A case for revising the strength of the relationship between childhood asthma and atopy in the developing world

Introduction. Asthma is the commonest chronic condition of children. Diagnosis remains difficult and many surrogate markers are used, such as documenting evidence of atopy. Method. Two studies investigated the role of atopy in childhood asthma. The first documented the prevalence and nature of allergy sensitivities in a group of asthmatic children compared with non-asthmatic children in Pretoria, South Africa. The second enrolled a random sample of asthmatic children and their mothers attending the Children's Chest and Allergy Clinic at Steve Biko Academic Hospital, Pretoria. Children were classified as having atopic or non-atopic asthma. Mothers completed a questionnaire to reveal atopic features. Results. In the first study, only 45.0% of asthmatic children had a positive skin-prick test (SPT), as opposed to 16.2% of control children. This is a lower proportion than in many reported international studies. In the second study, 64 children with atopic asthma and 36 with non-atopic asthma were studied, along with their mothers. The proportion of children with atopic asthma did not differ for mothers with and without a positive SPT (p=0.836), a history of asthma (p=0.045) or symptoms suggestive of an allergic disease (p=1.000), or who were considered to be allergic (p=0.806). The odds ratio (OR) of a child having atopic asthma when he or she had a mother with a doctor-diagnosed history of asthma was 4.76, but the sensitivity was low (21.9%). Conclusion. The data demonstrate that fewer asthmatic children in South Africa are atopic than was previously thought. Also, all maternal allergic or asthmatic associations are poor predictors of childhood atopic asthma. Despite the increased risk of atopic asthma in a child of a mother who has a doctor diagnosis of asthma (OR 4.76;p=0.045), this is a poor predictor of atopic asthma (sensitivity 21.9%).