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ALLERGIC RHINITIS IN PRESCHOOL CHILDREN OF ALTAI KRAI
:Altai State Medical University, Barnaul
2Siberian State Medical University, Tomsk
N.V. Shakhova1, E.M. Kamaltynova2, U.F. Lobanov1, T.S. Ardatova1
The aim of the study was to evaluate the prevalence, clinical-allergological characteristics and risk factors of allergic rhinitis in children of 3-6 years of age. Materials and methods: The study was cross-sectional, involving children from 3 to 6 years took from 5 cities of Altai Krai. The study consisted of 2 stages - screening (questionnaire using the Russian version of the ISAAC questionnaire and an additional questionnaire on risk factors, the questionnaires were filled by parents) and clinical (interviewing parents, clinical examination of patients, skin prick test and/or testing for specific IgE levels to inhalation and food allergens). Results: Prevalence of AR among children aged 3-6 was 12.3%, while only 48% of these children had a physician-verified AR. 85.0% of children have a persistent course and 69.0% have a mild severity of AP. The most significant inhalant allergens are home dust mites (61.6%), birch pollen (40.9%) and cat fur (19.4%). The risk factors for AR are an allergic family history (OR = 3.9, 95% CI = 2.8-5.4, p <0.01), males (OR = 2.6, 95% CI = 1.8 -3.7; p <0.01), passive smoking (smoking of parents during the 1st year of life OR = 1.6, 95% CI = 1.1-2.6, p <0.05, smoking of parents at the present time OR = 1, 7; 95% CI = 1,1-2,6; p <0,05); and violations of vitamin D3 intake in the first year of life (OR = 2.0, 95% CI = 1.3-3.0; p <0.01). Conclusion: The prevalence of AR among children aged 3-6 years is 12.3%. Most of the children have mild severity and persistent AR, and the most significant inhalant allergens are house dust mites, birch pollen and cat fur. Risk factors for the development of AR at preschool age are the allergic family history, the male gender of the child, passive smoking and the disorders of intake of vitamin D3 in the first year of life. Key words: prevalence, risk factors, children, allergic rhinitis, allergic diseases.
Allergic rhinitis (AR) is a widespread disease among the child population, the prevalence of which is increasing in different regions of the world [1-3]. Due to the international epidemiological study "International Study of Asthma and Allergies in Childhood" (ISAAC), the prevalence of AR among schoolchildren is well studied, with an average of 14.6% among children aged 1314, among children 6-7 years - 8.5% [4]. At the same time, the prevalence and risk factors of AR among pre-school children have not been adequately studied, as international epidemiological studies have not been conducted on this issue and to date only a small number of scientific papers have been published. Thus, according to research published in 2015-2016, the prevalence of AR among pre-school children in China varies between 7.3 and 22.5% [5.6], in South Korea - 20.8% [ 7], in Italy - 5.5% [8], in the United States - 13.7% [9]. According to research in 2017, the prevalence of AR among preschool children in Turkey is 13.4% [10], Australia - 8.3% [11], South Korea - 17.3% [12].
Due to the limited number of epidemiological studies, we do not possess convincing evidence on the prevalence and risk factors of AR in preschool children, which does not allow the formation of strategies aimed at its prevention at an early age. The article presents the results of a study of the prevalence, clinical-allergological characteristics and risk factors of AR among children aged 3-6 years in Altai Krai.
Research objective: to estimate the prevalence, clinical-allergological characteristics and risk factors of AR in children aged 3-6 years living in Altai Krai.
Materials and methods
The study was carried out at the clinical base of the "Altai State Medical University" of the Ministry of Health of the Russian Federation - Allergology and Immunology Department of the "Clinical Children's Hospital No. 7" and in municipal budgetary institutions of preschool education in Altai Krai. The study protocol was approved at a meeting of the local independent ethics committee of the Altai State Medical University of the Ministry of Health of the Russian Federation (No. 11 dated October 17, 2014) and coordinated with the Ministry of Education and Science of Altai Krai. The study was conducted in 2015 - 2017.
The study involved children aged 3-6 years attending pre-school educational institutions and living in 5 large cities of Altai Krai: Barnaul, Rubtsovsk, Biysk, Kamen-na-Obi, Novoaltaysk.
The study included screening and clinical stages.
Screening
The screening stage is performed in the design of a one-stage epidemiological study.
To study the prevalence of AR at the screening stage, a questionnaire containing questions of the Russian version of the ISAAC questionnaire (the module "Allergic rhinitis" for children 7-8 years old) was used:
1. Did your child have sneezing, runny nose, stuffy nose, without having cold and ARD over the past 12 months?
2. Were sneezing, runny nose, nasal congestion accompanied by eye itching and tearing over the past 12 months?
3. Has your ever been diagnosed with allergic rhinitis?
To investigate the risk factors for AR development, an additional questionnaire was used to assess the impact of family allergological history and external factors on the risk of AR development: allergic diseases in mother and father (bronchial asthma, allergic rhinitis, atopic dermatitis), duration of breastfeeding less than 6 months, prematurity, regular contact of the child with the animal in the first year of life (at least 1 time per week), mother's smoking during pregnancy, parents' smoking in the presence of the child at 1- year of the child's life, and at present, violations of vitamin D3 consumption in the first year of life (refusal of admission or administration of less 6 months).
78 pre-school educational establishments of Altai Krai were randomly selected: 45 in Barnaul, 8 in Novoaltaysk, 10 in Rubtsovsk, 5 in Kamen-na-Obi and 10 in Biysk. The questionnaires were given to parents or foster parents of children aged 3-6 years attending pre-school institutions. The filling procedure was conducted during a parent meeting or at home. Signing of informed consent at the screening stage was not provided, since consent to participate in the study was considered the return of completed questionnaires.
According to the results of the screening, for participation in the clinical stage, two samples of children were formed: those having symptoms of AR and not having symptoms of AR.
A patient who did not have symptoms of AR was considered to be a respondent whose parents answered "No" to all 3 questions of the questionnaire. All other patients were assigned to a group of children with symptoms of AR.
A screening study of prevalence of AR is based on subjective information obtained from the questionnaire of parents and/or foster parents, and as a result, the results obtained do not always correlate with the level of true prevalence of AR in the population. In this regard, the priority task of the clinical stage of the study was to estimate the true prevalence of AR, based on the diagnostic criteria of the international conciliation document: Allergic Rhinitis and its Impact on Asthma, ARIA 2008 [13].
Clinical stage
Participation in the clinical stage of the study was carried out after the parents and/or foster parents signed the informed consent.
Procedures for the clinical phase included interviewing parents/foster parents, clinical examination of patients, skin prick test with extracts of domestic, epidermal, pollen and food allergens (Allegopharma, Germany) and/or a study of the level of specific IgE to household, epidermal, pollen and food allergens (Immuno CAP, Phadia, Sweden).
Clinical examination, which was conducted by physicians allergy-immunologists, included the collection of anamnesis, complaints, physical examination and the filling of an individual registration card by a doctor-researcher. Diagnosis of AR, assessment of the severity and nature of the course was carried out on the basis of the diagnostic criteria of the international conciliation document ARIA 2008
Criteria for AR diagnosis
The diagnosis of AR was exposed in the presence of two or more of the symptoms listed in brackets for at least an hour (rhinorrhea, difficulty in nasal breathing, itching in the nasal cavity, repeated sneezing) and a positive skin prick test or an increase in the specific IgE level of more than 0.35 kU/l to at least one allergen.
Criteria for severity and course of AR
Mild severity of AR: the patient has minor clinical manifestations of the disease, not violating daytime activity and sleep); moderate/high severity of AR: symptoms disturb patient's sleep and daytime activity); intermittent AR course: symptoms of less than 4 days per week or less than 4 weeks per year; persistent AP course: symptoms more than 4 days a week or more than 4 weeks per year.
Skin prick test with allergens
The procedure of skin prick-testing was carried out in accordance with the standards approved by the European Academy of Allergology and Clinical Immunology. The panel of standardized extracts of allergens for household, pollen, epidermal and food groups (home dust mite Der-matophagoides pteronyssinus, house dust mite Dermatophagoides farinae, cat fur, dog fur, birch pollen, meadow pollen, wormwood pollen, cow milk, chicken egg, cod, wheat, as well as positive and negative control (Allegopharma, Germany) was used in the study. As a positive control, a his-tamine solution with a concentration of 10 mg/ml was used, a negative control (saline) - for the elimination of nonspecific reactions caused by skin trauma and dermographism. The results of skin tests were evaluated 20 minutes after the setting. The skin test was considered positive by formation ofa blister at least 3 mm more than the negative control.
The study assessed the presence of comorbid allergic diseases in children with AR - bronchial asthma (BA) and atopic dermatitis (AD). Diagnosis of asthma was made on the basis of the diagnostic criteria of the international conciliatory document Global Initiative for Asthma (GINA), the diagnosis of blood pressure was based on the diagnostic criteria by J. Hanifin (Hanifin J.) and H. Rajka (Rajka H.).
Statistical analysis
The database was compiled by means of the program "Microsoft Excel 2002" (Microsoft Corporation, 1983-2001). Statistical procedures were performed using the application software package "STATISTICA for Windows 6.0" and "SPSS Base 14.0" [37, 263].
The prevalence of AP in the population was calculated by the formula (AC + BD)/N, where A is the total number of children who had symptoms of AR according to the questionnaire; B - number of other participants in the study who did not have symptoms of AR according to the questionnaire; C - number of patients with diagnosed AR at the clinical stage,%; D - number of patients with diagnosed AR in the control group,%; N - number of the sample of the screening stage.
To assess the differences in frequency characteristics in the analyzed groups, the exact Fisher test or the Pearson x2 criterion with the Yates correction was used. Differences were considered statistically significant by p <0.05. To determine the risk factors of AR, a logistic regression analysis was performed with the determination of the odds ratio (OR) with 95% confidence interval (95% CI) for each factor.
Results
5156 parents received questionnaires for completion. Returned 3255 filled (63.1%), of which 50 were not filled in completely or incorrectly, and therefore were excluded from the study. Thus, during the analysis, the data of 3205 questionnaires were taken into account. A block diagram of the study is presented in Figure 1. According to the responses to the questionnaires, 577 (18%) of children were regarded as having symptoms of AR and 2628 - as having no symptoms of AR. Parents of 262 children (45.4%) from the group with symptoms of AR signed informed consent for the participation of children in the clinical phase of the study with skin prick tests and/or the determination of specific immunoglobulins E in blood serum. Parents of 92 children without symptoms of AR also signed informed consent for the participation of children in the clinical phase of the study.
Prevalence
According to the study, the prevalence of AR among children aged 3-6 was 12.3% (Table 1). At the same time, out of 154 children, who had been diagnosed with AR, only 74 (48%) had a medical-verified diagnosis of AR.
Prevalence of AR among children 3-4 was lower in comparison with children of 5-6 years (3-4 years - 10.5%, 5-6 years - 13.4%). Prevalence of AR among boys is higher than in girls in all age groups.
Clinical-allergological characteristics
The majority of children 131 (85.0%) had persistent course and mild severity of AR - 107 (69.0%)
(Table 2). The predominance of mild severity and persistent AR is noted in all age groups.
Of 154 children, 106 (68.8%) had comorbid allergic diseases: 47 (30.5%) of children had asthma, 39 (25.3%) had BA and 20 (12.0%) had AD and BA.
During the allergological survey, the three most important inhalant allergens were found - house dust mites (61.6%), birch pollen (40.9%) and cat fur (19.4%) (Table 3). Sensitization to house dust mites and birch pollen prevailed in all age groups. It was found that in children of 5-6 years, sensitization to the cat's fur (p <0.05), pollen of meadow grasses (p <0.05) and pollen worm (p <0.05) were significantly more often reported, compared with children of 3-4 years.
18 (11.6%) children were sensitized to food allergens, 8 (5.2%) to chicken eggs, 4 (2.6%) to cow's milk, 2 (1.3%) to wheat and 2 (1.3) to fish. Clinically significant sensitization to food allergens was registered only in 3 children: in 2 children for fish in the form of acute urticaria and oral allergic syndrome, in 1 child for cow milk in the form of acute urticaria.
Risk factors
The logistic regression analysis revealed a statistically significant direct relationship between the prevalence of AR in preschool age, the male sex with positive allergic family history, passive smoking and the violation of vitamin D3 intake in the first year of life of the child (Table 4). Male sex increases the risk of developing AR at preschool age by 2.6 times (OR = 2.6, 95% CI = 1.8-3.7, p <0.01), positive allergic family history increases the risk of AR development by almost 4 times (OR = 3.9, 95% CI = 2.8-5.4, p <0.01), passive smoking increases the risk of AR development by 1.5 times (smoking of parents at the 1st year of life OR = 1 , 6; 95% CI = 1.12.6; p <0.05; current smoking of the parents OR=1.7, 95% CI = 1.1-2.6, p <0.05) , a violation of vitamin D3 intake increases the risk of AR development by 2 times (OR = 2.0, 95% CI = 1.3-3.0, p <0.01). There was no statistically significant association between AD and prematurity, a short duration of breastfeeding (<6 months), contact with animals in the first year of life, and tobacco smoking during pregnancy.
Discussion
We compared the obtained data with the results of previously published epidemiological studies of AR in pre-school children (Table 5). The prevalence of AR among pre-schoolers in Altai Krai is comparable to the prevalence of AR among preschool children in China [14,15], the United States [9] and Turkey [10], while in Japan [16,17] and Korea [7] the prevalence of AR significantly exceeds. Differences in prevalence rates can be associated with age-related heterogeneity of children, climatic and geographical peculiarities of the country, dif-
ferent seasons of the year, during which the study was conducted and different design of studies.
Clinical and allergological characteristics of AR in preschool children of Altai Krai are comparable with previously published foreign studies. So, according to Zang et al. [15] light AR course was registered in 58.9% of children, moderate to severe - in 41.5%.
According to the results of our study, the most significant inhalant allergens in the development of AR in preschool children are home dust mites, the sensitization to which is established in 67.5% of children: sensitization to the Dermatophagoi-des pteronyssinus mite in 58.4% of children, sen-sitization to the Dermatophagoides farinae in 35.1 % of children. Similar indicators of sensitization to house dust mites by AR in preschool children were obtained by Kohn et al. [14] and Huang et al. [6]: sensitization to Dermatophagoides pteronyssi-nus was detected in 67.5% and 69.3% of children, respectively, sensitization to Dermatophagoides farinae was detected in 62.5% and 66.2% of children, respectively.
It was found that a family history, weakened by allergic diseases, passive smoking and vitamin D3 intake disorders in the first year of life increase the risk of AR development in preschool age. Similar results were obtained by foreign scientists. So, according to Alm et al. [18] male sex increases the risk of AR development by 1.8 times; according to Cho et al. [19] and Morais-Aimeda et al. [20] allergic diseases in parents increase the risk of AR development in preschool age by 3 times; passive smoking increases the risk of AR development according to Thacher et al. [21] and Peroni et al. [22] by 1,2 times; deficiency of vitamin D3 in the serum according to Bener et al. [23] increases the risk of AR in preschool children 1.6 times, and according to Yoon et al. [24] Vitamin D3 deficiency increases the risk of AR development in preschool age by 3.6 times.
Conclusion
The current study showed a high prevalence of AR among children aged 3-6 years - 12.3%, while less than half of these children (48%) had a medical-verified diagnosis of AR. Most of the children have mild severity and persistent AR, and the most significant inhalant allergens are house dust mites, birch pollen and cat fur. Factors of risk of AR development in preschool age are a burdened aller-gological family history, the male sex of the child, passive smoking and disorders of vitamin D3 intake in the first year of life.
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Contacts
Corresponding author: Shakhova Natalia Viktor-ovna, Candidate of Medical Sciences, Associate Professor of Propaedeutics Department of Children's Diseases of Altai State Medical University, Barnaul.
656038, Barnaul, Lenina Propekt, 40.
Tel.: (3852) 400883.
E-mail: natalia.shakhova@mail.ru
Kamaltynova Elena Mikhailovna, Doctor of Medical Sciences, Associate Professor of the Department of faculty pediatrics with the course of children's diseases of the medical faculty of the Siberian State Medical University, Tomsk. 634050, Tomsk, Moskovsky Prospekt, 2. Tel.: 89039529102. E-mail: eleant21@yandex.ru
Lobanov Yury Fedorovich, Doctor of Medical Sciences, Professor, Head of the Department of Propaedeutics of Children's Diseases of Altai State Medical University, Barnaul. 656038, Barnaul, Lenina Propekt, 40. Tel.: (3852) 400883. E-mail: luf@list.ru
Ardatova Tatyana Sergeyevna, Assistant of the Department of Propaedeutics of Children's Diseases of Altai State Medical University, Barnaul. 656038, r. Barnaul, Lenina Propekt, 40. Tel.: (3852) 400883. E-mail: ardatova_agmu@mail.ru
