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In this months Clinical Microbiology Reviews 2012, 25;(1):164-92, Dogget and co-workers review the unexplained worldwide resurgence in Cimex lecticularis (Bed bugs) blood sucking insects. Unless the bug burden is very high they may not always be visible. They can cause skin lesions which may mimic urticaria and other forms of dermatitis. Proteins from their gut wall are allergenic in humans and may cause asthma symptoms akin to more common dust mite. Skin test reactivity to their allergens has been described. Sounds disgusting ! but  the author has seen at least one case last year where asthma was triggered by these insects.

These new guidelines were released this month  (Dec 2011) by the UK’s National Institute for Clinical Excellence. Their expert panel reviewed all the available evidence on anaphylaxis for adults and children. The main recommendations regarding children are summarised as follows :

1) Children younger than 16 years who have had emergency treatment for suspected anaphylaxis should be admitted to hospital under the care of a paediatric medical team.

 2) After emergency treatment for suspected anaphylaxis, parents of children should be offered a referral to a specialist allergy service consisting of healthcare professionals with the skills and competencies necessary to accurately investigate, diagnose, monitor and provide ongoing management of, and patient education about, suspected anaphylaxis.

3) After emergency treatment for suspected anaphylaxis, individuals should be offered (or, as appropriate, their parent and/or carer) an appropriate adrenaline injector as an interim measure before the specialist allergy service appointment. Guidelines are available at http://guidance.nice.org.uk/CG134/Guidance/pdf/English

This book covers all aspects of asthma in an accesible Q&A style. Do you know someone who has a child with asthma ? or does your child have asthma. ? Consider buying this book. Published by Liberties Press, it is available in all good bookstores now and on-line RRP Euro 12.99. All royalties will go to the Asthma Society of Ireland.

Obese Children Have More Asthma Attacks !
Reuters recently reported a study published online in the Journal of Allergy and Clinical Immunology showing that heavier children with asthma tended to need more prescriptions for rescue inhalers as well as daily inhalers compared to non-obese children. The researchers speculated that obese children may feel more heaviness in their lungs, leading to the need for more reliever medication. or perhaps they do not respond as well to inhaled steroids as wells as others. It can be embarassing for a parent to be told that their child is overweight/obese. However, weight management must be a key component of a holistic asthma management plan in this situation.

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An interesting study published recently in the American Journal of Respiratory & Critical Care Medicine evaluated vitamin D status and its effect on asthma in children with severe treatment-resistant asthma.  Relationships between serum vitamin D, lung function,and pathology were investigated. Vitamin D levels were significantly lower in the treatment-resistant group compared to controls. There was a positive correlation between Vitamin D levels and  lung function and the asthma control test in all subjects. Vitamin D levels were inversely associated with asthma attacks and  dose of inhaled steroid . The link between Vitamin D and airway function suggests that Vitamin D supplementation may be useful in paediatric asthma where levels are deficient or insufficient.  Another study published earlier this year on asthmatic children from Poland demonstrated some interesting trends. Those children who received Vitamin D supplement at a dose 500iu daily as well an inhaled steroid appeared to have better outcomes in terms of asthma control compared to children who received the inhaled steroid alone. However this study size was small and the dose of Vitamin D quite low. Further large scale studies are underway and at the time of writing, routine supplementation with Vitamin D cannot be routinely recommended for improving asthma control

There are no signs that the asthma epidemic in children is abating in this country. It has been established in four successive phases of the questionnaire-based International Study of Asthma and Associated Allergic Conditions (ISAAC) study in Ireland (from 1995-2007) that the prevalence of asthma, those who responded yes to the question ‘ have you had asthma ever? ‘ has increased from 16.3% to 21.6% , an interval increase of 33%. If one examines those responded yes to ‘having wheezed in the past 12 months ‘ the prevalence rose over the same period from 29.5% to 38.9%, an interval increase of 32% (1,2).

This is in contrast to many high prevalence developed countries where rates of asthma are stabilizing or even falling. With increased awareness of the condition among the general public and clinicians and the availability evidence based treatment guidelines like GINA, SiGN/ BTS or PractALL it is easy for us to get complacent and one would anticipate improved outcomes for children with asthma. Death from childhood asthma remains a n uncommon event and undoubtedly there has been a significant fall in the rates of hospitalization for asthma particularly in pre-school children ( ). However these are crude outcome measures.

In 2005 we published results from the Asthma Insights and Reality in Ireland (AIRI study) which randomly ascertained a population of 400 individuals with current asthma (150 were children) to survey to determine their healthcare utilisation, symptom severity, activity limitations and level of asthma control. Over the previous year, 27% had either an emergency visit to the hospital or their general practitioner (GP) and 7% were hospitalised for asthma. In terms of asthma control, 19% experienced sleep disturbance at least once a week, 29% missed work or school and 37% of respondents experienced symptoms during physical activity over the previous 4-week period. Based on these findings, it was concluded that the level of asthma control and asthma management in Ireland falls well below of recommended national and international asthma guidelines.

Six years later there appears to be no significant improvement. In a survey of 271 randomly ascertained children with asthma, it was found that although 92% of parents were satisfied or very satisfied with their child’s asthma control, 35% used their rescue inhaler either daily or weekly. Furthermore, 59% experienced night-time awakenings, 25% had exercise limited days and 26% missed school on either daily or weekly basis. Poor asthma control affects sleep, school performance, sporting activity and self esteem. The apparent contradiction between parental perception of asthma symptoms and actual control using conventional criteria. Parents appear to have a tolerance for symptoms in their offspring and seem unaware of the criteria for good control. Further awareness raising measures directed at the general public , children themselves and schools about asthma and prospects for complete symptom control seem more than justified.

1) Manning PJ, Goodman P, O’Sullivan A et al. Rising prevalence of asthma but declining wheeze in teenagers (1995-2003): ISAAC protocol.

Ir Med J. 2007 Nov-Dec;100(10):614-5.

2) Lai CK, Beasley R, Crane J et al.

Global variation in the prevalence and severity of asthma symptoms: phase three of the International Study of Asthma and Allergies in Childhood.

Thorax. 2009 Jun;64(6):476-83.

3) Manning PJ, Greally P, Shanahan E.

Asthma Insights and Reality in Ireland.

Ir Med J 2005; 98(10):231-4.

4) Rollercoaster.ie Survey on Children’s Asthma

2010, Data on file MSD , Ireland.