Notable Comorbidities and Unmet Needs in Pediatric Asthma

Asthma is one of the most common chronic diseases in children, and in order to control it properly, risk factors, comorbidities, medication adverse events (AEs), and quality of life must be taken into consideration. Recognizing any comorbidities is essential because treating or managing them can improve asthma outcome or morbidity. Authors of a review published in World Allergy Organization Journal examined published data on the comorbidities related to or associated with pediatric asthma to raise awareness of their characteristics, management, and impact on patients, as well as address unmet needs.

Some comorbidities (which are mainly related to immunoglobulin E [IgE]-mediation) children with asthma may experience are allergic rhinitis (AR), food allergy (FA), and anaphylaxis. According to the authors, the prevalence of AR worldwide ranges from 0.8% to 14.9% in patients aged 6 to 7 years, and 1.4% to 39.7% in those aged 13 to 14 years. AR tends to coexist with asthma because both the upper and lower airways share anatomical, functional, pathogenic, and immunological patterns. Additionally, research has found that up to 80% of children with asthma also have AR, and approximately 30% of children with AR also have asthma. Concomitant AR can have a negative impact on asthma control—such as quality of life, asthma medication use, physician visits, emergency department visits, and hospitalization rates—and, according to the authors, asthma and AR present during childhood are early-life predictors of lung function decline in adulthood.

The diagnosis of AR, according to the authors, is clinically based on its typical symptoms along with supportive evidence that presents via skin prick testing or serum allergen specific IgE assay. AR’s symptoms are similar to other nasal conditions (eg, rhinosinusitis and non-allergic rhinitis), meaning that diagnosing the condition can be difficult, particularly in younger children. Nasal corticosteroid treatment can help improve disease control level and the extent of exercise-induced bronchoconstriction in children who have both asthma and AR, and subcutaneous or sublingual immunotherapy were also reported to reduce the risk of asthma development in children with isolated allergic rhinitis and rhinoconjunctivitis. The authors explain that early and accurate diagnoses are essential for better asthma management in children with comorbid AR and preventing the development of asthma in children with AR alone.

FA in asthma is usually underestimated, and it has been shown to either trigger or exacerbate symptoms in approximately 2% to 8.5% of children with asthma. Additionally, FA can be an indicator of severe atopic asthma, as well as other comorbidities—such as atopic dermatitis, urticaria, and rhinitis—and serum IgE level, as well as a risk factor for life-threatening asthma or severe anaphylaxis in children. Patients with food-induced anaphylaxis are also at a higher risk of wheezing (OR, 2.2; 95% CI, 1.1–4.5) and respiratory arrest (OR, 6.9; 95% CI, 1.4–34.2). The authors note that among the most important unmet needs is the suboptimal use of intramuscular epinephrine in patients with anaphylaxis.

Additionally, comorbidities that are mixed IgE and non-IgE immune mediated can include allergic bronchopulmonary aspergillosis (ABPA), fungal sensitizations, eosinophilic esophagitis, and chronic rhinosinusitis, among others. Aspergillus sensitization (AS) is considered to be the first step in the diagnosis of ABPA, which represents a complex immunological disorder that is a result of increased type-2 immune responses against Aspregillus fumigatus that inhabit the tracheobronchial tree. Prior research shows that AS and ABPA are present in approximately 16.1% and 9.9%, respectively, of children with asthma. With these conditions, there is a lack of clinical trials that include children and no specific diagnostic criteria for children; however, systemic corticosteroids and itraconazole, as well as omalizumab (Xolair; Genentech, Inc and Novartis Pharmaceuticals Corporation) and mepolizumab in refractory cases, are potential therapeutic options to treat ABPA and AS.

Chronic rhinosinusitis is estimated to affect approximately 5% of asthma cases, but the condition is less frequent in children than it is in adults, note the authors. Diagnosis requires at least 2 of 4 cardinal symptoms (eg, nasal obstruction, nasal congestion or discharge, facial pain, and cough) which must be present for 12 weeks, and in children, coughing is seen more frequently than in older patients. Research has demonstrated that the treatment of chronic rhinosinusitis contributes to better pediatric asthma control, decreases the number of exacerbations, and improves quality of life.

Other comorbidities include mechanical comorbidities—such as vocal cord dysfunction, obstructive sleep apnea and dysfunctional breathing, and gastroesophageal reflux disease. Additionally, metabolic comorbidities—such as obesity, metabolic or hormonal disturbances, and cardiovascular disease—can influence pediatric asthma, as well as psychiatric disorders (eg, schizophrenia, anxiety, depression, and attention deficit hyperactivity disorder), AEs related to drugs or treatments, and recurring or frequent infections.

According to the authors, children with asthma—notably those with difficult-to-control asthma—should be actively screened or monitored by pediatricians and primary health care providers. Careful monitoring can help detect the presence of obesity, upper airway allergies, dysfunctional breathing, multiple sensitizations, psychological disorders, FA, and gastro-esophageal reflux. Further, the authors emphasize that asthma can affect the well-being of pediatric patients; therefore, identification and addressing modifiable conditions or comorbidities are essential.

REFERENCE

Hossny E, Adachi Y, Anastasiou E, et al. Pediatric asthma comorbidities: Global impact and unmet needs. World Allergy Organization Journal. 2024;17(5):100909. doi:10.1016/j.waojou.2024.100909