In the JournalsPerspective

Benefits of FENO-guided asthma management passes from mother to child

Children born to women with asthma whose condition was managed based on the fraction of exhaled nitric oxide, or FENO, in addition to their asthma symptoms as opposed to asthma symptoms only were more than 50% less likely to have diagnosed asthma in early childhood, according to results of a double-blind, randomized clinical trial.

“Asthma during pregnancy may shape the child’s future asthma risk trajectory via an interaction between heritability and in utero exposures at the feto-maternal interface,” Matthew Morten, PhD, a research associate at the University of Newcastle School of Medicine and Public Health, and colleagues wrote. “Notably, very common exposures such as asthma medications and exacerbations during pregnancy have not been investigated for an association with the child’s asthma risk.”

The Managing Asthma in Pregnancy (MAP) trial included 179 pregnant women in Newcastle, Australia. The trial compared the efficacy of a treatment algorithm that combined the assessment of clinical symptoms of asthma with FENO against a symptoms-only approach to asthma management.

Follow-up information was collected for 78% of children aged between 4 and 6 years.

Children whose mothers received FENO-guided treatment were less likely to have diagnosed asthma compared with children whose mothers received treatment based only on symptoms (25.9% vs. 43.2%; OR = 0.46; 95% CI, 0.22-0.96). When the researchers examined health care outcomes in the past 12 months, children of mothers receiving FENO-guided treatment were also less likely to have frequent wheeze (OR = 0.27; 95% CI, 0.09-0.87), require short-acting beta-agonists (OR = 0.49; 95% CI, 0.25-0.97) and to have lower ED use (OR = 0.17; 95% CI, 0.04-0.76).

Morten and colleagues found that FENO-guided asthma management also had a “natural indirect effect” on any use of inhaled corticosteroids, or ICS (OR = 0.83; 95% CI, 0.59-0.99), and the time when the first change in dosing occurred (OR = 0.9; 95% CI, 0.7-1.03) for children with asthma.

The researchers noted that FENO-guided asthma management may have promoted more appropriate ICS use among pregnant women in the study, which therefore had an effect on the incidence childhood asthma.

“Importantly, our results provide long-term child health outcomes to further support the clinical consensus that the benefits of ICS therapy in pregnancy, when guided by FENO levels and clinical symptoms, largely outweigh their potential risks,” the researchers wrote. – by Katherine Bortz

Disclosures: Morten reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Children born to women with asthma whose condition was managed based on the fraction of exhaled nitric oxide, or FENO, in addition to their asthma symptoms as opposed to asthma symptoms only were more than 50% less likely to have diagnosed asthma in early childhood, according to results of a double-blind, randomized clinical trial.

“Asthma during pregnancy may shape the child’s future asthma risk trajectory via an interaction between heritability and in utero exposures at the feto-maternal interface,” Matthew Morten, PhD, a research associate at the University of Newcastle School of Medicine and Public Health, and colleagues wrote. “Notably, very common exposures such as asthma medications and exacerbations during pregnancy have not been investigated for an association with the child’s asthma risk.”

The Managing Asthma in Pregnancy (MAP) trial included 179 pregnant women in Newcastle, Australia. The trial compared the efficacy of a treatment algorithm that combined the assessment of clinical symptoms of asthma with FENO against a symptoms-only approach to asthma management.

Follow-up information was collected for 78% of children aged between 4 and 6 years.

Children whose mothers received FENO-guided treatment were less likely to have diagnosed asthma compared with children whose mothers received treatment based only on symptoms (25.9% vs. 43.2%; OR = 0.46; 95% CI, 0.22-0.96). When the researchers examined health care outcomes in the past 12 months, children of mothers receiving FENO-guided treatment were also less likely to have frequent wheeze (OR = 0.27; 95% CI, 0.09-0.87), require short-acting beta-agonists (OR = 0.49; 95% CI, 0.25-0.97) and to have lower ED use (OR = 0.17; 95% CI, 0.04-0.76).

Morten and colleagues found that FENO-guided asthma management also had a “natural indirect effect” on any use of inhaled corticosteroids, or ICS (OR = 0.83; 95% CI, 0.59-0.99), and the time when the first change in dosing occurred (OR = 0.9; 95% CI, 0.7-1.03) for children with asthma.

The researchers noted that FENO-guided asthma management may have promoted more appropriate ICS use among pregnant women in the study, which therefore had an effect on the incidence childhood asthma.

“Importantly, our results provide long-term child health outcomes to further support the clinical consensus that the benefits of ICS therapy in pregnancy, when guided by FENO levels and clinical symptoms, largely outweigh their potential risks,” the researchers wrote. – by Katherine Bortz

Disclosures: Morten reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

    Perspective

    Determinants of the development of childhood asthma include genetic susceptibility and environmental exposure, but also maternal exposures. For example, inadequate maternal asthma control during pregnancy is more strongly associated with development of asthma in offspring than well-controlled maternal asthma. While the exact mechanism is poorly understood, it seems that the predisposition toward later asthma development is influenced by factors occurring during gestation.

    FENO is a measure of eosinophilic airway inflammation and has been used by asthma specialists as an indicator of asthma control and potential nonadherence to inhaled corticosteroids. In this study, investigators showed that incorporating FENO into their treatment algorithm decreased the subsequent diagnosis of childhood asthma and asthma-related symptoms compared with symptom-guided treatment alone, likely related to improved maternal asthma control. Given that asthma is the most common chronic disease affecting women of childbearing age, improved maternal control has significant public health implications.

    Pediatricians should consider discussion of maternal comorbidities, including asthma, when meeting with pregnant women and prospective new families, and be aware of the potential impact of poor maternal asthma control on their future patients.

    • Michelle W. Parker, MD
    • Attending physician, division of hospital medicine
      Cincinnati Children’s Hospital Medical Center
      Assistant professor, department of pediatrics
      University of Cincinnati
      Infectious Diseases in Children Editorial Board member

    Disclosures: Parker reports no relevant financial disclosures.