The Journal of Asthma Research.
Vol. 12, No. 3, March, 1975
Asthma Predictors in Infantile Atopic Dermatitis*
J Asthma Downloaded from informahealthcare.com by University of Newcastle on 12/31/14 For personal use only.
ALEXANDER MEIJER,M.D.? Children who suffered or suffer in infancy from infantile eczema or atopic dermatitis run a considerable risk that they will contract asthma in early childhood (Hilman) . The prevalence reports of post-eczematous asthmatic conditions in children vary widely among the different authors. The main reason for these differences seems to lie in the time interval they chose between the onset of the infantile eczema and the follow-up examinations. The results of several studies show that for follow-up till age six the prevalence figures of posteczematous asthma in children are consistently between 5040% (Norins, Buffum, Glaser, Sedlis, Pasternack, Osborne, Ratner) , whereas in follow-up studies after a much longer time interval the figures taper off till about 20% for twenty years follow-up or more (Stifler, Vowles, Burrows). The follow-up studies of children up to age six include the peak of asthma incidence, which occurs in about 80% of all asthma cases in the age group 2-5 years. Recovery from asthma often takes place during the second decade of life (Buffum, Pinkerton) . I n the literature two main factors have repeatedly been mentioned as important eczematous antecedents for later developing asthma, and they are early onset and severity of the infantile eczema (Pasternack) . The object of this paper is to add evidence which may bring us nearer the prediction of asthma in children who suffered from atopic dermatitis in infancy. This prediction is particularly important since childhood asthma does develop in half of the children who suffered in infancy from atopic dermatitis (Norins). I n a United States National Health Survey for 1959 to 1961, it was found that one-third of all chronic illnesses in children and young people under seventeen were due to eczema, asthma, hayfever and other allergies. More than 4.5 million children and young people had lasting allergy ailments, and of these, 1.5 million suffered from asthma (Aas). It can be estimated th a t about threequarters of a million children and young people in the survey had infantile eczema. One can regard atopic dermatitis, asthma and hayfever as manifestations of a n allergic hereditary-constitutional diathesis, each of them a t its peak at a particular developmental stage. For infantile eczema this peak is in the first year of life, in which 80% of the cases occur (Norins) ; for asthma the peak is between 2-5 years and for hayfever between 5-9 years (Dees, Dawson, Williams). This seems to indicate that innate factors play a distinct role. I n addition, it is well known that external pathogenic factors often have a decisive influence in the clinical manifestations of these allergic conditions, in accordance *This study was supported by a Research Training Grant in Psychiatry from Boston University Medical School. t Hebrew University, Hadassah Medical School, Jerusalem.
181
IS2
ALEXANDER MEIJER
with the nature-nurture principle (Rogerson, Jacobs). It seems of great importance to detect external pathogenic factors a t a n early age and possibly prevent their influence. These factors would be nutritional, physical, chemical and psycho-social. Because of the complexity of the interacting determinants, it has generally been difficult to isolate them and to be confident about their exact role. Moreover, the various investigators often represent a different theory and approach, which influences their interpretation of their findings. J Asthma Downloaded from informahealthcare.com by University of Newcastle on 12/31/14 For personal use only.
Methodology The following material was gathered in the framework of a psychosomatic study. Searching for psycho-social pathogenic factors in childhood asthma, the problem arose concerning which control group to use and what to control for. It was considered important to control for the familial-constitutional aspect (Knapp) as well as for age and sex. Therefore, an asthma group and a nonasthma group were chosen. They both consisted of children who had all suffered from well-established infantile eczema in the first year of life, according to generally accepted criteria (Tuft). The occurrence of infantile eczema in both groups was considered proof of an individual allergic constitutional predisposition. Also, in all the families of both asthmatic and non-asthmatic children, some of the members of the nuclear family suffered from asthma, hayfever or eczema. Subjects
The age group of 6-11 years was chosen because it could reasonably be expected that the vast majority of the children who would contract asthma would have done so already, considering the above-mentioned peak at ages 2-5. The case-finding method from hospital and clinic files proved to be bothersome and unproductive. Another method which was used consisted of sending a letter to parents through the health department of a public school system. However, with this method, the number of cases was too limited to allow for adequate criterionbased selection and matching of cases. Therefore another method was introduced for case-finding. With the cooperation of the three big newspapers in the Boston area, a letter to the editor was published in which the purpose of the study was explained to the readers. I n this way more than two hundred volunteers called. After an initial telephone conversation they were sent a screening questionnaire. About two hundred of these screening questionnaires constituted the basis for selection and matching of cases. Missing details were checked by telephone, as were the invitations for the personal interview of mother and child. This method proved to be very effective. Before the personal interview we had the following data: name, birthdate, period of suffering from eczema and estimated severity, name and address of child's physician, present and past suffering from asthma, hayfever and other physical or mental handicaps, data on siblings, and data on'allergies in the families of both parents.
183
J Asthma Downloaded from informahealthcare.com by University of Newcastle on 12/31/14 For personal use only.
ASTHMA PREDICTORS IN INFANTILE ATOPIC DERMATITIS
These data were checked again at the personal interview, for which a total of sixty subjects were seen (see Table I ) . The ages of the children were as shown in Table 11. In the personal interview with the investigator, a standard procedure was followed which lasted two hours. A general questionnaire contained detailed questions on social, family and medical status, and coded answers which could easily be transferred to I.B.M. cards. Furthermore various tests were given to the mother and the child in the framework of this personal contact. The scoring data of these tests were also entered on the I.B.M. cards. The statistical work was performed in cooperation with the biometrics unit of the psychiatric departTABLE I
I Ast,hma Non-Asthma
N
=
I
Boys
21 19
10 10
60.
TABLE I1 A BOYS AGES Mean Age Asthmo /n:Z/)
8.5 Yrs
[7 Control / n = / 9 ) 8.5
0
5 s 4 $ 3
Vol. 12, No. 3, March, 1975
Asthma Predictors in Infantile Atopic Dermatitis*
J Asthma Downloaded from informahealthcare.com by University of Newcastle on 12/31/14 For personal use only.
ALEXANDER MEIJER,M.D.? Children who suffered or suffer in infancy from infantile eczema or atopic dermatitis run a considerable risk that they will contract asthma in early childhood (Hilman) . The prevalence reports of post-eczematous asthmatic conditions in children vary widely among the different authors. The main reason for these differences seems to lie in the time interval they chose between the onset of the infantile eczema and the follow-up examinations. The results of several studies show that for follow-up till age six the prevalence figures of posteczematous asthma in children are consistently between 5040% (Norins, Buffum, Glaser, Sedlis, Pasternack, Osborne, Ratner) , whereas in follow-up studies after a much longer time interval the figures taper off till about 20% for twenty years follow-up or more (Stifler, Vowles, Burrows). The follow-up studies of children up to age six include the peak of asthma incidence, which occurs in about 80% of all asthma cases in the age group 2-5 years. Recovery from asthma often takes place during the second decade of life (Buffum, Pinkerton) . I n the literature two main factors have repeatedly been mentioned as important eczematous antecedents for later developing asthma, and they are early onset and severity of the infantile eczema (Pasternack) . The object of this paper is to add evidence which may bring us nearer the prediction of asthma in children who suffered from atopic dermatitis in infancy. This prediction is particularly important since childhood asthma does develop in half of the children who suffered in infancy from atopic dermatitis (Norins). I n a United States National Health Survey for 1959 to 1961, it was found that one-third of all chronic illnesses in children and young people under seventeen were due to eczema, asthma, hayfever and other allergies. More than 4.5 million children and young people had lasting allergy ailments, and of these, 1.5 million suffered from asthma (Aas). It can be estimated th a t about threequarters of a million children and young people in the survey had infantile eczema. One can regard atopic dermatitis, asthma and hayfever as manifestations of a n allergic hereditary-constitutional diathesis, each of them a t its peak at a particular developmental stage. For infantile eczema this peak is in the first year of life, in which 80% of the cases occur (Norins) ; for asthma the peak is between 2-5 years and for hayfever between 5-9 years (Dees, Dawson, Williams). This seems to indicate that innate factors play a distinct role. I n addition, it is well known that external pathogenic factors often have a decisive influence in the clinical manifestations of these allergic conditions, in accordance *This study was supported by a Research Training Grant in Psychiatry from Boston University Medical School. t Hebrew University, Hadassah Medical School, Jerusalem.
181
IS2
ALEXANDER MEIJER
with the nature-nurture principle (Rogerson, Jacobs). It seems of great importance to detect external pathogenic factors a t a n early age and possibly prevent their influence. These factors would be nutritional, physical, chemical and psycho-social. Because of the complexity of the interacting determinants, it has generally been difficult to isolate them and to be confident about their exact role. Moreover, the various investigators often represent a different theory and approach, which influences their interpretation of their findings. J Asthma Downloaded from informahealthcare.com by University of Newcastle on 12/31/14 For personal use only.
Methodology The following material was gathered in the framework of a psychosomatic study. Searching for psycho-social pathogenic factors in childhood asthma, the problem arose concerning which control group to use and what to control for. It was considered important to control for the familial-constitutional aspect (Knapp) as well as for age and sex. Therefore, an asthma group and a nonasthma group were chosen. They both consisted of children who had all suffered from well-established infantile eczema in the first year of life, according to generally accepted criteria (Tuft). The occurrence of infantile eczema in both groups was considered proof of an individual allergic constitutional predisposition. Also, in all the families of both asthmatic and non-asthmatic children, some of the members of the nuclear family suffered from asthma, hayfever or eczema. Subjects
The age group of 6-11 years was chosen because it could reasonably be expected that the vast majority of the children who would contract asthma would have done so already, considering the above-mentioned peak at ages 2-5. The case-finding method from hospital and clinic files proved to be bothersome and unproductive. Another method which was used consisted of sending a letter to parents through the health department of a public school system. However, with this method, the number of cases was too limited to allow for adequate criterionbased selection and matching of cases. Therefore another method was introduced for case-finding. With the cooperation of the three big newspapers in the Boston area, a letter to the editor was published in which the purpose of the study was explained to the readers. I n this way more than two hundred volunteers called. After an initial telephone conversation they were sent a screening questionnaire. About two hundred of these screening questionnaires constituted the basis for selection and matching of cases. Missing details were checked by telephone, as were the invitations for the personal interview of mother and child. This method proved to be very effective. Before the personal interview we had the following data: name, birthdate, period of suffering from eczema and estimated severity, name and address of child's physician, present and past suffering from asthma, hayfever and other physical or mental handicaps, data on siblings, and data on'allergies in the families of both parents.
183
J Asthma Downloaded from informahealthcare.com by University of Newcastle on 12/31/14 For personal use only.
ASTHMA PREDICTORS IN INFANTILE ATOPIC DERMATITIS
These data were checked again at the personal interview, for which a total of sixty subjects were seen (see Table I ) . The ages of the children were as shown in Table 11. In the personal interview with the investigator, a standard procedure was followed which lasted two hours. A general questionnaire contained detailed questions on social, family and medical status, and coded answers which could easily be transferred to I.B.M. cards. Furthermore various tests were given to the mother and the child in the framework of this personal contact. The scoring data of these tests were also entered on the I.B.M. cards. The statistical work was performed in cooperation with the biometrics unit of the psychiatric departTABLE I
I Ast,hma Non-Asthma
N
=
I
Boys
21 19
10 10
60.
TABLE I1 A BOYS AGES Mean Age Asthmo /n:Z/)
8.5 Yrs
[7 Control / n = / 9 ) 8.5
0
5 s 4 $ 3
