroughs. Despite the medical profession’s best efforts to define asthma, identify risk factors and natural development of asthma in birth cohorts, and find characteristics that distinguish one type of asthma from another, we still do not know the relevant characteristics of the various subgroups of childhood asthma. This review will briefly describe the importance of identifying childhood asthma phenotypes, the observable characteristics of the disease, and the previous and current approaches used to find them.

Summary Background Early life appears optimal for prevention of asthma, but interventions require a relevant target population, to date not clearly identified at birth. Objective We therefore aimed to identify the predicting capacity of factors known around birth for asthma and rhinitis at 10 years. Methods The included 614 healthy term babies with lung function measured at birth in the 1992/1993 Environment and Childhood Asthma study in Oslo attended a 10-year follow-up visit including a structured interview and skin prick test (SPT) for allergies. The logistic regression analyses included 37 general variables from an extensive birth questionnaire; lung function; cord blood total immunoglobulin E and soluble CD14. A history of asthma, current asthma, history of rhinitis and ‘healthy’ (no history of asthma, rhinitis and negative SPT) was predicted on a group level and individual predicted probabilities were calculated. Results The predictability of the models [area under the curve (95% confidence intervals)] was 0.74 (0.69, 0.79), 0.72 (0.64, 0.78), 0.69 (0.54, 0.72) and 0.67 (0.62, 0.71) for a history of asthma, current asthma, rhinitis and ‘healthy’, respectively. The best model predicted a history of asthma correctly in 93/124 (75%), and incorrectly in 176/490 (36%) children without asthma. The positive predictive values for all outcomes were low (19–61), the highest predicting healthy. Conclusion Although at best 75% of children with a history of asthma could be predicted at birth, an intervention applied to our predicted high-risk children would be started more often in children without than with future disease. Parental allergic disease alone appears insufficient to identify high-risk populations in future studies of asthma and allergic disease. Cite this as: K. C. Lodrup Carlsen, P. Mowinckel, B. Granum and K.-H. Carlsen, Clinical & Experimental Allergy, 2010 (40) 1767–1775.

Paediatric respiratory disease has changed in the past 20 yrs; we could fill a whole issue of the journal paying tribute to our famous forebears. We are posing new challenges to our colleagues in the field of adult respiratory disease. They have to learn to deal with conditions that 20 yrs ago were rare in the adult chest clinic, such as cystic fibrosis (CF) and the long-term consequences of premature birth and congenital malformations of the respiratory tract. Furthermore, studies in childhood are challenging pathophysiological concepts throughout life. The many great prospective birth cohort studies have shed light on the different patterns of wheezing, their risk factors and their evolution through childhood. Who would have thought it was good to be born in a barn! It is becoming increasingly clear that even for “adult” diseases, such as chronic obstructive pulmonary disease (COPD), antenatal and early life events are at least as important as smoking in adulthood 1. CF has become a disease also of adults 2. Although many factors have contributed, the main reason has been the development of expert special CF centres, a model increasingly adopted by adult teams. This can serve as a model for other diseases; how a well-structured multidisciplinary approach to treatment can translate into benefits for patients. Perhaps numerically the most important achievement is in the field of public health. The benefit of the decrease in invasive bacterial infections, due to vaccination programmes for infants, is among the most important achievements of the past. Other areas of change include the survival of ever smaller preterm neonates. These children are reaching adult life with impaired lung function and abnormal computed tomography scans. What will happen to their ageing lungs? Interstitial lung disease (ILD) is becoming increasingly well understood, with new genetic entities, such as …

Summary Background Differences between boys and girls in allergic manifestations are well known, and this difference is possibly not attributed to physiological differences alone. Objective We, therefore, investigated whether boys and girls could be exposed to different allergen levels at home and whether indoor allergen levels could be differently associated with rhinitis in boys and girls at 10 years of age. Methods Cat, dog and house dust mite (HDM) allergen levels in mattress dust and interview data regarding current allergic disease were available for 797 10-year-old children (360 girls) in The Environment and Childhood Asthma Study in Oslo. Results Girls had higher concentrations of cat and dog allergens in their mattresses compared with boys, also in homes without cats [geometric mean 95% confidence intervals (95% CI): 0.37 (0.31, 0.44) for girls and 0.26 (0.23, 0.30) μg cat allergen/g dust for boys, P=0.002], and without dogs [girls: 0.74 (0.63, 0.86) and boys: 0.55 (0.48, 0.62) μg dog allergen/g dust, P=0.003]. No difference was observed for HDM allergen (Der p 1) levels. Of the 190 (23.8%) children reporting current rhinitis, 144 (75.8%) were sensitized to at least one allergen. The adjusted odds ratio for current rhinitis increased with 1.20 (95% CI: 1.01, 1.42) per 1 μg/g dust increase in Der p 1 for girls (P=0.037), but not for boys (P=0.91). Conclusion Girls had higher levels of cat and dog allergens in mattress dust compared with boys, whereas no difference was observed for Der p 1 allergen. Nevertheless, only increasing levels of Der p 1 and not cat and dog allergens significantly increased the risk of current rhinitis in girls, whereas no significant association was observed for boys. Cite this as: R. J. Bertelsen, C. Instanes, B. Granum, K. C. Lo;drup Carlsen, G. Hetland, K.-H. Carlsen, P. Mowinckel and M. Lovik, Clinical & Experimental Allergy, 2010 (40) 1388–1397.

Allergy affects at least one-quarter of European schoolchildren, it reduces quality of life and may impair school performance; there is a risk of severe reactions and, in rare cases, death. Allergy is a multi-system disorder, and children often have several co-existing diseases, i.e. allergic rhinitis, asthma, eczema and food allergy. Severe food allergy reactions may occur for the first time at school, and overall 20% of food allergy reactions occur in schools. Up to two-thirds of schools have at least one child at risk of anaphylaxis but many are poorly prepared. A cooperative partnership between doctors, community and school nurses, school staff, parents and the child is necessary to ensure allergic children are protected. Schools and doctors should adopt a comprehensive approach to allergy training, ensuring that all staff can prevent, recognize and initiate treatment of allergic reactions.

Aim: Reduced basal cortisol is reported in allergic disease. We investigated if basal salivary cortisol levels were reduced in children with asthma or allergic rhinitis, controlling for inhaled corticosteroids (ICS) use. Methods: Morning and evening saliva of asthmatic children aged 7–12 years (n = 50) and that of controls (n = 52) were sampled. A total of 19 asthmatics and four controls had allergic rhinitis. Healthy children were controls without rhinitis. Of all, 14 asthmatic children used low, and 12 used moderate or high doses of ICS. Cortisol was analysed by radioimmunoassay. Results: Morning salivary cortisol median (95% CI) was lower in asthmatics (8.7 (7.1, 9.7)) compared with that in controls (10.4 (9.6, 11.8); p = 0.006), which was similar for evening cortisol levels. Regression analyses demonstrated that asthmatics using moderate or high doses of ICS had reduced morning salivary cortisol adjusted (for age and gender) odds ratio (aOR) (95% CI) (0.54 (0.37, 0.80); p = 0.002) and reduced evening cortisol aOR (0.09 (0.01, 0.6); p = 0.02) compared with that in healthy children. Asthmatics with rhinitis on no or low doses of ICS had reduced morning cortisol aOR (0.73 (0.56, 0.96); p = 0.02) compared with that in healthy children. Conclusion: Asthmatic children on moderate or high doses of inhaled corticosteroids had reduced salivary cortisol, but co-morbidity of asthma and rhinitis was also associated with reduced cortisol levels.

Background Quality management is increasingly important in clinical practice. The Global Allergy and Asthma European Network (GA(2)LEN) is a network of clinical and scientific excellence with originally 25 allergy centres in 16 European countries, a scientific society (European Academy of Allergology and Clinical Immunology), and a patient organization (European Federation of Allergy and Airways Diseases Patients' Associations). Although some allergy centres adhere to internal quality criteria, the implementation of a standardized quality management system for allergy centres across Europe was lacking. Objectives To implement standardized quality criteria among allergy centres organized within GA(2)LEN and thus ensure equal standards of diagnosis and care as well as to establish a culture of continuous quality improvement. Methods Quality criteria covering, e.g., diagnostic and therapeutic procedures, and emergency preparedness to assure patient safety were developed and agreed upon by all 25 participating centres. To assure implementation of quality criteria, centres were audited to check quality indicators and document deviations. A follow-up survey was used to assess the usefulness of the project. Results Deviations were documented mainly in the areas of emergency care/patient safety (27.3% lacked regular emergency training of doctors and nurses; 22.7% inadequate emergency intervention equipment; 22.7% lacked critical incidence reporting/root cause analyses) and handling of extracts/pharmaceuticals (31.8% lacked temperature logs of fridges; 4.5% inadequate check of expiration dates). Quality improvement was initiated as shown by findings of re-audits. Usefulness of the project was rated high. Conclusion The establishment of a quality management system with joint standards of care and harmonized procedures can be achieved in an international health network and ensures quality of care.

Udgivelsesdato: 2008-Nov BACKGROUND: Studies on pet ownership as a risk or protective factor for asthma and allergy show inconsistent results. This may be on account of insufficient adjustment of confounding factors. AIM: The objective of this study was to describe determinants of cat and dog ownership in European families with and without allergies. METHODS: Within the EU-funded network of excellence GA(2)LEN, we performed meta-analyses with data from 12 ongoing European birth cohort studies on asthma and allergy. Each of the birth cohort studies enrolled between 485 and 4089 children. Pet ownership, allergic status (asthma, allergic rhinitis, eczema) of parents and siblings, parental education, access to ground floor, and number of people living at home were assessed by questionnaires. RESULTS: Among the 25 056 families from seven European countries cats (14.9%) were more common than dogs (12.0%). Allergic family history significantly reduced the odds to own a cat (adjusted combined random-effect OR 0.91; 95% CI 0.85-0.99), or dog (0.90; 0.86-0.94). A higher parental educational level had even more pronounced effects on cat (0.84; 0.71-0.98), and dog ownership (0.61; 0.54-0.70). Elder siblings reduced the odds to own cats, but not dogs. Convenient ground access significantly increased the odds, whereas crowding at home was not associated with cat or dog ownership. CONCLUSIONS: The chances to own a cat or dog were significantly reduced in allergic families, in parents with a higher educational level, and in homes without convenient ground access. In addition to parental allergies, social and housing factors should be considered as potential confounders in studies on pet exposure and allergic diseases.

Serum eosinophil cationic protein (ECP), but not serum myeloperoxidase (MPO), has been found to reflect disease activity of asthma and eczema, but no reference values exist for young children. Thus, we aimed to provide values of serum-ECP and serum-MPO in young children without obstructive airways disease (OAD), and determine possible influencing factors. Parental interview was performed and serum was collected from a total of 245 children (207 children aged 24-41 months and 76 children aged 0-23 months) with no history of lower respiratory disease. Repeated serum samples were obtained in 38 subjects. Ten percent of the children had active eczema at examination. All children were controls in the "Environment and Childhood Asthma" study in Oslo. Geometric means (GM +/- 1.96 SD) for serum ECP were 11.8 microg/l (2.5-56.0) and 7.9 microg/l (2.0-30.4), respectively, in the 0-23 and 24-41-month-old children, with the corresponding values for serum MPO 453 microg/l (153-1349) and 347 microg/l (142-859), respectively. Age was inversely associated with serum-ECP and serum-MPO, most pronounced in the youngest children. Active eczema and maternal daily smoking adversely affected serum-ECP, but not serum-MPO. Gender and parental atopy did not influence the results. We conclude that serum-ECP in very young children is influenced by age and active eczema and is related to maternal smoking in a dose-dependent fashion. These factors should be considered when assessing inflammatory markers in very young children.

Allergic diseases (asthma, rhinitis and atopic dermatitis) are complex. They are associated with allergen-specific IgE and non-allergic mechanisms that may coexist in the same patient. In addition, these diseases tend to cluster and patients present concomitant or consecutive diseases (multimorbidity). IgE sensitization should be considered as a quantitative trait. Important clinical and immunological differences exist between mono or polysensitized subjects. Multimorbidities of allergic diseases share common causal mechanisms that are only partly IgE-mediated. Persistence of allergic diseases over time is associated with multimorbidity and/or IgE polysensitization. The importance of the family history of allergy may decrease with age. This review puts forward the hypothesis that allergic multimorbidities and IgE polysensitization are associated and related to the persistence or re-occurrence of foetal Type 2 signalling. Asthma, rhinitis and atopic dermatitis are manifestations of a common systemic immune imbalance (mesodermal origin) with specific patterns of remodelling (ectodermal or endodermal origin). This paper proposes a new classification of IgE-mediated allergic diseases that allows the definition of novel phenotypes in order to (i) better understand genetic and epigenetic mechanisms, (ii) better stratify allergic preschool children for prognosis, and (iii) propose novel strategies of treatment and prevention.

BACKGROUND: The Global Allergy and Asthma European Network (GA2LEN) is a consortium of 26 leading European research centres committed to establish a European research area of excellence in the field of allergy and asthma. AIM: One of the GA2LEN work packages was designed to identify and compare the existing European birth cohort studies on asthma and atopic diseases. The present review compares their subjective and objective outcomes as well as exposure variables. METHODS: A common database was established to assess study characteristics of observational birth cohort studies designed to examine asthma and atopic diseases. Data were collected by visiting most of the participating research teams and interviewing all relevant study personnel. For each study, the type of objective/subjective outcome parameters and potentially influential factors were recorded precisely for every time point during follow-up. RESULTS: Eighteen birth cohort studies on asthma and atopic diseases were identified in eight European countries. Thirteen studies collected data on specific immunoglobulin E (IgE) to various inhalant and food allergens, whereas 12 performed skin prick tests (many at several time points during follow up). Several studies measured lung function, but across the cohorts no comparable standard procedures were used. For subjective evaluation of asthma and allergic rhinitis most studies applied the ISAAC questionnaire (sometimes modified), whereas the assessment of eczema was rather heterogeneous across the studies. CONCLUSION: This GA2LEN initiative established a unique common database of 18 European birth cohorts on asthma and atopic diseases. For selected cohorts, it seems that pooling data and performing common analyses may be possible to examine associations between certain exposure variables (e.g. pet ownership, tobacco smoke exposure and day-care) and selected outcome measures for atopy, asthma or allergic rhinitis (e.g. sensitization assessed by IgE or skin prick tests, doctor's diagnosis of asthma, parental perception regarding asthma/wheezing or hay fever symptoms).

Background: The reasons for the rise in asthma and allergies remain unclear. To identify risk or protective factors, it is essential to carry out longitudinal epidemiological studies, preferably birth cohort studies. In Europe, several birth cohort studies on asthma and atopic diseases have been initiated over the last two decades. Aim: One of the work packages within the Global Allergy and Asthma European Network (GA 2 LEN) project was designed to identify and compare European birth cohorts on asthma and atopic diseases. The present review (part I) describes their objectives, study settings, recruitment process and follow-up rates. A subsequent review (part II) will compare outcome and exposure parameters. Methods: For each birth cohort, we collected detailed information regarding recruitment process, study setting, baseline data (pregnancy, birth, parents/siblings) as well as follow-up rates, outcome and exposure parameters at each time point. Results: We identified and assessed 18 European birth cohorts on asthma, allergic rhinitis and eczema. Six of these studies also focused on food allergies. The birth cohorts were mostly initiated in the 1990s with predominantly urban/ metropolitan settings. Many studies were able to maintain high follow-up rates, even after five or more years. Conclusions: Due to the unique cooperation within the GA 2 LEN project a common database was established containing study characteristics of European birth cohorts on asthma and atopic diseases. This can be used as a basis for evaluating the possibility to pool data and perform meta-analyses, as well as to recommend criteria for conducting future birth cohorts.

The objectives of the present study were to determine the use of inhaled corticosteroids (ICS) for treating recurrent bronchial obstruction (rBO) in young children up to 2 yrs of age and to assess possible modifying effects of ICS on lung function in young children with rBO. From an observational, noninterventional birth cohort of 3,754 newborn children (3,697 with complete questionnaire data by 2 yrs of age), 306 children with documented rBO by age 2 yrs (cases) were identified along with 306 matched controls. Two tidal flow/volume measurements were taken, one at presentation of disease (children were steroid naive) and one at 2 yrs of age (mean age 11.2 and 25.6 months, respectively), from: 21 cases who subsequently received ICS (ICS+); 33 who did not (ICS−); and in 15 controls. The mean±sd duration of ICS treatment was 10.3±6.5 months. The main outcomes were treatment with ICS and baseline ratio of time to peak expiratory flow/total expiratory time ( t PTEF / t E ). From the entire cohort, 77 children (2.1%) and 21% of children with rBO had received ICS by 2 yrs of age. Baseline t PTEF / t E was significantly lower at the first visit only in ICS+ as compared to ICS− subjects, as well as in ICS+ and ICS- as compared to controls. The mean difference in baseline t PTEF / t E from first to second visit was borderline statistically significant in the ICS+ group only and correlated significantly with duration of ICS treatment. The present observational cohort study demonstrated that one-fifth of young children with recurrent bronchial obstruction had received inhaled corticosteroids. Early inhaled corticosteroid treatment improved lung function by age 2 yrs, mostly in those with the longest duration of treatment.

Background: Little is known about cockroach sensitization in Scandinavia, whereas cockroaches are implicated in allergic diseases throughout large parts of the world. In association with the Genetics of Asthma International Network (GAIN) study, we report sensitization to cockroaches and possible association with IgE-mediated diseases in Norway. Methods: 100 Norwegian families (426 subjects) of 7–35-year-old sibling-pairs with asthma and their parents underwent questionnaire/interview (medical and exposure history), skin prick test (SPT) to common local inhalant allergens and German cockroach, and IgE specific to mites, mosquito, shrimp and cockroach. Cockroach sensitization was defined as positive if there was a positive (≥ 3 mm) skin prick test and/or presence of IgE antibody of class 2 or more. Results: Thirty-one subjects (7.5%) were sensitized (five monosensitized) to cockroach (27 by skin prick test and seven by IgE antibody, all with additional inhalant allergy). Co-sensitization was most common to grass (in 61%), cat (48%), dog (48%) and mites (42%). Reported allergic diseases in cockroach-sensitized subjects were asthma and rhinitis (n = 10), asthma only (n = 9), rhinitis only (n = 2) and neither asthma nor rhinitis (n = 10). Conclusions: Since cockroach sensitization was relatively frequent in Norwegian atopic families, albeit with unclear clinical implications, we suggest that cockroach allergy should be considered in atopic subjects with respiratory disease.

Duchenne's muscular dystrophy (DMD), characterized by gradually developing muscular weakness, leads to respiratory symptoms and reduced lung function. We aimed to assess lung function in 25 patients with DMD in relationship to age and muscular function. The 25 boys, mean age 13 years, comprized patients in southern Norway with DMD, taking part in an epidemiological follow-up study. None had chronic respiratory disease. Lung function was measured by maximum expiratory flow–volume loops and whole body plethysmography, and repeated after 1 year ( n =14). Lung function was reduced compared to predicted values for healthy children. Forced expiratory volume in 1 sec (FEV 1 )% predicted and forced vital capacity (FVC)% predicted correlated (significantly) inversely to age. FEV 1 and FVC decreased annually 5·61 and 4·2% of predicted, respectively. Absolute values of FVC (litres) and FEV 1 (l sec −1 ) increased until mean age 14 years, decreasing thereafter. Values in % predicted decreased steadily throughout the age range (6–19 years). Lung function correlated closely to upper limb muscle function.

A multi-center, double-blind, randomized dose-response study was performed to assess the effect of 3 months of treatment with two different doses of inhaled nebulized budesonide in children with acute recurrent bronchial obstruction (BO) causing hospitalization. Steroid-naive children younger than 18 months were included when admitted to hospital because of BO for at least the second time, and were followed-up monthly for 15 months. Forty-five of 49 subjects (43 boys, 2 girls) (mean age 9.3 months upon inclusion) completed the study. Twenty-four patients (20 boys, 4 girls) received nebulized budesonide 0.5 mg twice daily for 1 month followed by 0.25 mg daily for the next 2 months, whereas 25 children received 0.1 mg twice daily throughout the 3-month treatment period. Outcome (number of BO episodes, time to first BO after start of treatment, and use of rescue medication), as well as height/length and weight, were assessed at the start of treatment and monthly for the following 3 months, as well as for 12 months after cessation of treatment (15 months in total). There was an overall tendency towards better symptom control (fewer episodes of acute BO during treatment and follow-up, fewer hospital visits because of acute BO, lower clinical score during follow-up, and less use of rescue medication during follow-up) in the high-dose treatment group vs. the low-dose treatment group. However, the differences did not reach statistical significance for any of the outcomes. The only significant difference in effect between the groups was fewer children in the high-dose group treated openly with nebulized budesonide during follow-up. Length/height and weight gain did not differ significantly between the two treatment groups throughout the study. There was no significant dose-dependent beneficial effect of 3 months of treatment with nebulized budesonide in infants and toddlers with at least two hospitalizations for acute bronchial obstruction.

β2-agonists have questionable symptomatic effect in infants with acute bronchiolitis, whereas inhaled, nebulized racemic adrenaline, commonly used in Norway, appears (clinically) to be effective. Limited lung function observations during acute bronchiolitis exists, and less for assessing possible effects inhaled adrenaline.In this preliminary study, tidal flow-volume loops were measured in 16 infants with acute bronchiolitis and seven healthy controls (mean age 7·9 and 4·4 months, respectively), with repeated measurements 15 min after inhaled nebulized racemic adrenaline (4 mg diluted in 2 ml saline) in nine bronchiolitis patients.The ratio of time to reach peak tidal expiratory flow to total expiratory time (tPTEF/tE) was significantly reduced in children with acute bronchiolitis (mean, 95% CI) (0·08, 0·05–0·10) compared to controls (0·31, 0·18–0·43), with significant improvement after inhaled racemic adrenaline 0·19 (0·13–0·25), parallel with significant clinical improvement.Lung function (tPTEF/tE) was reduced in infants with acute bronchiolitis and improved significantly after inhaled racemic adrenaline. Inhaled racemic adrenaline is potentially an important alternative for treating infants with acute bronchiolitis.

Background: Prevalence of asthma and quality of asthma care both influence hospital admission rates for childhood asthma. Therefore, we aimed to assess possible changes in hospital admission rate for acute asthma in Oslo, Norway, from 1980 to 1995, as well as evaluate the possible effect of changes in asthma treatment upon hospitalization for acute asthma in this period. Methods: All pediatric patient records from the two municipal hospitals in Oslo from 1980 through 1995 with the discharge diagnosis (ICD-9) acute asthma, acute bronchitis/bronchiolitis, pneumonia, and/or atelectasis were thoroughly reviewed. Results: Of the 3538 children admitted for acute asthma, 66% were boys and 75% were younger than 4 years, and the admittance rate increased significantly among children aged 0–3 years. First admissions increased throughout the study, whereas readmissions, as well as the mean duration of hospital stay, decreased significantly. Prophylactic treatment with inhaled steroids prior to admission increased over 1980–89, but stabilized thereafter. The use of a short course of systemic steroids during admission increased markedly from 1991. Conclusions: The findings of increasing first admission rate as well as overall admission rate for acute asthma in children under 4 years of age, but decreasing readmissions as well as number of treatment days in hospital, probably reflect changes in the management of the disease, as well as an increasing prevalence of childhood asthma.

Triclosan is a synthetic, broad-spectrum antimicrobial agent used extensively for more than 20 years to inhibit bacterial growth on skin and other surfaces. It is used in a variety of consumer products, including toothpaste, mouthwash, deodorants, soap, sportswear, toys, and plastic kitchenware (1, 2). In the European Union, about 85% of the total volume of triclosan is used in personal care products, with the balance going into textiles (5%) and plastic and food contact materials (10%) (3). In Norway, Sweden, and Denmark the main source of exposure is believed to be toothpaste (1, 4, 5). In Norway in 2001, toothpaste, for which the upper limit value of triclosan is 0.5% by weight, accounted for 74% of the total amount of triclosan applied in personal care products (5). Triclosan has been found in human urine, blood, plasma, and milk (1, 8, 9), with median plasma and urinary half-lives of 19 and 11 hours, respectively. Triclosan is completely and rapidly absorbed in the gastrointestinal tract, while a lower rate of absorption occurs dermally (7). It is excreted in urine mostly in its conjugated form (10). Triclosan works by blocking the active site of an enzyme that is essential for fatty acid synthesis in bacteria, enoyl-acyl carrier protein reductase (ENR) (11). Because humans lack this enzyme, triclosan was for many decades considered to be safe for human health. However, this has recently been questioned (12, 13) and human exposure to triclosan has been found to be within the range where significant in vitro bioactivity occurs (13). Concern has also been raised over triclosan's potential for endocrine disruption, as the antimicrobial had been shown to disrupt thyroid hormone homeostasis and possibly reproductive hormones (14). Because triclosan is effective against many, but not all strains of bacteria (3), it may alter the bacterial flora of the skin, the oral mucosa, and the intestines (14, 15). Based on the “hygiene hypothesis” of allergy in childhood, excessive use of triclosan may alter the commensal microbiota flora leading to impairment of normal maturation of the immune system (16–19). Moreover, recently an experimental study found triclosan to enhance allergic responses in a mouse model of asthma (20) and urinary triclosan levels in children and adolescents from the US National Health and Nutrition Examination Surveys (NHANES) 2005–2006 were found to be positively associated with allergic sensitization (21). We aimed to examine urinary concentrations of triclosan in relation to allergic sensitization by skin prick test and serum specific IgE (sIgE), current rhinitis and current asthma in Norwegian children.

p. 92-97 Submitted by Edileide Reis (leyde-landy@hotmail.com) on 2014-09-01T11:50:30Z No. of bitstreams: 1 Y.Z. Chen.pdf: 84566 bytes, checksum: 9259234da033cbecd48651bd191038cf (MD5) Approved for entry into archive by Delba Rosa (delba@ufba.br) on 2014-09-26T13:16:51Z (GMT) No. of bitstreams: 1 Y.Z. Chen.pdf: 84566 bytes, checksum: 9259234da033cbecd48651bd191038cf (MD5) Made available in DSpace on 2014-09-26T13:16:51Z (GMT). No. of bitstreams: 1 Y.Z. Chen.pdf: 84566 bytes, checksum: 9259234da033cbecd48651bd191038cf (MD5) Previous issue date: 2012 Allergic rhinitis and asthma represent global health problems for all age groups. Asthma and rhinitis frequently co-exist in the same subjects. Allergic Rhinitis and its Impact on Asthma (ARIA) was initiated during a World Health Organization (WHO) workshop in 1999 and was published in 2001. ARIA has reclassified allergic rhinitis as mild/moderate-severe and intermittent/persistent. This classification schema closely reflects the impact of allergic rhinitis on patients. In its 2010 Revision, ARIA developed clinical practice guidelines for the management of allergic rhinitis and asthma co-morbidities based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation). ARIA has been disseminated and implemented in over 50 countries of the world. In Turkey, it is important to make a record of ARIA achievements and to identify the still unmet clinical, research and implementation needs in order to strengthen the 2011 EU Priority on allergy and asthma in children.

The aim of this update is to describe the paediatric highlights from the 2010 European Respiratory Society Annual Congress in Barcelona, Spain. Abstracts from the seven groups of the Paediatric Assembly (Respiratory physiology, Asthma and allergy, Cystic fibrosis, Respiratory infection and immunology, Neonatology and paediatric intensive care, Respiratory epidemiology and Bronchology) are presented in the context of the current literature.

The effect of inhaled nebulised racemic adrenaline upon symptoms of acute bronchiolitis was investigated in 29 infants and toddlers aged 2-17.5 months by transcutaneous oxygen tension (TcPO2), oxygen saturation, transcutaneous carbon dioxide tension (TcPCO2), and clinical evaluation in a double blind placebo controlled study. Clinical score and TcPO2 improved significantly at 30, 45, and 60 minutes after inhalation of racemic adrenaline, with an increase in TcPO2 > or = 0.5 kPa in 72% of the children < 1 year of age. No significant improvement was observed after inhalation of placebo. No significant changes in heart rate or TcPCO2 were observed from before to after inhalation, but a small increase in mean systolic blood pressure was observed immediately and 45 minutes after racemic adrenaline inhalation. This study demonstrates that treatment with nebulised racemic adrenaline improved oxygenation and clinical signs in hospitalised children aged less than 18 months with bronchiolitis.

Sachs-Olsen C, Lodrup Carlsen KC, Mowinckel P, Haland G, Devulapalli CS, Munthe-Kaas MC, Carlsen K-H. Diagnostic value of exhaled nitric oxide in childhood asthma and allergy. Pediatr Allergy Immunol 2010: 21: e213–e221. © 2010 John Wiley & Sons A/S Fractional exhaled nitric oxide (FENO) has been proposed as a diagnostic test of asthma. We aimed to investigate in a population based birth cohort of children the usefulness of FENO as a diagnostic tool. The 10-yr follow up of the Environment and Childhood Asthma Study in Oslo included 616 children representative of the prospective birth cohort. Both FENO (single breath technique) and skin prick test (SPT) were measured in 331, limited at the time by equipment availability. Structural parental interview, spirometry, methacholine challenge and exercise test were performed. FENO was significantly elevated in children with current asthma (geometric mean 9.6 (95% confidence interval (CI) (6.9, 13.4) p.p.b.) compared with healthy children (5.8 (5.4, 6.3) p.p.b.; p

Early life appears optimal for prevention of asthma, but interventions require a relevant target population, to date not clearly identified at birth.We therefore aimed to identify the predicting capacity of factors known around birth for asthma and rhinitis at 10 years.The included 614 healthy term babies with lung function measured at birth in the 1992/1993 Environment and Childhood Asthma study in Oslo attended a 10-year follow-up visit including a structured interview and skin prick test (SPT) for allergies. The logistic regression analyses included 37 general variables from an extensive birth questionnaire; lung function; cord blood total immunoglobulin E and soluble CD14. A history of asthma, current asthma, history of rhinitis and 'healthy' (no history of asthma, rhinitis and negative SPT) was predicted on a group level and individual predicted probabilities were calculated.The predictability of the models [area under the curve (95% confidence intervals)] was 0.74 (0.69, 0.79), 0.72 (0.64, 0.78), 0.69 (0.54, 0.72) and 0.67 (0.62, 0.71) for a history of asthma, current asthma, rhinitis and 'healthy', respectively. The best model predicted a history of asthma correctly in 93/124 (75%), and incorrectly in 176/490 (36%) children without asthma. The positive predictive values for all outcomes were low (19-61), the highest predicting healthy.Although at best 75% of children with a history of asthma could be predicted at birth, an intervention applied to our predicted high-risk children would be started more often in children without than with future disease. Parental allergic disease alone appears insufficient to identify high-risk populations in future studies of asthma and allergic disease.

Differences between boys and girls in allergic manifestations are well known, and this difference is possibly not attributed to physiological differences alone.We, therefore, investigated whether boys and girls could be exposed to different allergen levels at home and whether indoor allergen levels could be differently associated with rhinitis in boys and girls at 10 years of age.Cat, dog and house dust mite (HDM) allergen levels in mattress dust and interview data regarding current allergic disease were available for 797 10-year-old children (360 girls) in The Environment and Childhood Asthma Study in Oslo.Girls had higher concentrations of cat and dog allergens in their mattresses compared with boys, also in homes without cats [geometric mean 95% confidence intervals (95% CI): 0.37 (0.31, 0.44) for girls and 0.26 (0.23, 0.30) microg cat allergen/g dust for boys, P=0.002], and without dogs [girls: 0.74 (0.63, 0.86) and boys: 0.55 (0.48, 0.62) microg dog allergen/g dust, P=0.003]. No difference was observed for HDM allergen (Der p 1) levels. Of the 190 (23.8%) children reporting current rhinitis, 144 (75.8%) were sensitized to at least one allergen. The adjusted odds ratio for current rhinitis increased with 1.20 (95% CI: 1.01, 1.42) per 1 microg/g dust increase in Der p 1 for girls (P=0.037), but not for boys (P=0.91).Girls had higher levels of cat and dog allergens in mattress dust compared with boys, whereas no difference was observed for Der p 1 allergen. Nevertheless, only increasing levels of Der p 1 and not cat and dog allergens significantly increased the risk of current rhinitis in girls, whereas no significant association was observed for boys.

Allergy affects at least one-quarter of European schoolchildren, it reduces quality of life and may impair school performance; there is a risk of severe reactions and, in rare cases, death. Allergy is a multi-system disorder, and children often have several co-existing diseases, i.e. allergic rhinitis, asthma, eczema and food allergy. Severe food allergy reactions may occur for the first time at school, and overall 20% of food allergy reactions occur in schools. Up to two-thirds of schools have at least one child at risk of anaphylaxis but many are poorly prepared. A cooperative partnership between doctors, community and school nurses, school staff, parents and the child is necessary to ensure allergic children are protected. Schools and doctors should adopt a comprehensive approach to allergy training, ensuring that all staff can prevent, recognize and initiate treatment of allergic reactions.

To cite this article: Lodrup Carlsen KC, Soderstrom L, Mowinckel P, Haland G, Pettersen M, Munthe Kaas MC, Devulapalli CS, Buchmann M, Ahlstedt S, Carlsen K-H. Asthma prediction in school children; the value of combined IgE-antibodies and obstructive airways disease severity score. Allergy 2010; 65: 1134–1140. Abstract Background: Allergic sensitisation increases the risk for asthma development. In this prospective birth cohort (Environment and Childhood Asthma) study, we hypothesized that combining quantitative measures of IgE antibodies (Σ-IgE) and Severity score of obstructive airways disease (OAD) at 2 years of age (Severity score) is superior to predict current asthma (CA) at 10 years than either measure alone. Secondarily, we assessed if gender modified the prediction of CA. Methods: A follow-up study at 10 years of age was performed in 371 2-year-old children with recurrent (n = 219) or no (n = 152) bronchial obstruction with available serum analysed for Σ-IgE to common food and inhalant allergens through a panel test, Phadiatop Infant® (Phadia, Uppsala, Sweden). Clinical variables included allergic sensitisation and exercise testing to characterise children with CA vs not CA at 10 years and the Severity score (0–12, 0 indicating no OAD) was used to assess risk modification. Results: Severity score alone explained 24% (Nagelkerke R2 = 0.24) of the variation in CA, whereas Σ-IgE explained only 6% (R2 = 0.06). Combining the two increased the explanatory capacity to R2 = 0.30. Gender interacted significantly with Σ-IgE; whereas Severity score predicted CA in both genders, the predictive capacity of Σ-IgE for CA at 10 years was significant in boys only. Conclusion: Combining Σ-IgE to inhalant allergens and Severity score at 2 years was superior to predict asthma at 10 years than either alone. Severity score predicted CA in both genders, whereas Σ-IgE significantly predicted CA in boys only.

Summary Background Divergent results have been reported regarding early life exposure to indoor environmental agents and the risk of asthma and allergic sensitization later in life. Objective To assess whether early exposure to indoor allergens, β(1,3)-glucans and endotoxin modifies the risk of allergic diseases at 10 years of age. Methods The concentrations of mite, cat and dog allergens, endotoxin and β(1,3)-glucans were determined in dust from the homes of 260 two-year-old children with lung function measured at birth (tidal flow volume loops) in the Environment and Childhood Asthma study in Oslo. At 10 years, the health status was assessed in a follow-up study including a structured interview of the parents and an extended clinical examination. Results Cat and dog keeping at 2 years of age was reported in 6.5% and 5.5% of the families, respectively. Mite allergens were detected in only 4/260 dust samples. The adjusted odds ratio for asthma at age 10 was 1.20 (95% confidence interval: 1.01–1.43) and 1.22 (1.02–1.46) for bronchial hyperresponsiveness (BHR) per 10 μg/g dust increase in cat allergen exposure at 2 years of age. No association was seen with allergic sensitization. Moreover, endotoxin and β(1,3)-glucan exposure did not modify the risk of asthma or allergic sensitization. None of the measured environmental factors were associated with lung function at 10 years of age or a relative change in lung function from birth. Conclusion In a community with a low prevalence of pet keeping and low mite allergen levels, exposure to cat allergens early in life increased the risk of late childhood asthma and BHR, but not the risk of allergic sensitization. No risk modification was seen for dog allergens, endotoxin and β(1,3)-glucans. Cite this as: R. J. Bertelsen, K. C. Lodrup CarlsenK.-H. Carlsen, B. Granum, G. Doekes, G. Haland, P. Mowinckel and M. Lovik, Clinical & Experimental Allergy, 2010 (40) 307– 316.

Measures of lung function (usually FEV(1)80% predicted) are used to classify asthma severity in both adults and children, despite evidence that lung function impairment is less pronounced in the paediatric asthma population. The present study assesses the relevance of lung function measurements as discriminators of severe childhood asthma.Fifty-one school-aged children with problematic severe asthma, 37 mild-to-moderate asthmatics and 29 healthy controls underwent a comprehensive clinical work-up. Problematic severe asthma was defined in patients exhibiting poor asthma control despite high-dose inhaled corticosteroid treatment and at least one other asthma controller drug. Mild-to-moderate asthmatic children used low-dose inhaled steroids and reported minimal asthma symptoms.Baseline FEV(1) values were significantly reduced in children with problematic severe asthma, yet FEV(1)80% predicted showed a low sensitivity (41%) for discriminating severe vs. mild-to-moderate asthma. Receiver-operated characteristic analysis estimated the optimal cut-off of FEV(1) to be 90% predicted in this population (sensitivity 61%, specificity 83%). Baseline FEV(1)/FVC and FEF(25-75) values were not superior to FEV(1) in discriminating problematic severe asthma, and neither exhaled nitric oxide levels nor bronchial hyperresponsiveness differentiated between the two asthmatic study populations.Spirometric measurements are insensitive discriminators of problematic severe asthma in childhood.

Reduced basal cortisol is reported in allergic disease. We investigated if basal salivary cortisol levels were reduced in children with asthma or allergic rhinitis, controlling for inhaled corticosteroids (ICS) use.Morning and evening saliva of asthmatic children aged 7-12 years (n = 50) and that of controls (n = 52) were sampled. A total of 19 asthmatics and four controls had allergic rhinitis. Healthy children were controls without rhinitis. Of all, 14 asthmatic children used low, and 12 used moderate or high doses of ICS. Cortisol was analysed by radioimmunoassay.Morning salivary cortisol median (95% CI) was lower in asthmatics (8.7 (7.1, 9.7)) compared with that in controls (10.4 (9.6, 11.8); p = 0.006), which was similar for evening cortisol levels. Regression analyses demonstrated that asthmatics using moderate or high doses of ICS had reduced morning salivary cortisol adjusted (for age and gender) odds ratio (aOR) (95% CI) (0.54 (0.37, 0.80); p = 0.002) and reduced evening cortisol aOR (0.09 (0.01, 0.6); p = 0.02) compared with that in healthy children. Asthmatics with rhinitis on no or low doses of ICS had reduced morning cortisol aOR (0.73 (0.56, 0.96); p = 0.02) compared with that in healthy children.Asthmatic children on moderate or high doses of inhaled corticosteroids had reduced salivary cortisol, but co-morbidity of asthma and rhinitis was also associated with reduced cortisol levels.

Quality management is increasingly important in clinical practice. The Global Allergy and Asthma European Network (GA(2)LEN) is a network of clinical and scientific excellence with originally 25 allergy centres in 16 European countries, a scientific society (European Academy of Allergology and Clinical Immunology), and a patient organization (European Federation of Allergy and Airways Diseases Patients' Associations). Although some allergy centres adhere to internal quality criteria, the implementation of a standardized quality management system for allergy centres across Europe was lacking.To implement standardized quality criteria among allergy centres organized within GA(2)LEN and thus ensure equal standards of diagnosis and care as well as to establish a culture of continuous quality improvement.Quality criteria covering, e.g., diagnostic and therapeutic procedures, and emergency preparedness to assure patient safety were developed and agreed upon by all 25 participating centres. To assure implementation of quality criteria, centres were audited to check quality indicators and document deviations. A follow-up survey was used to assess the usefulness of the project.Deviations were documented mainly in the areas of emergency care/patient safety (27.3% lacked regular emergency training of doctors and nurses; 22.7% inadequate emergency intervention equipment; 22.7% lacked critical incidence reporting/root cause analyses) and handling of extracts/pharmaceuticals (31.8% lacked temperature logs of fridges; 4.5% inadequate check of expiration dates). Quality improvement was initiated as shown by findings of re-audits. Usefulness of the project was rated high.The establishment of a quality management system with joint standards of care and harmonized procedures can be achieved in an international health network and ensures quality of care.

Objective: To determine the prevalence of asthma symptoms in children from a rural district in North-Tanzania, and their relationship to aerobic fitness and body fat. Methods: In Manyara region in Tanzania, children (aged 9–10 years) were randomly selected to participate in the present cross-sectional study. Hundred and seventy two participants completed a video questionnaire showing the symptoms and signs of asthma. Lung function was measured by maximum forced expiratory flow-volume curves. Aerobic fitness was estimated from a standardized indirect maximal cycle ergometer test and sum of three skinfolds reflected body fat. Results: Twenty four per cent reported asthma symptoms last year. Severe wheezing attacks last year were reported in 5% of the participants. Thirty seven per cent of the participants were underweight. Underweight children had significantly lower (P

The endotoxin receptor soluble CD14 (sCD14) has been implicated in the 'hygiene hypothesis' suggesting reduced allergic sensitization with bacterial stimulation. However, the relationship between early life sCD14 and allergic diseases is conflicting. We aimed to investigate whether possible risk factors for allergic diseases were associated with sCD14 levels at 2 yr of age. In the nested case-control study of the birth cohort studies 'Environment and Childhood Asthma study in Oslo' 411 children selected with recurrent bronchial obstruction (rBO) (n=241) and no bronchial obstruction (n=170) by 2 yr were investigated with skin prick test and structured parental interview at age 2 yr. Exposure to tobacco smoke, pets and infections was recorded semi-annually by questionnaires (0-2 yr). The sCD14 was analysed from frozen, stored serum by ELISA technique. Regression analyses were performed in all subjects with complete data (n=406, 180 girls), and in girls and in boys separately. Mean sCD14 (ng/ml) was significantly higher among girls 2035 (1973-2096) vs. 1947 (1890-2004) (boys). The sCD14 was significantly reduced among girls exposed to antenatal maternal smoking and with parental asthma, after adjusting for age, parental rhino-conjunctivitis, pet keeping and childhood infections. Recurrent otitis media (OM) increased and common colds significantly decreased sCD14 levels in girls. Boys with atopic dermatitis and rBO had reduced sCD14. Pet exposure was not significantly associated with sCD14. We report novel gender-related effects of sCD14 in early life and suggest that gender, tobacco smoke exposure, age and middle ear disease in particular should be accounted for when assessing the role of sCD14 in childhood allergic diseases.

Background: The western world's increase in childhood asthma is suggested to level off. We aimed to investigate asthma prevalence in 10-year-old children within the prospective birth cohort Environment and Childhood Asthma (ECA) Study in Oslo established in 1992/1993. Subjects and methods: Six hundred and sixteen (77%) of 803 children (mean age 10.9 ± 0.9 (SD) years) with lung function measurements at birth were reinvestigated at age 10 years. At birth they corresponded to the entire birth cohort (n = 3754) regarding gender, socio-demographic factors, parental allergic diseases, pet keeping and maternal smoking. Results from structured parental interview, spirometry, and skin prick test for inhalant and food allergens are presented. Asthma definition required minimum two positive criteria, (i) doctor's diagnosis of asthma, (ii) wheeze and/or chest tightness, (iii) use of anti-asthmatic treatment. Current asthma required asthma definition plus either (ii) and/or (iii) in the last 12 months, and/or ≥10% fall in forced expired volume in 1 s after treadmill running. Results: Lifetime prevalence of asthma was 20.2%; current asthma 11.1%, doctor diagnosis of asthma 16.1% and wheezes ever 30.3%. Allergic sensitization (29.3% overall) was more common among children with current (56.3%) compared to asymptomatic (last 12 months) (26.0%) or no asthma (27.6%) (P