Specific Social, Environmental Factors May Influence Incidence Rates of Childhood Asthma with Recurrent Exacerbations

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Specific Social, Environmental Factors May Influence Incidence Rates of Childhood Asthma with Recurrent Exacerbations

Authors: Rachel L. Miller; Christine C. Johnson, et al.

 

Who sponsored this study?

This research was supported by the Environmental influences on Child Health Outcomes (ECHO) Program, Office of The Director, National Institutes of Health.

 

Why was this study needed?

While the prevalence of asthma has been reported widely in the United States and elsewhere, studies on childhood asthma incidence rates within specific populations and across various types of asthma and age ranges have been relatively sparse. Describing the incidence rates of ARE across various pediatric populations is a critical first step for identifying potential risk factors and causes.

 

What were the study results?

In this study, investigators wanted to gather more information about factors that influence the rates of childhood asthma with recurrent exacerbations (ARE)—a subtype of asthma where children experience frequent, severe episodes of asthma.

ARE incidence rates were highest among children ages 2-4 years old, and among non-Hispanic Black and Hispanic Black children. ARE rates were also higher among children living in the Northeast and Midwest compared to those living in the West. Children with a parental history of asthma had ARE rates 2.9 times greater compared to those with no parental history.

Footnote: Results reported here are for a single study. Other or future studies may provide new information or different results. You should not make changes to your health without first consulting your healthcare professional.

 

What was the impact?

Higher incidence rates of ARE among young children, non-Hispanic Black and Hispanic Black children, and children living in the Northeast and Midwest suggest that differential environmental exposures may play a significant role in the onset of recurring asthma issues in children. ARE rates are consistently higher among children with a parental history of asthma, especially for young children, which may be due to a combination of genetic, environmental, and family lifestyle factors.

 

Who was involved?

The research team leveraged data from 17,246 children born between 1990 and 2017 who were enrolled in 60 ECHO research sites in the U.S. and Puerto Rico. Child participants or their caregivers reported whether and when the child had an asthma diagnosis and any oral corticosteroids prescribed from a health care provider.  Incidence rates of ARE were based on reports of systemic (not inhaled) corticosteroid use.

Of the 4,114 children diagnosed with asthma during this study, there were 2,061 children with at least one asthma episode when they used oral steroid medication; 734 of these children had 2 or more asthma episodes with steroid medication use and met the conditions for ARE.

 

What happened during the study?

The researchers calculated the incidence rates of ARE for the study population as a whole, along with the rates for subsets of the population defined by the year of ARE diagnosis, the decade they were born, their age and sex, their race and ethnicity, their residence at birth, and their parents’ history of asthma. The researchers followed the children from birth until they developed ARE, reached the age of 20 years or the study period ended. The study identified children who developed ARE based on at least two reports of systemic steroid medication use at any time during the entire follow-up period. Children who received asthma diagnoses before age 5 years were required to have confirmation after 5 years, either by a parent or caregiver, adolescent self-report of asthma symptoms, hospitalization, emergency department or urgent care visit for asthma, provider visits due to asthma, or asthma medication use.

 

What happens next?

ECHO researchers are planning new studies that examine key early environmental exposures that could contribute to ARE, including viral respiratory tract infections, indoor allergens, environmental tobacco smoke, air pollution, stress, socioeconomic status, and where children live.

 

Where can I learn more?

Access the full journal article, titled “Incidence Rates of Childhood Asthma with Recurrent Exacerbations in the U.S. Environmental influences on Child Health Outcomes (ECHO) Program,” in The Journal of Allergy and Clinical Immunology.

 

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

 

Published March 25, 2023

 

Access the associated article.

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ECHO Researchers Examine Incidence Rates for Childhood Asthma With Recurrent Exacerbations and Suggest Possible Social and Environmental Risk Factors

Collaborative ECHO research led by Rachel L. Miller, MD of Icahn School of Medicine at Mount Sinai and Christine C. Johnson, PhD, MPH of Henry Ford Health System investigates the factors that influence the rates of childhood asthma with recurrent exacerbations (ARE)—a subtype of asthma where children experience frequent, severe episodes of asthma. The researchers leveraged data from over 17,000 children born between 1990 and 2017 and found that children ages 2-4 years old, non-Hispanic Black and Hispanic Black children, and children who lived in the Northeast and Midwest had the highest incidence rates of ARE. Additionally, children with a parental history of asthma had ARE rates almost 3 times greater compared to those with no parental history. This research, titled “Incidence Rates of Childhood Asthma with Recurrent Exacerbations in the U.S. Environmental influences on Child Health Outcomes (ECHO) Program,” is published in The Journal of Allergy and Child Immunology.

While the prevalence of asthma has been reported widely in the United States and elsewhere, studies on childhood asthma incidence rates within specific populations and across various types of asthma and age ranges have been limited. “Describing the incidence rates of ARE across a large, diverse population of children is a critical first step for identifying potential risk factors and causes,” explained Dr. Johnson.

To conduct this research, the research team leveraged data from children enrolled in 60 ECHO cohorts across the U.S. and Puerto Rico. Child participants or their caregivers reported whether and when the child had an asthma diagnosis and any corticosteroids prescribed over time from their health care providers.  Recurrent exacerbations of asthma were based on reports of systemic (not inhaled) corticosteroid use. The researchers calculated incidence rates of ARE for the study population overall, along with rates for subsets of the population defined by the years the ARE were diagnosed, the decade children were born, their age and sex, their race and ethnicity, their residence at birth, and their parents’ history of asthma.

“While children with ARE are all different, these findings suggest that we should examine in the future key elements of the early environment, including viral respiratory tract infections, indoor allergens, environmental tobacco smoke, air pollution, stress, and socioeconomic status, which could contribute to ARE,” said Dr. Miller. “Understanding these causes will help researchers determine how to best prevent ARE and associated asthma outcomes.”

Read the research summary.­­

NIH Study Investigates Factors Affecting Asthma With Frequent Symptom Flare Ups in Young Children

FOR IMMEDIATE RELEASE

 

Young children, ages 2 to 4 years, especially those with parental history of asthma, suffered the highest rates of asthma with recurrent exacerbations (ARE) over a nearly 30-year period studied in new research funded by the Environmental influences on Child Health Outcomes Program (ECHO) at the National Institutes of Health.

“Describing the incidence rates of ARE across a large, diverse population of children is a critical first step for identifying potential risk factors and causes,” explained Christine Johnson, PhD, MPH, an ECHO Program investigator at Henry Ford Health.

During this study, ECHO researchers looked at data from over 17,000 children between 1990 and 2017 from across the U.S. including Puerto Rico in order to learn which factors influenced the rates of childhood ARE—a subtype of asthma where children experience frequent, severe episodes of asthma. They found that non-Hispanic Black and Hispanic Black children, children ages 2 to 4 years old, and children who lived in the Northeast and Midwest had the highest rates of ARE.

These findings suggest that different environmental and social factors may play a significant role in the onset of recurring asthma issues in children.

“Understanding these causes will help researchers determine how to best prevent ARE and associated asthma outcomes,” said Rachel L. Miller, MD, an ECHO Program investigator at the Icahn School of Medicine at Mount Sinai.

Drs. Miller and Johnson led this collaborative research published in the Journal of Allergy and Clinical Immunology.

Miller, R. et al. Incidence Rates of Childhood Asthma with Recurrent Exacerbations in the U.S. Environmental influences on Child Health Outcomes (ECHO) Program. DOI: 10.1016/j.jaci.2023.03.016

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About ECHO: ECHO is a nationwide research program supported by the NIH. Launched in 2016, ECHO aims to enhance the health of children for generations to come. ECHO investigators study the effects of a broad range of early environmental influences on child health and development. For more information, visit echochildren.org.

About the NIH: NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information, visit www.nih.gov.

Media Contacts

For information or to request an interview, contact Rebekah Yeager,  rebekah.yeager@nih.gov.

If you are not a member of the media, but have a general inquiry, please contact  NIHKidsandEnvironment@od.nih.gov.

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ECHO Researchers Investigate the Effect of Family Hardships and Newborn Health Outcomes on the Behavior and Well-being of Young Children

Collaborative ECHO research led by Julie Hofheimer, PhD of the University of North Carolina at Chapel Hill and Monica McGrath, ScD and Rashelle Musci, PhD, both of Johns Hopkins Bloomberg School of Public Health, investigates the link between family hardships, newborn health outcomes, and the behavior of young children. The researchers collected information on the behavior of 3,934 children between the ages of 18 and 72 months and used that data to identify early factors that increase a child’s risk for experiencing behavioral and emotional difficulties. The study found that children born preterm and those whose families had been exposed to more social, economic, or environmental hardships were more likely to experience continuous behavioral difficulties. This research, titled “Psychosocial and Neonatal Risk Factors Associated with Behavioral Dysregulation Trajectories Among Young Children from 18 through 72 Months of Age,” is published in JAMA Network Open.

Adverse conditions and family hardships have steadily increased over the past two decades, challenging the emotional and behavioral well-being of children and their families. To understand how health and environmental hardships affect a child’s risk for developing continuous behavioral problems, ECHO researchers collected early childhood behavior data from 20 ECHO cohorts from across the United States. About 20% of these children were born preterm (before 37 weeks of gestation).

The researchers collected caregiver self-reports, demographics, and medical and environmental data about the children and their mothers before and during pregnancy and from infancy through age six. Caregivers completed the Child Behavior Checklist at several study visits, and the researchers compared the children’s combined difficulty with anxiety, depression, attention, and aggression to their behavioral well-being across the first six years of life.

Some children who experienced less family adversity showed improved behavior over time. Importantly, some children were able to overcome hardships and improve their behavior. Through this study, the researchers were able identify early factors that increase a child’s risk for experiencing behavioral and emotional difficulties.

“Conditions during pregnancy and early infancy can identify toddlers who may benefit from early enriched services,” said Dr. Hofheimer. “Family support services tailored to the individual needs of children may prevent later behavioral problems and improve future outcomes for vulnerable children and their families.”

Future ECHO research may examine how childhood behavior continues to develop from six years onward, examining the link between early risk factors and behavioral patterns in middle school and adolescence.

Read the research summary.

ECHO Researchers Investigate Effects of Preterm Birth, Environmental Exposures on Child Health

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ECHO Researchers Investigate Effects of Preterm Birth, Environmental Exposures on Child Health

Authors: Michael O’Shea, Monica McGrath, Judy Aschner, Barry Lester, et al.

 

Who sponsored this study?

This research was supported by the Environmental influences on Child Health Outcomes (ECHO) Program, Office of The Director, National Institutes of Health.

 

What were the study results?

ECHO researchers are collecting extensive data from very preterm infants, including data on learning and intellectual impairments, asthma, obesity, sleep health, and the effects of the COVID-19 pandemic. This article provides an overview of how data from ECHO cohorts are being used to address questions about the combined effects of preterm birth and environmental exposures on child health outcomes.

 

What was the study's impact?

Researchers can use the information in this review to enhance their knowledge of the ECHO Program’s resources to study preterm infants. Researchers can use ECHO data to investigate the relationship between preterm birth, environmental exposures, and childhood risk of chronic and developmental health conditions.

 

Why was this study needed?

Infants who are born premature (before 32 weeks of pregnancy) are at a high risk for multiple health disorders. This review paper outlines resources available within the ECHO Program for researchers seeking to study the effects of preterm birth and environmental exposures on child health outcomes.

 

Who was involved?

This review article includes ECHO cohorts that enrolled infants who were born premature. These cohorts enrolled almost 1,800 preterm infants across 14 states that were born between April 2002 and March 2020, including three ECHO cohorts that are almost exclusively comprised of preterm infants.

 

What happened during the study?

A team of experts reviewed the characteristics of the ECHO cohorts that are collecting data on preterm infants. Through this review, they sought to describe the research goals, participant selection criteria, key environmental exposures, and child health outcomes of each cohort.

 

What happens next?

ECHO researchers will continue to investigate early life factors and environmental exposures that may affect children’s health outcomes later in life. Researchers not participating in the ECHO Program will be able to obtain de-identified data from preterm children in the ECHO-wide Cohort, along with data from around 30,000 children born at term through a controlled-access public use database. This data will include information about a broad range of environmental exposures and outcomes related to chronic illness among children in the United States. Using this data, researchers can continue to build off of ECHO’s mission to enhance the health of children for generations to come.

 

Where can I learn more?

Access the full journal article, titled “Environmental influences on Child Health Outcomes: Cohorts of Individuals Born Very Preterm,” in Pediatric Research.

 

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Published August 10, 2022

Access the associated article.

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Effects of Metal Mixture Exposure During Pregnancy on Fetal Growth

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Do chemicals that break down slowly in the environment affect how long it takes to become pregnant?  

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A review of studies that look at whether exposure to common non-persistent chemicals in consumer products delays the time it takes to become pregnant

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The Effect of Air Pollution on Time to Pregnancy

Linda Kahn, PhD, MPH

Collaborative ECHO research, led by Linda Kahn, PhD, MPH at NYU Langone Health, suggests traffic-related air pollution, secondhand smoke, and formaldehyde are associated with longer time to pregnancy. Specifically, exposure to particulate matter and nitrogen oxide gases lowered couples’ chances of becoming pregnant. Traffic and the burning of other types of materials besides gas and diesel, such as wildfires or other sources of combustion, create particulate matter and nitrogen oxide gases.

These results are based on a systematic review of 33 articles pertaining to air pollution and time to pregnancy, an indicator of a couple’s reproductive health. The team’s research, titled “Indoor and outdoor air pollution and couple fecundability: a systematic review,” is published in Human Reproduction Update.

Mounting evidence suggests an association between air pollution and longer time to pregnancy. The goal of this review was to compare results from previous studies and identify whether different types of pollution, such as pollution from traffic, chemicals in the workplace, and secondhand smoke, are consistently related to time to pregnancy.

To conduct this research, the team searched six science libraries and reviewed 33 relevant articles published in English between January 1, 1990 and February 11, 2021. Of these 33 articles, eight examined air quality, six looked at secondhand smoke exposure, and 19 studied air quality in the workplace. Researchers assigned each article a quality score based on the study design and extracted relevant data on time to pregnancy.

“This review shows that certain chemicals can increase the amount of time it takes for a couple to conceive, which may cause stress and lead them to seek fertility treatments,” said Dr. Kahn.

Researchers still need more insight into exactly how these chemicals affect reproduction. Future studies should be designed to collect more accurate exposure data, ideally from personal air monitors.

“Our team is still uncertain about whether the air people breathe around time of conception is most important or if there are certain life stages such as puberty when individuals may be especially susceptible to the harmful effects of air pollution,” Dr. Kahn added.

The ECHO Program will provide a useful framework for collecting more detailed information on how chemical exposures across the life course affect reproduction.

Read the research summary.

ECHO researchers study the effects of neighborhood environmental and social conditions on pregnancy and infant health

Collaborative ECHO research led by Sheena Martenies, PhD, MPH of the University of Illinois at Urbana-Champaign investigates the combined effects of environmental hazards and social stressors on pregnancy and infant health. This research included information on more than 13,000 infants born between 2010 and 2019 from 41 ECHO cohorts located throughout the United States. In this study, researchers found that pregnant people living in neighborhoods with higher combined exposures had shorter pregnancies and smaller babies. This research, titled “Associations between combined exposure to environmental hazards and social stressors at the neighborhood level and individual perinatal outcomes in the ECHO-wide cohort,” is published in Health & Place.

Previous studies have found that neighborhood conditions can influence pregnancy and infant health, but few have examined the effects of exposure to a combination of environmental and social conditions. It is important to look at multiple exposures simultaneously because this more closely mirrors real-world experiences. There are existing tools for looking at combined exposures to environmental hazards and social stressors in neighborhoods, but they either do not have national coverage or they do not cover the time frames needed.

ECHO researchers developed an exposure index which combined data on multiple environmental hazards and social circumstances—including air pollutants, vehicle traffic, poverty, and crowded housing—into a single measure of neighborhood conditions. Pregnant people were assigned an index score based on where they lived during their pregnancy. Then, the researchers looked at how this index score was associated with birthweight, length of pregnancy, and other pregnancy outcomes.

The researchers found that pregnant people living in neighborhoods with higher combined exposures had shorter pregnancies and smaller babies. For Black pregnant people, there was a higher risk of preterm birth associated with increased combined exposures during pregnancy compared to White pregnant people. The researchers also found that pregnant people living in rural areas had shorter pregnancies and smaller babies compared to pregnant people living in urban areas who had similar index scores.

More research is needed to determine which factors included in the exposure index are most important in pregnancy and child health outcomes. Some members of the research team are currently studying data from two ECHO cohorts (Healthy Start and MADRES) to explore how neighborhood-level exposures might interact to influence obesity later in life.

Read the research summary.

ECHO Researchers Report Higher Levels of Oxidative Stress among Socioeconomically Disadvantaged Pregnant People

A collaborative research effort led by Stephanie Eick, PhD, MPH of Emory University’s Rollins School of Public Health and Rachel Morello-Frosch PhD, MPH of the University of California, Berkeley investigated the relationship between various biological, behavioral, and social factors and higher levels of oxidative stress in pregnant people, which is often associated with poor prenatal health outcomes. Pregnant people who were 30+ years old and had a college degree had lower levels of oxidative stress. In contrast, levels of oxidative stress were higher among pregnant people who were overweight or obese, or unmarried. Levels of oxidative stress biomarkers were also higher among pregnant people who were current smokers or had less than a high school education.

This research, titled “Associations between social, biologic, and behavioral factors and biomarkers of oxidative stress during pregnancy: Findings from four ECHO cohorts,” is published in Science of the Total Environment.

To measure oxidative stress, the researchers collected urine samples from approximately 2,000 pregnant people in the mainland United States and Puerto Rico who were enrolled in one of four ECHO cohorts. They measured the levels of oxidative stress biomarkers at up to three time points during pregnancy and calculated the association between biomarker levels and biological, behavioral, and social factors. Maternal age, pre-pregnancy body mass index, marital/partnered status, parity, and smoking status were included as biological and behavioral factors while race/ethnicity, maternal education, and stressful life events were considered social factors.

“This is the largest study to date to examine the relationship between biologic, social, and behavioral factors and oxidative stress during pregnancy,” said Dr. Eick. “Our results provide important clues into how social and economic inequalities lead to poor health in pregnant people.” This study may also inform future studies looking at risk factors for preterm birth.

As for ongoing research, the team is examining the impact of oxidative stress on adverse pregnancy outcomes, such as preterm birth.

Read the Research Summary.

ECHO Researchers Identify Effects of Mixed Metal Exposures on Fetal Growth

In a collaborative research effort led by Caitlin Howe, PhD and Margaret Karagas, PhD of Dartmouth College, researchers observed an inverse association between the metalloid antimony and birth weight for gestational age, suggesting that this understudied metalloid may harm fetal growth. Their study, titled “Prenatal metal(loid) mixtures and birth weight for gestational age: a pooled analysis of three cohorts participating in the ECHO Program” is published in Environment International.

The study included approximately 1,000 mother-newborn pairs in three geographically and demographically diverse ECHO cohorts:

  • The Maternal And Developmental Risks from Environmental and Social Stressors (MADRES) study, a predominantly lower-income Hispanic cohort in Los Angeles, California
  • The New Hampshire Birth Cohort Study (NHBCS), a primarily non-Hispanic white cohort in northern New England
  • The Puerto Rico Testsite for Exploring Contamination Threats (PROTECT) study, a Hispanic cohort in northern Puerto Rico.

The team pooled data from these three cohorts, measured multiple metals in the mothers’ urine samples collected during pregnancy and evaluated the associations with birth weight for gestational age using a multipollutant analysis approach. In addition to the findings for antimony, the team reported that the effects of other metals (cobalt, mercury, nickel, tin) on birth weight for gestational age differed by cohort and/or infant sex. The mixture of metals together did not impact birth weight for gestational age. Cadmium and molybdenum individually were not associated with differences in birth weight for gestational age.

“Previous research on this topic has mainly focused on one metal at a time, but individuals are often exposed to multiple metals simultaneously, which may interact in complex ways to impact health,” said Howe.

This research highlights the need to identify major sources of antimony, which may differ depending on the population, such that interventions can be developed to reduce exposure to this toxic metalloid. In the future, the research team would also like to expand their analysis to additional ECHO cohorts and participants, investigate other biomarkers of metal and metalloid exposures, and identify windows in pregnancy when the developing fetus may be most susceptible to these exposures.

Read the research summary.

ECHO Research Explores the Relationship between Early Life and Puberty

Izzuddin M. Aris, PhD
Izzuddin M. Aris, PhD

Collaborative ECHO research led by Izzuddin M. Aris, PhD of Harvard University found that children who grew more quickly than their peers in the first five years of life were more likely to start puberty earlier. The study examined the importance of early life factors in puberty development and found that male children who gained weight or grew faster than their peers in the first five years of life were associated with entering puberty at a younger age. The researchers found similar results in female children but only among those with faster weight gains during early childhood (two to five years of age). The article, titled “Analysis of early life growth and age at pubertal onset in US children,” is published in JAMA Network Open.

To obtain these findings, the researchers gathered height and weight data from nearly 7,500 children in 36 ECHO cohorts and examined the following markers of puberty:

  • Age at which the child reached maximum growth due to puberty
  • Age at first period (in female children only)
  • Pubertal development score
  • Onset of pubic hair development

The team studied how weight gain, height, and body mass index at ages 0–0.5, 0.5–2, and 2–5 years were related to puberty later in childhood.

“Puberty is a key stage during child development,” explained Dr. Aris. “Having a better understanding of the early life factors related to puberty is important to develop intervention strategies to prevent earlier pubertal onset.” Previous studies in the US have linked earlier puberty onset to diseases later in life, such as type 2 diabetes.

Dr. Aris says follow-up studies will aim to identify puberty’s role in explaining the relationship between early life factors and longer-term chronic diseases.

Read the research summary.