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Wheeze, Eczema and Rhinitis in 6-7 year old Irish Schoolchildren   Back Bookmark and Share
Nicholson AJ
The aim of this study was to determine the prevalence of wheeze, eczema and rhinitis in 6-7 year old schoolchildren in Louth and Meath and assess their risk factors.

The ISAAC (International Study for Asthma and Allergies in Childhood) questionnaire was used. The response rate was 64.1%(n=1899). The prevalence rates for wheeze, eczema and rhinitis were 17.4%, 11.2% and 20.2% respectively, with 2.4% of children reported to be suffering from all 3 conditions. The main risk factors for wheeze were male sex and smoking in the home. Ninety-five (28.7%) children with wheeze had no diagnosis of asthma. Of these children 36(37.9%) had wheeze with exercise, 55(59.9%) had a dry cough not associated with a cold or flu and 13 (13.7%) reported more than 4 attacks of wheeze in the last year. This study suggests underdiagnosis and undertreatment of atopic illness in this age group. It also suggests decreasing exposure to passive smoking and early recognition and treatment will improve quality of life for many children.

Author : Nicholson AJ, Harty SB, Howell Fenton, Sheridan P

Abstract

The aim of this study was to determine the prevalence of wheeze, eczema and rhinitis in 6-7 year old schoolchildren in Louth and Meath and assess their risk factors.

The ISAAC (International Study for Asthma and Allergies in Childhood) questionnaire was used. The response rate was 64.1%(n=1899). The prevalence rates for wheeze, eczema and rhinitis were 17.4%, 11.2% and 20.2% respectively, with 2.4% of children reported to be suffering from all 3 conditions. The main risk factors for wheeze were male sex and smoking in the home. Ninety-five (28.7%) children with wheeze had no diagnosis of asthma. Of these children 36(37.9%) had wheeze with exercise, 55(59.9%) had a dry cough not associated with a cold or flu and 13 (13.7%) reported more than 4 attacks of wheeze in the last year. This study suggests underdiagnosis and undertreatment of atopic illness in this age group. It also suggests decreasing exposure to passive smoking and early recognition and treatment will improve quality of life for many children.

Introduction

In western society asthma is the most common chronic illness in childhood. Worldwide the prevalence has increased dramatically over the last three decades1-4. In 1996 a threefold increase in prevalence over a decade was demonstrated in Irish schoolchildren aged 4 to 19 years of age5. Children aged 6 to 7 years are a subgroup, which reflect the early childhood years when asthma tends to be more prevalent and hospital admission rates tend to be higher6. Little data are available regarding the prevalence of atopic disease in 6 to 7 year Old Irish schoolchildren. Figures published in 1998 on behalf of the ISAAC steering committee showed a five-fold difference in prevalence between countries worldwide from 4.1-32.1% for 6-7 year old schoolchildren7. In 1999 6-7 year olds in the north east of England were found to have prevalence rates of 29.6% for wheeze, 27.8% for atopic eczema and 23.1% for rhinitis8.

The aim of this study was to document the prevalence of wheeze, eczema and rhinitis in 6-7 year old schoolchildren in Counties Louth and Meath and to assess the risk factors. In addition the study investigated whether atopic illness is underdiagnosed or undertreated in this age group.

Methods

The population studied consisted of schoolchildren aged 6-7 years residing in a geographically defined area. The basic sampling frame included all first class pupils in 158 primary schools (n=3176) in Louth and Meath. We obtained school lists for counties Louth and Meath from the department of Education and Sciences. A letter to the principal followed by a telephone call recruited the schools. The first class teacher distributed a written questionnaire with a covering letter explaining the study to the childrens parents who were asked to complete the questionnaire and return it to the teacher.

The questionnaire consisted of the core questions regarding wheeze, eczema and rhinitis from the international study of asthma and allergies in childhood (ISAAC) questionnaire. This questionnaire has been internationally validated for estimating the prevalence of wheezing, eczema and rhinitis in children6.

Additional questions regarding demographics and home environment were also added. We inquired about methods of home heating, whether there was a pet at home and if so what kind. We also asked if anybody smoked at home and if Mum had smoked during pregnancy. Data was analyzed using the JMP9 statistical package, version 3 and logistic regression was carried out.

Results

The data were collected between September and December 2000. Of the 158 schools (3176 schoolchildren) in this area, 112 schools participated in the study from which 2111 questionnaires were completed and returned giving an initial response rate of 66.5%. One hundred and twenty schoolchildren were outside the 6-7 year age range and were excluded, as were a further 90 who lived outside the area. This left 1899 children remaining in the study (response rate 64.1%), of whom 985 (51.9%) children were male and 914 (48.1%) were female.

The number and percentage of children reporting wheeze, eczema and rhinitis in the last year are given in Table 1. Many children had combinations of two or three of these conditions. One hundred and sixteen children with wheeze also had rhinitis alone (prevalence-6.1%) and 29 children with wheeze also had eczema alone (prevalence -1.5%). In addition a further 45 children reported to be suffering from all 3 conditions (prevalence - 2.4%).

Males had a significantly higher prevalence of wheeze (odds ratio = 1.3, 95% CI 1.0-1.7 p< 0.05) and rhinitis (odds ratio = 1.7, 95% CI 1.3-2.1, p<0.01) but not eczema.

782 (41.2%) of children lived in a house where at least one parent smoked. These children had a significantly higher prevalence of wheeze (Odds ratio = 1.3, 95% CI 1.0 - 1.7, p< 0.05) but not eczema or rhinitis. 373 (19.6%) of mothers had smoked during their pregnancies. This risk factor was not statistically significant.
 

Table 1 Prevalence of wheeze, eczema and rhinitis in 6-7 year olds in the Louth/Meath area in the year 2000 (n=1899)
SymptomsNumber Prevalence %
Wheeze33117.4%
Eczema21211.2%
Rhinitis38320.2%

942(49.6%) of children had pets at home which included dogs (n=630), cats (n=353), rabbits (n=51), birds (n=52) and others (n=126). Children who had pets at home were less likely to have wheeze (Odds ratio = 0.79, 95% CI.062-1.01, p<0.1) or rhinitis (Odds ratio = 0.82, 95% CI 0.65 - 0.1.04, p<0.1) but this was not statistically significant. However children who reported having cats at home were significantly less likely to have wheeze (Odds ratio = 0.55, 95% CI 0.38 - 0.79, p<0.001).

Of the 331 children reporting wheeze in the last year 88 (26.6%) had between 4 and 12 attacks of wheezing while 18 (5.4%) children had more than 12 attacks of wheezing in the last 12 months. Sixty (18.1%) of these children were reported to have sleep disturbance of 1 or more nights per week and in 60 cases (18.1%) wheezing had been severe enough to limit the childs speech.

Of the 331 children with wheeze, only 232 (70.1%) report a diagnosis of asthma. Of the 95 children with wheeze, and no diagnosis of asthma, 36 (37.9%) reported wheeze during or after exercise, 55 (57.9%) reported a dry cough at night not associated with a cold or a flu and 13 (13.7%) reported more than 4 attacks of wheeze in the last year as outlined in Table 2.

Only 201 (10.6%) of children ever had a diagnosis of hayfever yet 433 (22.8%) of the children in this study had a problem with sneezing, or a runny, or a blocked nose when they did not have a cold or a flu.

Discussion

This study shows a small but sustained increase in prevalence of wheeze in Irish schoolchildren when compared to previous Irish studies carried out by Loftus10 in 1993 and Taylor in 19965. This may reflect a true increase in prevalence or that the studies were carried out in a different manner. When compared to a more recent Irish study by Manning et al11, who also used the ISAAC questionnaire, our prevalence is still higher although in his study a different age group of 13-14 year olds was assessed. Our prevalence compares favorably when compared to worldwide figures and the prevalence rates found in the North East of England in 19997,8.

However our figures have to be interpreted in light of our response rate which is due to the fact that it was a postal survey and a number of schools did not take part in the study. We also may have missed some 6-year-old children in senior infants by targeting first class pupils alone and not sending questionnaires outside the study area that might have had children from Louth and Meath therein.
 

Table 2 Prevalence of symptoms in the previous year within the population of children who wheeze with no diagnosis of asthma (n=95)
SymptomsNumber%
Attacks of wheezing
None0(0.0%)
1 to 381(85.3%)
4 to 1211(11.6%)
More than 122( 2.1%)
Unanswered1(1.1%)
Sleep disturbance
Never40(40.2%)
< 1 night per week37(38.9%)
>= 1 night per week12(12.6%)
Unanswered6(6.3%)
Wheezy after exercise
Yes36(37.9%)
No53(55.8%)
Unanswered6(6.3%)
Dry cough at night
Yes55(57.9%)
No(40.2%)

In this study male sex is a significant risk factor for the development of both wheezing and rhinitis but not eczema. Many previous studies have demonstrated the substantial contribution of environmental tobacco smoke on childhood asthma and wheezing12,13. In this study 782 (41%) of children were exposed to passive smoking at home and we to found that passive smoking at home is a risk factor for the development of wheeze, but not eczema or rhinitis. We did not however inquire how many cigarettes were smoked each day or whether the smoking took place inside or outside the home.

Maternal smoking during pregnancy was not found to be significantly associated with wheeze, contrary to a large U.K study which found that maternal smoking during pregnancy was a more significant factor for the development of wheeze than having a mother who smoked when you are 5 years old14.

We found a negative association between having a pet at home and wheeze and rhinitis. This negative association was significant for children who reported having a cat at home. This may reflect that parents of children with atopic illness will either not acquire or remove a pet from the home. Recent literature suggests that exposure to pets in the first 2 years of life has an inverse relationship with pollen sensitization but this is partly due to removal of the pets from homes with sensitized children15. Unfortunately we did not inquire whether the pet was indoors or outdoors or whether the pet went to the childs bedroom.

Despite earlier warnings of underdiagnosis and undertreatment of asthma in schoolchildren, it is worrying that our study also shows that many cases of asthma may go undiagnosed and thus untreated16. Up to 30% of children who had wheeze in the last year had no diagnosis of asthma. Of these children nearly 60% of them reported a dry cough at night not associated with a cold or flu and 13.7% had suffered more than 4 attacks of wheeze in the last 12 months.

Although no question in this study inquired about the use of medication, our results reveal that of the children who had wheeze in the last year, over 30% had more than 4 attacks in the last 12 months and almost one fifth had one or more nights of sleep disturbance per week. This figures indicate that these children are either undiagnosed, not on adequate treatment or not taking their treatment properly representing an ongoing public health problem.

In conclusion this study provides valuable information regarding the prevalence of atopic illness in 6-7 year old schoolchildren. It provides a baseline measurement for assessing future trends in prevalence in this and other populations of children. It also suggests decreasing exposure to passive smoking and early recognition and treatment will improve quality of life for many children.

Acknowledgements

We wish to acknowledge the assistance from the schools and teachers who helped to carry out this study.

Correspondence:
A Nicholson,
Our Lady of Lourdes Hospital,
Drogheda, Co. Louth.
Telephone: 041- 9837601
Fax: 041 - 9833868.
Email: [email protected]

References

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  2. Omran M, Russell G. Continuing increase in respiratory symptoms and atopy in Aberdeen schoolchildren. BMJ. 1996;312:34
  3. Venn A, Lewis S, Cooper M, Hill J, Britton J. Increasing prevalence of wheeze and asthma in Nottingham primary schoolchildren 1988-1995. Eur.Respir.J 1998;11:1324-1328.
  4. Downs SH, Marks GB, Sporik R, Belosouva EG, Car NG, Peat JK. Continued increase in the prevalence of asthma and atopy. Arch.Dis Child 2001.Jan.;84.(1.):20.-23. 84:20-23.
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  12. Martinez FD, Cline M, Burrows B. Increased incidence of asthma in children of smoking mothers. Pediatrics 1992;89:21-26.
  13. Gilliland FD, Li YF, Peters JM. Effects of maternal smoking during pregnancy and environmental tobacco smoke on asthma and wheezing in children. Am J Respir. Crit.Care Med 2001.Feb.;163.(2.):429.-36. 163:429-436.
  14. Lewis S, Richards D, Bynner J, Butler N, Britton J. Prospective study of risk factors for early and persistent wheezing in childhood. Eur.Respir.J 1995;8:349-356.
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  16. Speight AN, Lee DA, Hey EN. Underdiagnosis and undertreatment of asthma in childhood. Br.Med J (Clin.Res.Ed.) 1983;286:1253-1256.
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