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\begin{document}

\title{Development of allergic rhinitis in early life: A prospective cohort
study in high-risk infants}



\author[1]{Sawako Masuda}%
\author[1]{Mizuho Nagao}%
\author[1]{Satoko Usui}%
\author[1]{Kazutaka Nogami}%
\author[2]{Yuji Tohda}%
\author[1]{Takao Fujisawa}%
\affil[1]{National Hospital Organization Mie National Hospital}%
\affil[2]{Kindai University Faculty of Medicine Graduate School of Medical Sciences}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Background: Allergic rhinitis (AR) is the most common allergic disease
in children and is closely associated with asthma in the context of
atopic march. The development process of AR in early childhood, however,
is not well understood due to the absence of definitive diagnostic
criteria. We prospectively investigated the process in regard to not
only the nasal symptoms and sensitization, but also the nasal cytology,
in relation to asthma in a high-risk cohort. Methods: Infants under 2
years of age with atopic dermatitis (AD) and/or food allergy (FA)
without a diagnosis of asthma were recruited and followed prospectively
for 2 years. The phenotype of perennial AR was classified based on the
presence/absence of 1) persistent nasal symptoms, 2) nasal eosinophils
and 3) HDM sensitization, the most common allergen for perennial AR in
Japan. AR-like phenotypes were defined as positive for at least 2 of
those 3 categories. Results: A total of 304 children were enrolled, and
242 subjects (80\%) completed the 2-year observation. The prevalence of
eosinophilia in nasal secretions increased from 18.5\% to 69.9\%, while
HDM-specific IgE \textgreater{}0.35 kUA/L increased from 30.6\% to
74.8\%. AR-like phenotypes increased from 18.4\% to 65.0\%. The
cumulative incidence of physician-diagnosed asthma during the 2-year
follow-up was significantly higher in the subjects with an AR-like
phenotype at 1 year than in those with a non-AR phenotypes. Conclusions:
The prevalence of an HDM-related AR-like phenotype was markedly
increased during infancy in high-risk infants with AD/FA and was
associated with asthma.%
\end{abstract}%



\sloppy


\textbf{Development of allergic rhinitis in early life: A prospective
cohort study in high-risk infants}

Sawako Masuda\textsuperscript{1}, Mizuho Nagao\textsuperscript{2},
Satoko Usui\textsuperscript{1}, Kazutaka Nogami\textsuperscript{2}, Yuji
Tohda\textsuperscript{3}, Takao Fujisawa\textsuperscript{2},
Investigators of Kinki Hokuriku Airway Disease Conference (KiHAC)

\textsuperscript{1}Department of Otorhinolaryngology and Allergy Center,
National Hospital Organization Mie National Hospital, Tsu, Japan

\textsuperscript{2}Department of Pediatrics and Allergy Center, National
Hospital Organization Mie National Hospital, Tsu, Japan

\textsuperscript{3}Department of Respiratory Medicine and Allergology,
KINDAI UNIVERSITY, Faculty of Medicine, Osaka-Sayama, Japan

Running title: Development of allergic rhinitis in early life

Correspondence

Takao Fujisawa, M.D.

National Hospital Organization Mie National Hospital

357 Osato-Kubota, Tsu, Mie 514-0125, Japan

Tel: 81-59-232-2531, Fax: 81-59-232-5994

E-mail: eosinophilosophy@gmail.com

Word count: 2615

Number of tables: 3; number of figures: 3

(2 supplemental figures)

\textbf{Conflicts of interest}

SM has received research grants from Torii Pharmaceutical Co., Ltd. TF
has received lecture fees from Maruho Co., Ltd., and Torii
Pharmaceutical Co., Ltd.. All other authors declare that they have no
conflicts of interest.

\textbf{Funding information} :

This research was supported in part by an unconditional grant-in-aid
from Kyorin Pharmaceutical Co., Ltd.

\textbf{Abstract}

\textbf{Background:} Allergic rhinitis (AR) is the most common allergic
disease in children and is closely associated with asthma in the context
of atopic march. The development process of AR in early childhood,
however, is not well understood due to the absence of definitive
diagnostic criteria. We prospectively investigated the process in regard
to not only the nasal symptoms and sensitization, but also the nasal
cytology, in relation to asthma in a high-risk cohort.

\textbf{Methods:} Infants under 2 years of age with atopic dermatitis
(AD) and/or food allergy (FA) without a diagnosis of asthma were
recruited and followed prospectively for 2 years. The phenotype of
perennial AR was classified based on the presence/absence of 1)
persistent nasal symptoms, 2) nasal eosinophils and 3) HDM
sensitization, the most common allergen for perennial AR in Japan.
AR-like phenotypes were defined as positive for at least 2 of those 3
categories.

\textbf{Results:} A total of 304 children were enrolled, and 242
subjects (80\%) completed the 2-year observation. The prevalence of
eosinophilia in nasal secretions increased from 18.5\% to 69.9\%, while
HDM-specific IgE \textgreater{}0.35 kUA/L increased from 30.6\% to
74.8\%. AR-like phenotypes increased from 18.4\% to 65.0\%. The
cumulative incidence of physician-diagnosed asthma during the 2-year
follow-up was significantly higher in the subjects with an AR-like
phenotype at 1 year than in those with a non-AR phenotypes.

\textbf{Conclusions:} The prevalence of an HDM-related AR-like phenotype
was markedly increased during infancy in high-risk infants with AD/FA
and was associated with asthma.

(245 words)

\textbf{Keywords}

Rhinitis, allergic, perennial, asthma, infant, child, cell count,
eosinophils

\textbf{ABBREVIATIONS}

??

\textbf{Key Message}

Allergic rhinitis (AR) is a cardinal disease in the atopic march.
However, the precise course of AR's development has remained unclear,
partly due to the absence of diagnostic criteria for early AR. We
investigated AR development in a cohort of high-risk infants with atopic
dermatitis and/or food allergy by prospectively observing them for
symptoms and sensitization and also their nasal cytology. We found that
the prevalence of AR increased markedly between 1 and 3 years of age and
was associated with onset of asthma.



\textbf{INTRODUCTION}

Allergic rhinitis (AR) is a common allergic disease in childhood, and
its prevalence is increasing worldwide.\textsuperscript{1-3} AR
significantly impacts the quality of life by causing various problems,
such as sleep disturbance, emotional stress and impairment of school
activities.\textsuperscript{4} More importantly, AR is a risk factor for
asthma as ``one airway, one disease''.\textsuperscript{5-7} The
International Study of Asthma and Allergies in Childhood (ISAAC)
employed standardized methodology and showed clearly that the prevalence
of AR increased during childhood, i.e., from 6-7 y.o. to 13-14
y.o.\textsuperscript{8}

However, the onset of AR in children is not well understood due to the
absence of definitive diagnostic criteria. We previously reported that,
in school children with asthma, AR started even before 3 years of
age.\textsuperscript{9} In the PARIS birth cohort study, the prevalence
of AR-like symptoms was 9.1\% at 18 months of
age.\textsuperscript{10}However, in the above studies, diagnosis of AR
was based only on the parents' recall in the former and a symptom
questionnaire in the latter. In addition, those reports did not provide
a good description of the development process.

With the aim of improving our understanding of the onset of AR, we
designed and carried out a high-risk infant cohort study, the Impact of
Allergic Rhinitis on Atopic March (IRAM) in children. Infants less than
2 years of age who had food allergy or atopic dermatitis were recruited
into the study. We prospectively followed up not only their nasal
symptoms, but also their nasal cytology and allergic sensitization for 2
years. The ARIA guidelines classify AR as intermittent or persistent,
not seasonal or perennial.\textsuperscript{11} However, Japan is
characterized by sole high morbidity of seasonal AR due to Japanese
cedar pollen and a high prevalence of perennial AR due to house dust
mite (HDM). Accordingly, the Japanese guidelines include classifications
for seasonal AR and perennial AR.\textsuperscript{12} Here, in light of
the relatively late development of pollen sensitization in young
children,\textsuperscript{13} we focused on development of
HDM-sensitized perennial AR in infancy.

\textbf{METHODS}

\textbf{Study design and subjects}

This is a multicenter observational prospective cohort study named IRAM
(Impact of Rhinitis on Atopic March; UMIN000004157). Children aged 6--23
months with physician-diagnosed atopic dermatitis (AD), food allergy
(FA) and/or AR were recruited from 30 sites in the central region of
Japan in 2011 by investigators of the IRAM study group in Kinki Hokuriku
Airway Disease Conference (KiHAC).\textsuperscript{14} The IRAM study
aimed to delineate atopic march in high-risk infants, focusing
especially on development of AR and asthma. Children who had been
diagnosed with asthma were not enrolled. In the on-going follow-up of
the IRAM cohort, the first part consisted of 5 visits---at 6-month
intervals---in the first 2 years.\textsuperscript{13} At enrollment, the
following background factors were surveyed: the family history of
allergic diseases, history of wheezing not diagnosed as asthma, history
of lower respiratory infections, number of siblings, environmental
factors such as pets and passive smoking at home, and other medical
information. Every 6 months, the study physicians diagnosed asthma based
on the Japanese guidelines for pediatric
asthma.\textsuperscript{15}Blood and nasal secretion samples were
collected at enrollment, 1 year and 2 years.

The study was approved by the Ethics Committee of Mie National Hospital,
(\#21-9). The parents/guardians of all participants gave written
informed consent.

\textbf{Assessment of respiratory symptoms}

A questionnaire regarding respiratory symptoms was developed by making
minor modifications of the questionnaire of the International Study of
Asthma and Allergies in Childhood.\textsuperscript{16} The
parents/guardians completed the questionnaire at 6-month intervals. For
perennial AR, the following question was used: ``In the past 6 months,
has your child consistently had a problem with sneezing, or a runny or
blocked nose, even when he/she DID NOT have a cold or flu?'' If the
answer was ``yes'', the parents further indicated each symptom, i.e.,
sneezing, runny nose, and/or blocked nose. For asthma, the core question
was: ``Has your child had wheezing or whistling in the chest in the last
6 months?''

\textbf{Examination of nasal secretions}

Cytological examination of nasal secretions was performed when children
had no signs of an acute respiratory infection. Nasal secretions were
sampled by swabbing the bilateral inferior turbinates with cotton swabs.
The samples were spread onto a slide glass, air-dried, fixed and stained
with Hansel solution (Eosinostein\selectlanguage{ngerman}\textsuperscript{®}; Torii
Pharmaceutical, Tokyo, Japan). The specimens were examined by light
microscopy for eosinophils, neutrophils and bacteria by a single
well-trained laboratory technician. Nasal eosinophilia was defined as
the presence of more than a few eosinophils in the whole field. The
percentage of eosinophils compared with neutrophils was also determined,
and \textgreater{}10\% was defined as significant nasal
eosinophilia.\textsuperscript{17}

\textbf{Sensitization to common allergens}

Serum samples were analyzed for total IgE and specific IgE antibodies
using the ImmunoCAP\textsuperscript{®} system according to the
manufacturer's guidelines (Phadia AB, Uppsala, Sweden). The tested
allergens were as reported elsewhere.\textsuperscript{13} In this study,
we focused on house dust mite (HDM) sensitization (positive = HDM-sIgE
\textgreater{}0.34 U\textsubscript{A}/ml).

\textbf{Classification ofHDM-sensitized perennial AR in young children}

AR is IgE-mediated inflammation of the nasal mucosa. It is diagnosed
based on the presence of typical allergic symptoms and nasal
eosinophilia, and identification of the causative
allergen(s).\textsuperscript{18,19} AR in children, however, is often
undiagnosed, or misdiagnosed because of the multitude of causes for
rhinitis.\textsuperscript{18} Thus, we tentatively classified the
phenotypes of the nasal condition in young children in relation to
HDM-sensitized perennial AR based on 3 clinical criteria: persistent
nasal symptoms, nasal eosinophilia and HDM sensitization. The various
combinations of those 3 criteria make up 8 phenotypes, as shown in Table
1. We defined the subtype that was positive for all 3 criteria as
''classical AR'', and the subtypes that were positive for 2 of the 3
criteria as ''eosinophilic rhinitis'', ''AR without nasal eosinophilia''
and ''subclinical AR'', respectively. We classified those 4 subtypes as
''AR-like phenotypes'' (Table 1). Four subtypes that met only one, or
none, of the 3 criteria were classified as ''non-AR phenotypes'' (Table
1).

\textbf{Statistical analysis}

The chi-square test for trend was used to compare the distribution of
the prevalence of various factors at each of the yearly visits. The
Kaplan-Meier method was applied to estimate the probability of asthma
onset, and the log-rank test was used to compare the probability between
AR phenotypes. All reported P values are 2-tailed, with a P value of
\textless{}.05 considered to be statistically significant. Statistical
analyses were performed with GraphPad Prism 8 (GraphPad Software; La
Jolla, California) and SPSS (version 26; SPSS; Chicago, Illinois).

\textbf{RESULTS}

\textbf{Study population}

A total of 304 children were screened, and 299 were enrolled in the
study. Of them, 269 (90\%) were retained at the
1\textsuperscript{st}year, and 237 (79\%) were retained at the
2\textsuperscript{nd} year (Figure S1). Table 2 presents the
characteristics of the study population. The mean age in months was
13.3, and 51\% of the children were less than 12 months. Figure S2 shows
the age distribution. More boys (64.5\%) than girls were enrolled. Most
(86.3\%) of the children had food allergies, including to egg (77\%),
milk (43\%), wheat (25\%) and other foods (17\%). Those rates correspond
with the reported prevalences of food allergies in
Japan.\textsuperscript{20} Atopic dermatitis was diagnosed in 70.2\% of
the children. A history of wheezing that was not diagnosed as asthma was
found in 17.3\%, and a history of lower respiratory infection was found
in 10.0\%. Table 2 also shows the prevalences of various environmental
factors such as pet keeping, presence of siblings, daycare use and
passive smoking, and a parental history of asthma and allergic rhinitis.

\textbf{Prevalence of persistent nasal symptoms}

Table 3 summarizes the changes in the prevalences of the nasal symptoms,
nasal cytology findings and HDM sensitization during the 2-year
observation period. The prevalence of each of sneezing, runny nose,
nasal eosinophils and positive HDM-specific IgE increased significantly
from enrollment to the 2\textsuperscript{nd}-year visit. Although the
high initial prevalence of neutrophils in the nasal secretions increased
even further over the 2 years, the eosinophil/neutrophil ratio also
increased, indicating that nasal eosinophilia became progressively
prevalent in early childhood.

\textbf{Prevalence of phenotypes related to perennial AR}

Figure 1 shows the changes in the prevalence of the 8 phenotypes related
to early AR. The prevalence of ''classical AR'' that met all 3 criteria
was 2.9\% at enrollment, 17.1\% at the 1\textsuperscript{st}-year visit
and 29.5\% at the 2\textsuperscript{nd}-year visit. The prevalence of
''subclinical AR''---in which nasal eosinophilia and HDM sensitization
were present even when there were no nasal symptoms---also increased
from 3.3\% at entry to 11.7 \% and 26.6 \%, respectively, at the 2 later
time-points. In contrast, the prevalence of the ''no rhinitis''
phenotype, which met none of the 3 criteria, decreased from 33.1\% to
15.2\% and 8.4\%, respectively (Fig. 1).

Since the presence/absence of each criterion individually had the
potential to have changed at each visit, a positive finding did not
always persist throughout the study. Figure 2 shows the actual numbers
of subjects classified as 3+ criteria and 2+ criteria (AR-like
phenotypes), HDM-sensitization-only, and other non-AR phenotypes at each
visit. Overall, it can be seen that the AR-like phenotypes increased
during the observation period, whereas the HDM-sensitization-only
phenotype population remained small, and the other non-AR phenotypes
decreased markedly (Fig. 2).

\textbf{Association of AR-like phenotypes with asthma during the study}

Figure 3 shows the cumulative prevalence of physician-diagnosed asthma.
The subjects who were classified as AR-like phenotypes at 1 year and 2
years had significantly higher prevalences of asthma compared with those
who were classified as non-AR phenotypes (Fig. 3B and 3C). The
cumulative prevalence of asthma did not differ between patients who were
classified as an AR-phenotype at enrollment and those who were
classified as a non-AR phenotype (Fig. 3A).

\textbf{DISCUSSION}

This study aimed to elucidate and characterize the development of
allergic rhinitis (AR) in young children below 2 y.o. who had atopic
dermatitis and/or food allergy. Those children are regarded as a
high-risk population for atopic march leading to respiratory allergies,
including asthma and AR, in later life. Since there are no definitive
diagnostic criteria for AR in young children, we tentatively defined 8
subgroups based on 3 major clinical features of HDM-related AR, which is
the most prevalent type of AR in Japanese children below the age of 6
years.\textsuperscript{12} We found that the prevalence of AR-like
phenotypes, which meet 2 or more of the 3 clinical criteria (i.e.,
persistent nasalsymptoms, nasal eosinophilia and HDM sensitization),
increased significantly during the 2-year follow-up, from an average age
of 13 months to 27 months, and was associated with the cumulative
prevalence of physician-diagnosed asthma.

Several papers have reported on the prevalence of AR in infants and
young children. The PARIS birth cohort study found that 9.1\% of infants
at age 18 months had AR-like symptoms (runny nose, blocked nose,
sneezing; apart from a cold).\textsuperscript{10} Positive associations
of AR-like symptoms with inhalant allergen sensitization, HDM
sensitization and a blood eosinophil count \selectlanguage{english}[?]400/mL were described, with
adjusted odds ratios of 2.2, 2.9 and 1.5, respectively. Osawa et
al.\textsuperscript{21} reported that general health examinations at age
18 months found that 8 (2\%) of 408 infants had both inhalant allergen
sensitization and nasal eosinophils, and 6 (1.5\%) infants also had
rhinorrhea. Zeiger et al.\textsuperscript{22} investigated nasal
basophilic cells and eosinophils in a cohort of high-risk infants with
atopic parents who participated in an intervention study of maternal
allergenic food avoidance for allergy prevention. They found that the
prevalence of nasal eosinophils increased from 0.7\% at age 4 months to
38.2\% at 48 months, and the prevalence was higher in infants with an
allergic disease such as FA. In the MAS birth cohort, the prevalence of
AR (based on the ISAAC questionnaire) was investigated from age 3 years
to 13 years.\textsuperscript{23} The prevalence of symptom-based AR
increased continuously from 6\% at age 3 to 24\% at age 13 in children
with no parental history of allergy and from 13\% to 44\% in those with
parental allergy. Sensitization to aeroallergens was a significant risk
for AR, with an odds ratio of 18.9. Collectively, AR starts in infancy
and becomes more common as children grow older, especially in those with
a genetic predisposition to allergy and/or aeroallergen sensitization.

Our present results from a high-risk cohort of infants with AD and/or FA
were in accord with those earlier findings. An added strength of our
study is that we prospectively investigated AR development in regard to
not only the nasal symptoms but also nasal eosinophilia and
sensitization during a critical 2-year period of infancy (up to 37.3
months of age).

AR is a Th2-type inflammatory disease of the upper
airways.\textsuperscript{24,25} It is diagnosed on the basis of the
pathogenesis, i.e, IgE antibody to an aeroallergen, IgE-mediated mast
cell activation leading to mucosal symptoms such as rhinorrhea, nose
itching, sneezing, blocked nose, and eosinophilic inflammation of the
nasal mucosa leading to nasal hyper-reactivity. Positive findings for
the ''triad'' of AR criteria, i.e., 1) ``allergic'' nasal symptoms, 2)
aeroallergen sensitization and 3) nasal eosinophilia, can establish the
diagnosis. However, in the early stage of AR development, the triad may
not be present due to the non-specific nature of symptoms and variable
nasal mucosal pathology. Moreover, in preschool children, viral upper
respiratory infections are common and symptom-recognition relies on a
mother's observation, not the perception or complaints of the child
him/herself. To circumvent those problems, we employed a classification
system of AR-like phenotypes that allows for fluctuation of AR
manifestations in children. We found that our classifications
corresponded well with previous observations in several birth cohort
studies and, importantly, correlated positively with the prevalence of
asthma.

Nasal eosinophilia has been variously defined. In adults, more than
10\%\textsuperscript{17} or 20\%\textsuperscript{26} eosinophils in
inflammatory cells were regarded to be eosinophilia. In 11- to
15-year-old children, more than 10 eosinophils per high-power field was
defined as nasal eosinophilia, with a diagnostic specificity of 96\% and
a sensitivity of 62\% for AR.\textsuperscript{27} We defined nasal
eosinophilia in young children as when more than a few eosinophils were
present in the whole field, which may be a lower cut-off level for nasal
eosinophilia compared with those in adults and older children. Because
the number of eosinophils in nasal smears was reported to be much lower
in young children with rhinorrhea and no signs of acute
infection,\textsuperscript{28} we employed our above definition. Yet, we
found that a higher cut-off of \selectlanguage{english}[?]10\% for the eosinophil/neutrophil ratio
yielded similar results, although the prevalence of eosinophilia with
this definition was lower than that with the former definition. Overall,
we believe that our definition of positive nasal eosinophilia may be
optimal due to its higher sensitivity.

Multimorbidity is a characteristic feature of allergies in
children.\textsuperscript{25} The MeDALL (Mechanisms of the development
of ALLergy) study, involving 12 cohort studies, reported that
coexistence of asthma, rhinitis and eczema in the same child was more
prevalent than would be expected by chance.\textsuperscript{29} An
important aspect of multimorbidity is development of asthma, because it
places the largest burden on children. We previously reported that 78\%
of children younger than 10 years old with asthma had AR, and onset of
AR preceded asthma onset in one-third of them.\textsuperscript{9} In a
German MAS birth cohort, AR at 2 years and 5 years of age predicted
later development of wheeze.\textsuperscript{6} Our present study, in
which we focused on ``multimorbid'' infants with AD and/or FA, confirmed
those earlier findings.

This study has several limitations. First, the number of subjects was
relatively small compared with large birth cohort studies. However,
prospective investigation of the development of AR relied on not only
the nasal symptoms but also HDM sensitization and nasal eosinophilia,
which we believe enhanced the reliability of our findings. Second,
definitive diagnosis of asthma at an early age is difficult, and the
asthma outcome findings of this study may not be accurate. For that
reason, we continue to follow the subjects for development of school-age
asthma and will confirm our results by using more objective findings,
such as lung function. Third, our cohort was high-risk infants with
AD/FA, and we may not be able to extrapolate the findings to natural
history in the general population. However, because of the focused
population, we were able to describe the clinical course of early AR in
our relatively small number of subjects.

In conclusion, we described the early phase of AR development in a
high-risk cohort of children and proposed practical diagnostic criteria
for AR in young children. Our findings show that AR increased markedly
during 1 to 3 years of age, and that increase was positively associated
with the prevalence of asthma. Additional studies will be needed to
clarify the natural history of AR in children in the context of atopic
march.

\textbf{Authors' contributions}

SM, TF and MN conceived the idea and designed this study. SM, SU, MN,
and TF collected the data, and MN and SM performed the statistical
analyses. All co-authors gave input and agreed to the final submitted
version. All authors read and approved the final manuscript.

\textbf{Acknowledgements}

The authors would like to thank Mr. Yoshiki Segawa at the Institute for
Clinical Research, Mie National Hospital, for his excellent technical
assistance. The authors would also like to thank the IRAM study
investigators who actively participated in the study: Dr. Ogura Kanae
(Department of Pediatrics, Kyoto Yawata Hospital); Drs. Yutaka Suehiro,
Yukiko Hiraguchi, Yuko Ebishima and Saeko Shimodera (Department of
Pediatrics, Osaka Prefectural Medical Center for Respiratory and
Allergic Diseases); Drs. Makoto Kameda, Yuri Takaoka, Tomoki Nishikido,
Hiroko Yajima and Mineko Ikeoka (Department of Pediatrics, Osaka
Prefectural Medical Center for Respiratory and Allergic Diseases); Drs.
Hideo Ogura and Yukiko Ogura (Department of Pediatrics, Kochi National
Hospital); Dr. Gyokei Murakami (Murakami Pediatric \& Allergy Clinic);
Drs. Toshimi Nakamura and Yoko Yamashita (Department of Pediatrics,
Kanazawa Medical University Hospital); Dr. Yoko Kawasaki (Hotarugawa
Clinic), Drs. Taku Oishi, Hiroaki Hisakawa, Akihiko Hisakawa and Hiroshi
Wakiguchi (Department of Pediatrics, Kochi University); Dr. Hiroyasu
Okahata (Department of Pediatrics, Kure Kyousai Hospital); Drs. Ikuo
Okafuji and Shigeta Shimizu (Kobe City Medical Center General Hospital);
Drs. Naomi Kondo, Eiko Matsui and Kazuo Kubota (Department of
Pediatrics, Gifu University Hospital); Dr. Yutaka Morisawa (Kera Child
\& Allergy Clinic); Dr. Mitsuhiko Nambu (Department of Pediatrics, Tenri
Hospital); Dr. Miki Takao (Department of Pediatrics, Takashige Memorial
Hospital); Dr. Yoshinori Matsuwaki (Department of Otorhinolaryngology,
Ota General Hospital); Drs. Yuichi Adachi and Toshiko Itazawa
(Department of Pediatrics, Toyama University); Dr. Youichi Onoue (Onoue
Pediatric Clinic); Dr. Osamu Higuchi (Department of Pediatrics, Kurobe
City Hospital); Dr. Yoko Adachi (Department of Pediatrics, Takaoka
Minami Hospital); Dr. Akihiko Terada (Terada Kid's Allergy \& Asthma
Clinic); Dr. Yoko Osawa (Department of Otorhinolaryngology, Tannan
Regional Medical Center); Dr. Rentaro Abumi (Abumi Clinic); Drs. Tatsuya
Fuchizawa and Junko Yamamoto (Saiseikai Takaoka Hospital), Drs. Motokazu
Nakabayashi and Masaharu Kasei (Department of Pediatrics, Kouseiren
Takaoka Hospital); Drs. Takanori Abe and Mayumi Sugimoto (Department of
Pediatrics, Japanese Red Cross Kochi Hospital); Dr. Hisashi Kondo (Kondo
Pediatrics Clinic); and Drs. Akiko Toga and Nobuyuki Doichi (Department
of Pediatrics, Fukui-ken Saiseikai Hospital).

\textbf{Funding}

This study was supported, in part, by an unconditional grant from Kyorin
Pharmaceutical Inc.

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Child Health.} 2012;48(10):913-920.

2. Bjorksten B, Clayton T, Ellwood P, Stewart A, Strachan D, Group IPIS.
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\textbf{Figure legends}

FIGURE 1

Prevalence of 8 rhinitis-related phenotypes (Table 1) classified based
on the 3 features of allergic rhinitis (AR), i.e., nasal symptoms, nasal
eosinophilia and HDM-sensitization at entry (open bar), 1 year
(dot-shaded bar) and 2 years (cross-shaded bar).

FIGURE 2

Transition of phenotypes during 2-year follow-up. The numerical values
are the number of subjects, and the size of each circle reflects the
numerical value.

FIGURE 3

Cumulative percentage of subjects with physician-diagnosed asthma in
AR-like phenotypes (solid line) and non-AR-like phenotypes (dotted line)
diagnosed at entry (A), 1 year (B) and 2 years (C). The children with
AR-like phenotypes at entry (hazard ratio: 1.5 (95\% CI: 0.75--3.0); P =
0.26), at 1 year (hazard ratio: 2.0 (95\% CI: 1.2--3.5); *P =0.02) and
at 2 years (hazard ratio: 2.0 (95\% CI: 1.2--3.5); *P =0.04) had higher
cumulative percentages of asthma than children with the non-AR-like
phenotypes.

\textbf{Legends for supplemental figures}

FIGURE S1

Flow-diagram showing enrollment and retention of subjects.

FIGURE S2

Age-distribution of subjects at enrollment.

\textbf{Hosted file}

\verb`Table_new2.docx`  available at \url{https://authorea.com/users/435621/articles/538515-development-of-allergic-rhinitis-in-early-life-a-prospective-cohort-study-in-high-risk-infants}

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