EC

doi: 10.1111/j.1365-2222.2010.03541.x

Clinical & Experimental Allergy, 40, 11301141

 2010 c

REVIEW

Blackwell Publishing Ltd

Phenotypes of childhood asthma: are they real?

B. D. Spycher1, M. Silverman2,3 and C. E. Kuehni1
1

Swiss Paediatric Respiratory Research Group, Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland, 2Department of Infection,

Immunity & Inammation, The Leicester Childrens Asthma Centre, Division of Child Health, University of Leicester, Leicester, UK and 3Department of Respiratory Medicine, Institute for Lung Health, University of Leicester, Leicester, UK

Clinical & Experimental Allergy

Correspondence: Claudia E. Kuehni, Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, CH-3012 Bern, Switzerland. E-mail: kuehni@ispm.unibe.ch Cite this as: B. D. Spycher, M. Silverman and C. E. Kuehni, Clinical & Experimental Allergy, 2010 (40) 11301141.

Summary It has been suggested that there are several distinct phenotypes of childhood asthma or childhood wheezing. Here, we review the research relating to these phenotypes, with a focus on the methods used to dene and validate them. Childhood wheezing disorders manifest themselves in a range of observable (phenotypic) features such as lung function, bronchial responsiveness, atopy and a highly variable time course (prognosis). The underlying causes are not sufciently understood to dene disease entities based on aetiology. Nevertheless, there is a need for a classication that would (i) facilitate research into aetiology and pathophysiology, (ii) allow targeted treatment and preventive measures and (iii) improve the prediction of long-term outcome. Classical attempts to dene phenotypes have been onedimensional, relying on few or single features such as triggers (exclusive viral wheeze vs. multiple trigger wheeze) or time course (early transient wheeze, persistent and late onset wheeze). These denitions are simple but essentially subjective. Recently, a multidimensional approach has been adopted. This approach is based on a wide range of features and relies on multivariate methods such as cluster or latent class analysis. Phenotypes identied in this manner are more complex but arguably more objective. Although phenotypes have an undisputed standing in current research on childhood asthma and wheezing, there is confusion about the meaning of the term phenotype causing much circular debate. If phenotypes are meant to represent real underlying disease entities rather than supercial features, there is a need for validation and harmonization of denitions. The multi-dimensional approach allows validation by replication across different populations and may contribute to a more reliable classication of childhood wheezing disorders and to improved precision of research relying on phenotype recognition, particularly in genetics. Ultimately, the underlying pathophysiology and aetiology will need to be understood to properly characterize the diseases causing recurrent wheeze in children.

What is a phenotype? Childhood asthma, or wheezing disease, is highly variable in both its clinical presentation and time course [1]. Throughout the last century, there have been conicting views of wheezing disorders in childhood as either a group of several discrete disease entities or a single although variable disease [26]. In particular, it was unclear whether wheezing associated with recurrent respiratory infection in the rst years of life (wheezy bronchitis), is a precursor of asthma or whether it is a different disease [24, 7, 8]. In the past few decades, a growing number of cohort studies have documented the natural history of these disorders in more detail, and results have been used to support one or the other view [2, 3, 9].

Currently, the prevailing paradigm is that asthma (and wheezing) in children consists of several discrete disease entities or syndromes [1013]. For lack of a denite biological basis for disease heterogeneity genetics or causal agent classication has been based on phenotypes. Some phenotypic classications such as that by the Tucson group into early transient, late onset and persistent wheeze [9] have found wide popularity. The number of publications containing the terms phenotype, asthma or wheeze and paediatric or child in Pubmed (excluding articles with genetics as a keyword, because of the alternative use of the term phenotype) has increased steeply, from less than ve publications annually until the mid-1990s to well over 40 in recent years (Fig. 1).

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50 40 30 20 10 0 1980 1985 1990 1995 2000 2005 2010

Table 1. Different usages of the term phenotype Usage Description Example of usage

Bronchial Any observable Includes signs, symptoms, hyperresponsiveness measurements and trait (partial [103], see also Table 2 biological markers phenotype) Difcult or severe Clinically useful Denes groups that differ asthma [104] see also grouping with respect to features of Tables 3 and 4 interest: e.g. risk factors, response to treatment, prognosis Hypothesized Denes a condition that is Atopic asthma and disease entity thought to represent a virus-induced wheeze distinct disease entity [71] see also Tables 3 and 4

Fig. 1. Annual tally of articles found in Pubmed using the terms phenotyp AND (wheez OR asthma) AND (child OR pediatric) (all terms searched in all elds, excluding articles with genetics as a keyword).

Currently, phenotypes have an undisputed standing in the research on childhood asthma, and their existence is often uncritically accepted. They are also increasingly used for clinical decision making in treatment guidelines [1418]. Despite this widespread usage, there is confusion about what the term phenotype actually means. In particular, it is unclear whether phenotypes are simply pragmatic constructs or whether they have a more fundamental meaning, standing for separate disease entities. This matters: if they describe something real, the classication should be harmonized so that it best represents the true underlying entities. If, however, asthma phenotypes are merely utilitarian, any classication may be valid. As introduced by Johannsen and Shull early last century [1920], the term phenotype was intended to characterize different types of organisms distinguishable by their observable characteristics such as their shape, structure, size or colour. Today, the term phenotype is used in a variety of ways. To geneticists, a phenotype can be any observable trait of an organism, such as its morphology, biochemical or physiological properties or behaviour, without assuming the existence of distinct types (Table 1, row 1). In the literature on phenotypes of wheezing illness, the meaning of the term is vague and rarely specied. Usage ranges from the view that phenotypes are useful but entirely articial constructs (Table 1, row 2) to the belief that they represent underlying disease entities that, like biological species, await discovery (Table 1, row 3). Here, we adopt the view that phenotypes are hypothesized disease entities but use the term more loosely when reviewing some of the literature. To qualify as a disease entity, we would require a condition to affect a signicant number of patients and be aetiologically distinguishable from other conditions.
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This review is a critical summary of past and current approaches to categorizing children who wheeze into phenotypes. In particular, we: (1) briey describe childhood wheezing disease with its associated symptoms and traits; (2) explain why it might be important to distinguish phenotypes; (3) describe different methodological approaches to dene phenotypes; (4) discuss methods for validating phenotypes as true disease entities or at least clinically useful constructs and (5) make some suggestions for further research. The clinical spectrum of wheezing disease and asthma where are the boundaries? Wheezing disease in children manifests itself in a wide spectrum of measurable features, including symptoms, signs and associated traits (Table 2). These features are not the main focus of the present review and the list in Table 2 is not exhaustive. Important, however, are the following observations. First, these features are associated with each other (i.e. they are not independent) but the associations are modest. For instance, children with wheeze will be more likely to have bronchial hyperresponsiveness (BHR) than children without wheeze. This means there are more children with both wheeze and BHR than would be expected if these features were independent that is, if each feature were randomly distributed among all children regardless of the presence of other features. However, quite surprisingly, the overlap between the features is only moderately greater than it would be assuming independence (Fig. 2) [21, 22]. A consequence of this is that if the denition of asthma or of an asthma phenotype requires the presence of more than one of these features, group sizes quickly become small. For instance, a phenotype requiring wheeze, atopy and BHR would include only 7.3% of children who have any one of these features (Fig. 2). Second, the presence of these features, particularly symptoms, varies by age [3, 2325] and over short periods

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Table 2. Features of wheezing illness in children Dimensions Symptoms Features Wheeze Cough Shortness of breath/ difculty breathing/ chest tightness Symptom history/age of onset Expiratory polyphonic wheeze Barrel chest, etc. Reversible airway obstruction Air ow variability Bronchial hyperresponsiveness Skin sensitivity Increased total IgE Increased specic IgE Blood eosinophilia Diagnostic process Self, parental or clinical observation

Signs

Physical examination

Lung function

Bronchial responsiveness Atopy

Airway inammation

Response to therapy

Raised exhaled nitric oxide fraction (FeNO) Sputum eosinophilia Bronchoalveolar lavage, and/or other sputum induction or inammatory markers exhaled breath Airway wall Bronchial biopsy inammation and/or remodelling Bronchodilator response Spirometry Corticosteroid responsiveness Treatment trial

Spirometry plus bronchodilator response Twice daily peak ow meter/serial spirometry Diverse direct and indirect bronchial challenge tests Skin prick tests Serum IgE RAST, ELISA Differential white cell count FeNO measurement

of time [26]. Third, many of the listed measurements are costly, difcult to perform in infants and young children or pose ethical problems. Bronchial biopsy is an example. There is therefore a paucity of data on children that would allow the interdependencies of these measurements and their association with wheezing illness throughout childhood to be examined. Selection of the features dening asthma has been much debated. While the diagnosis of asthma may be easy to make in a patient with all the classical features of asthma such as recurrent attacks of wheeze, reversible airway obstruction, sensitization to aeroallergens and bronchial hyperresponsiveness, it can be quite difcult in patients who have only some of these features. In fact, only a few features are necessary for a clinical diagnosis of asthma in children and none are sufcient. At some stage, the prevailing denition of asthma has required recurrent wheeze, reversible airway obstruction, BHR and

Fig. 2. Venn diagrams showing overlap of the features wheeze, atopy and bronchial hyperresponsiveness (BHR) in: (a) a real general population; and (b) a hypothetical population in which these features have the same prevalence but are totally independent. The prevalences (pb) in (b) were computed by multiplying the prevalences (pa) of respective features in the original real population with each other, e.g. pb(Current wheeze, BHR but no atopy) = pa(Current wheeze) pa(BHR)(1pa(atopy)). Source: Unpublished data from the 1990 Leicester respiratory cohorts. Current wheeze, Z1 episode of wheeze in the past 12 months; atopy, Z1 positive skin prick test (dog, cat, grass or house dust mite); BHR, bronchial hyperresponsiveness (lowest quintile of PC20).

airway inammation as necessary elements [27]. The current trend is again, as proposed decades ago by Dame TurnerWarwick, towards a simpler more pragmatic denition (variable wheeze with no other identiable causes and responding to asthma treatment) [28, 29] requiring only wheeze (or dry cough assuming that a cough-variant form of asthma exists) and evidence of reversible airway obstruction (including bronchodilator response) [18, 30]. Even these features may be absent during long, symptomfree intervals. Other features such as atopy, BHR and
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measures of airway inammation, although typical of asthma, are often absent in children with clinically relevant disease [3133] and occur in many asymptomatic children (Fig. 2). Why distinguish phenotypes? Ideally, we would like to dene groups of patients that are homogenous in their clinical features, risk factor proles, responses to treatment and prognoses. Such coherent groups would greatly facilitate research and clinical management by (A) improving precision in epidemiological and clinical studies, (B) enabling targeted treatment and preventive strategies and (C) improving the prediction of long-term outcomes. The most coherent groups with regard to these aspects are those representing different underlying diseases (Table 1, row 3). If underlying biological processes were clearly understood, precise diagnostic markers could be used to dene these groups. However, in the absence of such gold standards, there is a need for a phenotypic classication. Incidentally, even within a well-characterized disease for which a diagnostic gold standard exists, such as cystic brosis, there may be large phenotypic variability and a need to dene more homogenous subgroups. (A) Improving precision in genetic and epidemiological studies Poor phenotype denition has been recognized as one of the main limitations for studying the genetics of asthma [3436]. The vast majority of genetic association studies have used the broad category asthma (usually doctor diagnosed) as outcome [37] and only few studies [38, 39] have focused on more specic phenotypes of childhood wheezing. Causative genes discovered to date explain only a small fraction of asthma heritability despite the considerable investment in asthma genetic research [40, 41]. Improved phenotype denition may help in identifying the missing heritability [42]. Numerous studies have shown that phenotypes can differ in their association with asthma risk factors [9, 33, 4348]. Phenotypic differences in the outcomes used may explain some of the contradictory ndings from studies relating to the effects of risk factors on the development of wheeze, such as breastfeeding [49], or exposure to pets [50]. In the Tucson cohort, for instance, breastfeeding was associated with a lower overall incidence of wheeze in the rst 2 years of life. However, breastfed children of atopic mothers had an increased risk of recurrent wheeze at age 6 [51]. (B) Improving treatment Importantly for clinical practice, phenotypes can differ in their response to treatment [5254]. For instance, main 2010 c

tenance treatment with inhaled corticosteroids appears to be more effective in children with risk factors for later asthma than in children with intermittent wheezing [53]. Increasingly, asthma guidelines therefore recommend phenotype-specic treatment [1416, 5558]. This might be particularly important with regard to very severe asthma. Patient selection becomes essential for cytokinespecic therapies such as monoclonal antibodies against interleukin-5 [59, 60]. Although these therapies are currently mainly targeted at adults, future paediatric usage is likely for children with very severe disease. (C) Improving the prediction of long-term outcomes Identifying phenotypes that would allow predicting longterm disease outcome from an early age has been a long sought goal. Phenotypes dened in early childhood have been shown to differ markedly in their prognosis into later childhood [61], adolescence [62] and adulthood [63, 64]. Even wheezing conditions that appear to be transient in early childhood may be precursors of obstructive airway disease in later life [65]. How are phenotypes dened? Phenotype denitions have followed one of two approaches. The rst uses a single or few disease characteristics to dene phenotypes, here referred to as onedimensional. The second approach uses a wide range of characteristics or disease dimensions, referred to as multidimensional. The one-dimensional approach The common way to dene phenotypes has been to classify children with wheeze into groups based on simple criteria involving one or few clinical features. Popular criteria include triggers of wheezing episodes (or shortterm temporal pattern), severity of wheezing (usually based on the frequency of episodes), or retrospective symptom history since early childhood (long-term temporal pattern) (Table 3). These phenotype denitions were typically introduced in single cohort studies. In the Melbourne cohort, one of the oldest respiratory cohort studies, children with wheeze at age 7 years were divided into three groups based on frequency and triggers of wheezing episodes in the past year: (1) mild wheezy bronchitis (less than ve episodes, only associated with apparent respiratory tract infection (RTI); (2) wheezy bronchitis (greater than or equal to ve episodes, only associated with RTI); and (3) asthma (at least one episode not associated with RTI) (Table 3, part D) [3]. Compared with controls (asymptomatic at age 7) the groups 13 had increasingly worse prognosis at later follow ups to the age of 42 [64, 66, 67] leading to the conclusion that these

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Table 3. Summary of frequently used phenotypes of childhood wheeze and asthma Related but not synonymous labels Non-atopic wheeze Early transient wheeze

Labels

Synonyms

Denitions Episodes of wheeze only during viral RTI

Published associations Risk factors [26, 96] Other clinical features [3] Gene expression [93] Prognosis [6466, 73] Response to treatment [52, 53] Risk factors [9, 25, 4348, 77, 81, 82, 94, 95, 105107] Other clinical features [9, 32, 44, 45, 77] Prognosis [62, 63]

(A) Triggers/short-term temporal pattern Exclusive viral wheeze Episodic (viral) wheeze [15] [4, 71, 72] Recurrent bronchiolitis (USA) Wheezy bronchitis [3] Multiple trigger wheeze [26] Asthma [3] Chronic wheeze (B) Long-term temporal pattern Early transient wheeze [9]

Wheeze during but also apart from viral RTI Wheeze only during the rst 3 years of life with remission Wheeze during the rst 3 years of life persisting into school-age Wheeze beginning after 3 years of age

Atopic asthma

Exclusive viral wheeze Episodic viral wheeze Non-atopic persistent wheeze (GINA) [30] Intrinsic asthma Multiple trigger wheeze Atopic wheeze/asthma Extrinsic asthma Exclusive viral-induced wheeze In older children/adults: Exercise-induced asthma Drug-induced asthma Multiple trigger wheeze

Persistent wheeze [9]

Persistent early onset wheezing

Late-onset wheeze [9]

(C) Atopy Non-atopic wheeze/asthma

Intrinsic asthma [108] Non-atopic persistent wheeze [109]

Wheeze/reversible airow obstruction without allergic sensitization

Risk factors [97, 110112] Other clinical features [97] Prognosis [63, 95] Response to treatment [113]

Atopic wheeze/asthma

Extrinsic asthma [108] Atopic persistent wheeze [109] Childhood asthma

Wheeze/reversible airow obstruction with allergic sensitization

(D) Severity Childhood wheeze (e.g. Melbourne cohort [3])

Asthma (e.g. GINA [30])

Asthma Childhood wheeze as a single disorder varying by degrees of severity Grades dened by number of episodes, and association or not with RTI Asthma as a single disorder varying by degrees of severity Grades dened by frequency of symptoms, or lung function decit

Risk factors [114] Other clinical features [3] Prognosis [3, 64, 66, 67, 114] Response to treatment [115]

RTI, respiratory tract infection.

phenotypes represented varying grades of severity of the same disease [3, 68, 69]. This all is one disease concept contradicted earlier claims that wheezy bronchitis was a separate disease, distinct from asthma, and propagated a change in the treatment of wheezy bronchitis, from antibiotics to inhaled bronchodilators and steroids. In the early 1990s, Wilson and Silverman reintroduced the hypothesis that several diseases exist within the spectrum of wheezing disorders in childhood [4, 8, 26, 70]. They distinguished children who experience episodes of wheeze only during viral RTI (exclusive viral wheeze)

from those who also wheeze between viral RTI, i.e. have interval symptoms (multiple-trigger wheeze) and reviewed evidence showing that these groups differ in many aspects, including association with atopy, measures of bronchial inammation, response to treatment and longterm prognosis (Table 3, part A) [71, 72]. This phenotype classication has been applied in different cohort studies [65, 73, 74] and has recently been recommended as an aid for treatment decisions [15]. In the mid-1990s, the Tucson group introduced a classication of children based on retrospective symptom
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history in the rst 6 years of life into transient early wheezing (wheeze in rst 3 years of life but no wheeze at 6 years), late-onset wheezing (no wheeze until age 3 years of life, but wheeze at 6 years) and persistent wheezing (wheeze both before age 3 and at age 6) (Table 3, part B) [9]. As this classication is based on retrospective symptom history at the age of 6, it cannot be used to guide treatment decisions for younger children. However, it has become the most widely used model in epidemiological studies [25, 4346, 7582]. Pros and cons of the one-dimensional approach The obvious advantage of one-dimensional phenotype denitions is that they are simple. If they are useful, simple phenotypic denitions are preferable to complex ones in both clinical and epidemiological settings. More questionable is whether they represent underlying disease entities. It is possible, but unlikely, that disease processes specically affect only one or a few clinical features. And clearly, selecting only a few features from among many to dene the phenotypes requires subjective choices. Including more features as necessary components of asthma phenotypes is difcult because this results in smaller groups. For instance, if all combinations of only three dichotomous features, say age of onset (late, early), persistence (transient, persistent) and triggers (only with, also without RTI), are considered, eight separate phenotypes result. With four dichotomous features 16 phenotypes result and so on. Of course, some of these groups could be combined, but the choice of which ones to combine is again subjective. To include more features, we need a classication that is less rigid and does not require arbitrary selection. The multi-dimensional approach The multi-dimensional approach attempts to include a wide range of features (Table 2) in the denition of phenotypes. This approach was recently proposed by Wardlaw et al. [83] as a means to develop a new taxonomy of asthma and airways disease in general. The authors suggested the use of cluster analysis, a group of techniques that seek to organize the subjects of a multivariate dataset into relatively homogenous groups. Such methods allow phenotypes to be identied in a data-driven manner and might therefore minimize the subjectivity involved in selecting the features [61, 8385]. Haldar and colleagues applied cluster analysis to three independent adult asthma populations using measurements of symptoms, atopy, eosinophilic inammation, psychological status and variable airow obstruction [84]. In each dataset, they identied three or four clusters, two of which showed a feature prole that was consistent over the three populations. We recently used latent class
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analysis (LCA), a type of cluster analysis based on a formal statistical model to identify phenotypes of childhood wheeze using data from a cohort study in Leicester, UK (skin prick tests, airway responsiveness, lung function and repeated assessment of symptoms of wheeze and cough) [61, 85]. The model distinguished two phenotypes of chronic cough, a persistent and a transient form, and three phenotypes of wheeze, a transient form associated with viral infections, a persistent form associated with other triggers, and a non-atopic but mostly persistent form (Fig. 3). Recently Clarisse and colleagues used a different clustering method (partitioning around medoids) to identify phenotypes of bronchial obstructive symptoms in infants from the Paris birth cohort [86]. Two symptomatic groups emerged, one characterized by dyspnoea with sleep disturbance and the other by nocturnal dry cough. Using data from the Avon Longitudinal Study of Parents and Children (ALSPAC), Henderson and colleagues applied LCA to seven repeated assessments of current wheeze during the rst 6 years of life [76], thus rening the approach from the Tucson group. Their approach was essentially one-dimensional because it included only one feature (the occurrence of wheeze attacks) measured at different points. However, the phenotypes were derived in data-driven manner from the symptom histories of a large number of children from the general population (n = 6265). The analysis identied ve types of longitudinal trajectories distinguished by age at onset and persistence of symptoms (Fig. 4). Multivariate techniques can also be used to model variability along a continuum rather than by discrete phenotypes. A commonly used method is factor analysis, which assumes that the observed features are related through one or few unobserved continuous variables, called factors. Features that are highly correlated with each other contribute to the same factor and the factor becomes a composite measure of these features. Several studies have applied factor analysis and related methods to data on wheezing and asthma in childhood [8789].

Pros and cons of the multi-dimensional approach The main advantage of the multi-dimensional approach is that it attempts to involve all features of the disease without making presumptions about which features are the most distinguishing ones. Proponents argue that resulting phenotypes might better reect underlying disease entities as they are dened in a more objective manner using information contained in the data [61, 76, 84, 85]. However, these methods are not entirely objective because the investigator needs to make choices about which particular method to use and which variables to include.

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319 (100)

208 (65.2)

111 (34.8)

159 (49.8)

97 (30.4)

63 (19.7)

86 (27.0)

86 (27.0)

84 (26.3)

63 (19.7)

97 (30.4) Persistent cough

82 (25.7) Transient cough

58 (18.2) Atopic persistent wheeze

47 (14.7)

35 (11.0) Transient viral wheeze

Nonatopic persistent

Fig. 4. Developmental trajectories in six phenotypes of wheezing identied by Henderson et al. [76]: estimated prevalence of wheezing at each time-point from birth to 81 months for each of the six wheezing phenotypes identied by latent class analysis in 6265 children with complete data on wheezing in the past 12 months over seven sequential surveys. Reproduced from Henderson J et al. [76] with permission from BMJ Publishing Group Ltd.

Fig. 3. Formation of phenotypes in a study of symptomatic children by Spycher et al. [61]: Phenotypes were identied from multivariate data including repeated symptom measurements, atopy, lung function and BHR using latent class analysis. The branching between layers shows how children are redistributed to new phenotypes as the number of phenotypes in the model is increased. Box widths are proportional to numbers of children assigned to the phenotypes (number and percentage reported). A model with ve phenotypes (bottom layer) was selected based on statistical criteria but the branching pattern shows that essential differences between these phenotypes were identied in earlier stages. The phenotypes of the nal model are labelled according to their main distinctive characteristics. Data are presented as n (%). Adapted from Spycher BD et al. [61] with permission from European Respiratory Society Journals Ltd.

A disadvantage is that the resulting phenotypes are not dened by a simple combination of features. The phenotype of a particular group identied by cluster analysis is dened by the characteristic features of this group. Such a denition is more like a description, and cannot be reduced to a single feature. For example, a phenotype might be characterized by a tendency for early onset of wheeze, usually persisting into the school age or later, with attacks usually occurring not only during colds but also apart from colds. This type of soft denition may resemble processes going on in the minds of clinicians who combine multi-dimensional observations to make a clinical diagnosis. Validating phenotypes as real clinical entities If phenotypes were visible objects, then their existence and characteristics would be undisputed. However, we still lack such a gold standard against which phenotypes could be validated. Because the underlying disease process is not fully understood, it is not possible to prove that a particular phenotype classication correctly represents it.

Therefore, rather than proofs, other indications that phenotypes could represent disease entities are sought. Such indications include whether disease phenotypes (a) are associated with features not used to dene them (usually physiological measurements), (b) predict future outcomes, (c) have distinctive risk factors, (d) have specic responses to treatment, (e) are stable over time or (f) are consistent across populations. A large number of studies have tested whether different phenotypes (varyingly dened) of wheezing or asthma in children are differently associated with concurrent or later physiological measurements (e.g. lung function, bronchial responsiveness, atopy and airway inammation) [3, 9, 23, 32, 33, 44, 45, 47, 68, 69, 76, 77, 9093], with distinctive risk factors [9, 23, 25, 33, 4346, 48, 81, 82, 9496], with later disease outcomes (prognosis) [6166, 73] or with response to treatment [5254] (Table 3). A general rule is that features used to dene phenotypes cannot be used for validation, meaning that for phenotypes dened by a multi-dimensional approach fewer features remain for this purpose (Table 4). However, the multi-dimensional approach accounts for associations existing between many of the features in the process of phenotype denition. Validating phenotypes by testing for associations with other features can be misleading. If, for example, the phenotype-persistent wheezing is associated with a maternal history of asthma [9] while the transient phenotype is not [9, 82], this does not mean that the phenotypic distinction transient vs. persistent is superior to other distinctions. Other classications, for instance by atopy [97] or by triggers [26], produce similar results. The question should rather be whether certain phenotype classications predict the presence of features (earlier, concurrent or later) better than other classications. Such
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Wheezing phenotypes in childhood Table 4. Variables used to dene phenotypes or analysed for association with phenotypes (validation) in different studies

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Disease variables or dimensions Aetiology Disease characteristics

Description Environmental risk factors Genetics Symptoms Signs Pathophysiology Short-term time course Previous time course (symptom history) Subsequent time course (prognosis)

Used for phenotype denition

Examined for associations with phenotypes Martinez et al. [9] Silverman [26] Martinez et al. [9] Henderson et al. [76]

Silverman [26, 116] Spycher et al. [61]z

Long-term time course

Martinez et al. [9]w Henderson et al. [76]z Spycher et al. [61]z Martinez [62, 63] Spycher et al. [61]

Table 3, row A.

wTable 3, row B. zData-driven denition using latent class analysis. Multi-dimensional approach.

comparisons could be made using statistics such as sensitivity, specicity or the likelihood ratio [98]. Because this is rarely, if ever, done the observed associations, even if well replicated across different studies, do not provide support for any particular phenotypic classication over the others. Recently, a study investigated whether children with a certain phenotype continued to have the same phenotype at a later time-point, i.e. whether phenotypes were stable over time [99]. One would expect phenotypes representing actual diseases to persist for the duration of these diseases. However, given the possibility of remission and relapse it is unclear over how long a period a phenotype should be stable. Also, stability may be an artefact of phenotype denition. For instance, a phenotype dened by the wheezing pattern of the past year is by denition stable over 1 year. The Tucson classication is necessarily stable over the rst 6 years of life because it is based on the symptom history of this period. A possibility for validating phenotypes identied by data-driven methods is the replication of results in different datasets. For instance, Haldar et al. [84] found similar results of the same clustering method across three populations. Phenotypes reecting true biological entities should reappear in a similar form in different populations. Such comparisons are complicated by differences in study design, such as differences in the age when children were examined or in features assessed. True phenotypes may, however, be robust against such differences. The way forward In spite of its popularity, the meaning of the term phenotype, as used in the context of childhood asthma, is vague and rarely specied. It is usually unclear whether
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phenotypes are simply practical denitions or are intended to represent real entities. Stating this clearly could avoid much confusion and circular debate. If phenotypes are just useful denitions, for instance because they are associated with different response to treatment, then only their usefulness needs to be shown, not whether or not they represent real diseases. If, on the other hand, phenotypes are thought to be real, then there is a need for validation and for harmonization of denitions. Currently, there is a wide range of concepts among clinicians [13] and among researchers. Despite numerous validation studies, no phenotype model stands out as more valid than others. In future, multi-dimensional approaches to phenotype denition could complement the traditional one-dimensional approach. Multi-dimensional approaches allow to include more disease features and to dene phenotypes that can be validated across populations. They could be used to assess the importance of the dening features of traditional phenotypes in context with other features. For instance, in the three wheezing phenotypes identied in our study using LCA, both triggers and the persistence of symptoms, the dening features of the popular classications by the Tucson group and by Silverman and colleagues, were important in conjunction with other features such as atopy and BHR [61]. Such additional features could be incorporated into traditional classications. This will require softer and more complex denitions, for instance, using decision trees or a probabilistic assignment of children to phenotypes. Different phenotypes may be needed for clinical practice and for research. One size is not likely to t all. From the clinicians perspective, phenotypes should be clinically useful and preferably simple. They need to be relevant for treatment decisions or prognosis and be

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1138 B. D. Spycher et al dened using readily accessible clinical information (family and patient history, symptoms, signs and simple measurements). Symptom control may be similar in different patients even if the symptoms have different underlying causes. In research, however, the main focus is the underlying disease processes and their mechanisms. Having phenotypes that are specic for the main underlying disease processes can greatly improve the precision of research into mechanisms and causes. The importance of precise phenotype denitions is becoming increasingly clear in genetic research. Phenotypes of childhood wheezing have rarely been used in genetic association studies although they may reect important susceptibilities to respiratory disease throughout life [6365]. A question that should be addressed is whether phenotypic variability between children is better represented by discrete groups (distinct phenotypes) or by a continuum (one or more continuous factors). This is important because if children are categorized into discrete groups when in fact they lie along a single continuum, information is lost and statistical power to detect genetic associations is reduced [100, 101]. A study by the Tucson group demonstrated stronger associations between a continuous score of atopy obtained by factor analysis with specic genetic markers than with individual dichotomous results of skin tests [87]. Using a cross-sectional dataset, we determined whether a model with continuous factors or one with discrete groups better represented variability of parent-reported symptoms. Preliminary results [102] point to a continuum of disease rather than to discrete phenotypes; however, further work is required to see whether the inclusion of time course and objective measurements might reveal discrete patterns. Ultimately, only knowledge of genetic and environmental determinants and pathophysiological pathways can reveal the true nature of the diseases causing recurrent wheeze in children. Reaching this goal is an iterative process: better phenotype denitions increase the precision of research into causes and mechanisms, while a better understanding of the underlying processes leads to more meaningful labels, until eventually new diseases might be dened based on aetiology. In this process, we may need to discard old distinctions and possibly even shift our focus away from wheezing as the cardinal symptom. Like all hypotheses, current phenotypes will eventually be superseded. In the meantime, we should treat phenotypes as exactly that: the best current working hypotheses. Acknowledgements The authors would like to thank: all the children and families participating in Leicestershire cohort studies for contributing data; Urs Frey and Philip Latzin for critical discussions on this topic; and Lutz Dumbgen, John Thompson and Marie Pierre Strippoli for their methodological and technical support in our work on phenotypes of wheeze. Funding: The work was supported by Asthma UK (grant 07/048) and the Swiss National Science Foundation (PROSPER grant 3233-069348 and 3200-069349, and SNF grant 823B - 046481). Competing interests: There are no competing interests.

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