Bronchial asthma is a chronic inflammatory disease in airway. The basic strategy of the treatment of asthma is to control airway-inflammation with anti-inflammatory drugs. Recently, It has been demonstrated that there are naturally occurring active anti-inflammatory and inflammation-resolving mechanisms, which are mediated through newly identified omega-3 unsaturated fatty acid metabolites; protectin and resolvin, and some of omega-6 unsaturated fatty acid metabolites; lipoxin and PGE2. It is important to investigate this area for development of new therapeutic strategy of childhood asthma in the future.

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Hygiene hypothesis suggests that some infections play a protective role in development of asthma. Concentration of environmental endotoxin reversely correlates to the incidence of atopic asthma. On the other hand, RS virus infection and rhinovirus infection worsen asthma. In addition, asthmatic bronchial epithelial cells have a deficient innate immune response to infection with rhinovirus. The timing of viral infections from infancy to adolescence has an effect on the condition of asthma in terms of the maturation of immune system. In antigen-presenting cells the signaling from toll-like receptors, cytokine productions from epithelial cells and antigen-presenting cells and Th2 dominancy in Th1-Th2 balance influence the development of asthma.

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A Post-marketing surveillance study was carried out to investigate the safety and effectiveness of Onon Dry Syrup 10% (Pranlukast hydrate) in actual clinical settings in pediatric patients with bronchial asthma aged less than 1 year.
For the investigation, a prospective, central registry system was employed, and as a result, a total of 192 cases were collected from 93 medical institutions all over Japan. Among 184 patients included in the safety analysis population, no occurrence of adverse drug reaction was observed. Among 173 patients included in the efficacy analysis population, 159 showed improvement (improvement rate of 91.9%). The result of the analysis by patient background factors showed no special concern with the effectiveness of drug.
In conclusion, it was confirmed that Onon Dry Syrup is a highly safe and effective medication for bronchial asthma in infants aged less than 1 year.

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In the eating habits support of patients with food allergy, a role of the dietitian is expected, but the nutritional education method has not been established yet. Therefore, we performed questionnaire-based survey for parents of food allergic children and the non-food allergic children (about eating habits at home and outside, stress of mothers, understanding degrees on the disease by surrounding people, and the correspondence of kindergarten and school) to determine the problems that they faced in everyday life and then we tried to clarify the main nutritional education item. The subjects were 286 food allergic children and 258 non-food allergic children as a total of 544. It was 21.7% of non-food allergic children and 40.1% of food allergic children who had a separate meal menu from that of their families. The parents of 67.5% of non-food allergic children and 96.8% of food allergic children paid attention carefully to food materials. The parents of 40.1% of food allergic children felt an economic burden, and 54.1% of them couldn't go out for eating. Numerousness of the number of the removal food items promoted the burden. Also, the parents of 28.2% of food allergic children and 4.6% of non-food allergic children were dissatisfied with lunch provided by kindergartens or schools and correspondence of the dietitians. Dietitians should cooperate with physicians through the support (nutritional education) of food allergy patients to reduce these burden.

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Preschool children with intermittent or mild persistent asthma may have recurrent severe exacerbations, which can be described as “severe intermittent asthma”. This subtype of infant asthma, however, has not been well characterized. We prospectively observed clinical course of infants with intermittent asthma after the ‘first’ severe exacerbation. A total of 29 children with asthma aged 6 to 59 months who had been classified as intermittent or mild asthma and were hospitalized because of the first episode of severe exacerbation were enrolled in the observation study. Controller medication including inhaled steroids and/or leukotriene receptor antagonists were administered to 22 patients at discharge and no controller medication was administered in 7 patients. Clinical course after discharge was prospectively followed for 6 months and outcomes were compared based on the medication status. Primary outcome was recurrence of severe exacerbation and secondary outcomes were time to exacerbation and time to loss of control. Risk factors relating to the outcomes were also analyzed. Incidence of recurrence of exacerbation was 0.66 time/patient/ year in those with controller medication and 1.00 time/patient/ year in those without controller medications. Exacerbation and loss-of-control were delayed in those with controllers. Exacerbation and/or loss-of-control were significantly associated with history of other allergic diseases, eosinophilia, and sensitization to house dust mite. These results suggested that controller medication may be beneficial for infants with intermittent asthma who are hospitalized because of the first severe exacerbation, especially for those with atopic risk factors.

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The current questionnaire survey was conducted to clarify the need of food allergic safety procedures in hospital settings. The questionnaire included concerns for the choice of starting materials (hypoallergenic diet and specific avoidance diet), risk of contamination during preparation, and product traceability. Forty-three of the hospital food production units (42%) replied to 102-questionnaire distribution. Twenty-six percent of the respondents reported the cases of food allergy due to hospital diet. Eggs, yogurt and wheat were the most common materials given in the third term or later of the weaning period. Salmon roe, soft-boiled eggs, mackerel, buckwheat noodles, and peanuts were frequently eliminated from hospital meals for infants. A deliberate program for the choice of allergic materials is important to set up food allergic safety in hospitals.

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A survey of 2,052 pediatric asthma patients (male : female=1,290:762, 0-1-year-old : 2-5-year-old patients : 6-15-year-old patients=130:1,009:913) using the Japanese Pediatric Asthma Control Program (JPAC) in Hiroshima area was performed from September to December in 2008. In this survey, 878 patients showed wheezing, 426 patients experienced dyspnea, and asthmatic exacerbations disturbed 476 patients′ sleep at night, whereas 1,093 patients experienced no such symptoms. 681 patients showed a score of 15 of JPAC, indicating complete control, 813 patients showed a score of 12-14, indicating good control, and 558 patients showed a score of less than 12, indicating poor control. Most of the patients (79.6% of the 130 patients aged 0-1 years, 87.4% of the 1,009 patients aged 2-5 years, and 91.5% of the 913 patients aged 6-15 years) were treated with leukotriene modifiers, and almost half of the patients (53.8% of those aged 0-1 years, 38.4% of those aged 2-5 years, and 43.3% of those aged 6-15 years) were treated with inhaled corticosteroids. In this study, severity of asthma according to the Japanese Pediatric Guideline for the Treatment and Management of Asthma 2008 showed 80 patients were in remission, 574 patients were intermittent-mild persistent, 522 were mild persistent, 357 moderate persistent, 415 severe persistent, and 63 most severe persistent. Younger patients showed a greater severity than older patients. JPAC was useful to assess the control of asthma patients.

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The points of management for acute exacerbation of asthma were described as below.
1, Home-based interventions;
Clinicians give the patients and family self-management education about care for acute exacerbations according to the severity. Especially early recognition and prompt actions for severe conditions such as life-threatening exacerbations are important.
2, Hospital-based managements
All clinicians treating patients with asthma should be familiar with the actions and side effects of beta₂ agonists, systemic corticosteroids, aminophyllin, isoproterenol, O₂ inhalation and transfusion. Treatment should begin immediately following recognition of a mild, moderate, severe or life-threatening exacerbation by assessment of symptoms, signs, Spo₂, or, when possible, lung function.

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Asthma is a chronic inflammatory airway disease. To improve the prognosis, achieve remission and even cure, it is important to keep patients in good control by appropriate long-term management. Evaluation of asthma severity is thus pivotal to choose treatment plan for each patient. One needs to take present medications into consideration to determine “real” severity, which is different from symptoms on current therapy. Once good control is achieved, step-down of treatment may be planned while keeping symptoms on current therapy under intermittent level.

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[in Japanese]

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