Pediatrics Subject Collection: Asthma

Asthma Morbidity Among Children Evaluated by Asthma Case Detection [ARTICLES]

Gerald, J. K. — 2009-11-01

OBJECTIVE: Population-based asthma detection is a potential strategy to reduce asthma morbidity in children; however, the burden of respiratory symptoms and health care use among children identified by case detection is not well known. METHODS: Data come from a school-based asthma case detection validation study of 3539 children. Respiratory symptoms, emergency department (ED) visits, and hospitalizations were assessed by questionnaire for children whose case detection result and physician study diagnosis agreed. RESULTS: Physician evaluation of 530 case detection results yielded 420 cases of agreement (168 children with previously diagnosed asthma, 39 with undiagnosed asthma, and 213 without asthma). Children with previously diagnosed asthma were more likely to be male (P < .0001). No differences in severity were observed in children with previously and undiagnosed asthma (P = .31). Children with undiagnosed asthma reported less frequent daytime and nighttime symptoms than children with previously diagnosed asthma but more than those without asthma (P < .0001). The proportion of children with at least 1 respiratory-related ED visit in the past year was 32%, 3%, and 3% for those with previously diagnosed, undiagnosed, and no asthma, respectively (P < .0001). The proportion with at least 1 respiratory-related hospitalization was 8%, 0%, and 0%, respectively (P < .0001). There were no differences in nonrespiratory ED visits (P = .93). CONCLUSIONS: Despite similar physician-rated severity, children with undiagnosed asthma reported significantly less frequent respiratory symptoms and health care use than children with previously diagnosed asthma. These findings suggest that the potential health gains from case detection may be smaller than expected.

Familial Factors Do not Confound the Association Between Birth Weight and Childhood Asthma [ARTICLES]

Ortqvist, A. K. — 2009-10-01

OBJECTIVE: Studies have found associations between low birth weight and asthma. However, this association could be due to familial confounding. Our objective was to investigate whether fetal growth and birth weight affect the risk of asthma in childhood, controlling for gestational age (GA), and shared (familial) environment and genetic factors. PATIENT AND METHODS: Information on asthma, zygosity, birth characteristics, and potential confounders was collected for all 9- and 12-year-old twins through the Swedish Twin Register and Medical Birth Register. To obtain an overall effect of birth weight on risk of asthma, we performed cohort analyses on all twins (N = 10918). To address genetic and shared environmental confounding, we performed a co-twin control analysis by using the 157 monozygotic and 289 dizygotic same-sex twin pairs who were discordant for asthma. RESULTS: The overall rate of asthma ever was 13.7%. In the cohort analysis, the adjusted odds ratio (OR) for asthma in relation to a 1000-g decrease in birth weight was 1.57 (95% confidence interval [CI]: 1.38-1.79), and for each reduced gestational week the OR was 1.10 (95% CI: 1.07-1.13). In the co-twin control analyses, a 1000-g decrease in birth weight corresponded to an OR of 1.25 (95% CI: 0.74-2.10) for dizygotic same-sex twins and 2.42 (95% CI: 1.00-5.88) for monozygotic twins. CONCLUSIONS: There is an association between fetal growth and childhood asthma that is independent of GA and shared (familial) environment and genetic factors, which indicates that fetal growth restriction affects lung development, supporting additional studies on the early metabolic and physiologic mechanisms of childhood asthma.

Beliefs and Barriers to Follow-up After an Emergency Department Asthma Visit: A Randomized Trial [ARTICLES]

Zorc, J. J. — 2009-10-01

BACKGROUND: Studies in urban emergency departments (EDs) have found poor quality of chronic asthma care and identified beliefs and barriers associated with low rates of follow-up with a primary care provider (PCP). OBJECTIVES: To develop an ED-based intervention including asthma symptom screening, a video addressing beliefs and a mailed reminder; and measure the effect on PCP follow-up and asthma-related outcomes. METHODS: This randomized, controlled trial enrolled children aged 1 to 18 years who were discharged after asthma treatment in an urban pediatric ED. Control subjects received instructions to follow-up with a PCP within 3 to 5 days. In addition, intervention subjects (1) received a letter to take to their PCP if they screened positive for persistent asthma symptoms, (2) viewed a video featuring families and providers discussing the importance of asthma control, and (3) received a mailed reminder to follow-up with a PCP. All subjects were contacted by telephone 1, 3, and 6 months after the ED visit, and follow-up was confirmed by PCP record review. Asthma-related quality of life (AQoL), symptoms, and beliefs about asthma care were assessed by using validated surveys. RESULTS: A total of 433 subjects were randomly assigned, and baseline measures were similar between study groups. After the intervention and before ED discharge, intervention subjects were more likely to endorse beliefs about the benefits of follow-up than controls. However, rates of PCP follow-up during the month after the ED visit (44.5%) were similar to control subjects (43.8%) as were AQoL, medication use, and ED visits. CONCLUSIONS: An ED-based intervention influenced beliefs but did not increase PCP follow-up or asthma-related outcomes.

How Do We Support Follow-up With the Primary Care Provider After an Emergency Department Visit for Asthma? [COMMENTARIES]

Mansour, M. E. — 2009-10-01

Many investigators and clinicians have struggled to understand 2 related problems: (1) why urban children seek care in the emergency department (ED) for ambulatory care-sensitive conditions and (2) how to ensure follow-up for that visit with the medical home. Gaining insight into these patient health care-seeking behaviors will aid in the development of interventions to help design the health care system to improve health outcomes for children and reduce health care costs. In this issue of Pediatrics, the study conducted by Zorc et al1 highlights an attempt to implement an intervention that would be feasible to deliver in an ED setting and would increase the likelihood of follow-up with the primary care provider (PCP) for a group of urban children with asthma. The study is unique in that it ad ...

Confirmed Moisture Damage at Home, Respiratory Symptoms and Atopy in Early Life: A Birth-Cohort Study [ARTICLES]

Karvonen, A. M. — 2009-08-01

OBJECTIVES: Most previous studies on the association between moisture or mold problems in the home and respiratory symptoms in children were cross-sectional and based on self-reported exposure. The aim of this study was to evaluate the impact of objectively observed moisture damage and visible mold in the homes on early-life respiratory morbidity and atopic sensitization in a birth cohort. METHODS: Building inspection was performed by building engineers in the homes of 396 children, and the children were followed up with questionnaires from birth to the age of 18 months. Specific immunoglobulin E levels were measured at the age of 1 year. RESULTS: Doctor-diagnosed wheezing was associated with the severity of moisture damage in the kitchen and with visible mold in the main living area and especially in the bedroom of the child. The risk for parent-reported wheezing apart from cold increased with the severity of moisture damage in the kitchen. Moisture damage in the bathrooms or other interior spaces had no significant association with wheezing. No significant associations were observed for other end points, such as cough, or respiratory infections. There was a suggestion for an increased risk for sensitization to cat dander linked with moisture and mold exposure. CONCLUSIONS: This birth-cohort study supports previous observations that moisture mold problems in the kitchen and in the main living area increase the risk for wheezing in early childhood. The results underline the importance of assessing separately the health effects of moisture and mold problems in different areas of the home.

Do School-Based Asthma Education Programs Improve Self-Management and Health Outcomes? [REVIEW ARTICLES]

Coffman, J. M. — 2009-08-01

CONTEXT: Asthma self-management education is critical for high-quality asthma care for children. A number of studies have assessed the effectiveness of providing asthma education in schools to augment education provided by primary care providers. OBJECTIVE: To conduct a systematic review of the literature on school-based asthma education programs. METHODS: As our data sources, we used 3 databases that index peer-reviewed literature: MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature. Inclusion criteria included publication in English and enrollment of children aged 4 to 17 years with a clinical diagnosis of asthma or symptoms consistent with asthma. RESULTS: Twenty-five articles met the inclusion criteria. Synthesizing findings across studies was difficult because the characteristics of interventions and target populations varied widely, as did the outcomes assessed. In addition, some studies had major methodologic weaknesses. Most studies that compared asthma education to usual care found that school-based asthma education improved knowledge of asthma (7 of 10 studies), self-efficacy (6 of 8 studies), and self-management behaviors (7 of 8 studies). Fewer studies reported favorable effects on quality of life (4 of 8 studies), days of symptoms (5 of 11 studies), nights with symptoms (2 of 4 studies), and school absences (5 of 17 studies). CONCLUSIONS: Although findings regarding effects of school-based asthma education programs on quality of life, school absences, and days and nights with symptoms were not consistent, our analyses suggest that school-based asthma education improves knowledge of asthma, self-efficacy, and self-management behaviors.

Asthma Education: Are Pediatricians Ready and Willing to Collaborate With Schools? [COMMENTARIES]

Frankowski, B. L. — 2009-08-01

It has almost become a cliche to say that significant gaps remain between recommended and actual care for children with asthma despite the availability of evidence-based guidelines since 1991. Let's focus on the gap in providing asthma education. The Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma,1 published in 2007, highlight "education for a partnership in asthma care" as 1 of the 4 major components of asthma management. The guidelines clearly recommend that providers educate patients and their caregivers about 4 major topics: basic facts about pathophysiology of asthma; correct usage of medications; techniques for monitoring symptoms; and the importance of avoiding triggers. In addition, the guidelines stress the use of multiple sites for asthma education. For children and adol ...

Sleep-Disordered Breathing and Behaviors of Inner-City Children With Asthma [ARTICLES]

Fagnano, M. — 2009-07-01

OBJECTIVE: To explore the relationship between sleep-disordered breathing (SDB) and behavioral problems among inner-city children with asthma. METHODS: We examined data for 194 children (aged 4-10 years) who were enrolled in a school-based asthma intervention program (response rate: 72%). SDB was assessed by using the Sleep-Related Breathing Disorder Questionnaire that contains 3 subscales: snoring, sleepiness, and attention/hyperactivity. For the current study, we modified the Sleep-Related Breathing Disorder Questionnaire by removing the 6 attention/hyperactivity items. A sleep score of >0.33 was considered indicative of SDB. To assess behavior, caregivers completed the Behavior Problem Index (BPI), which includes 8 behavioral subdomains. We conducted bivariate analyses and multiple linear regression to determine the association of SDB with BPI scores. RESULTS: The majority of children (mean age: 8.2 years) were male (56%), black (66%), and insured by Medicaid (73%). Overall, 33% of the children experienced SDB. In bivariate analyses, children with SDB had significantly higher (worse) behavior scores compared with children without SDB on total BPI (13.7 vs 8.8) and the subdomains externalizing (9.4 vs 6.3), internalizing (4.4 vs 2.5), anxious/depressed (2.4 vs 1.3), headstrong (3.2 vs 2.1), antisocial (2.3 vs 1.7), hyperactive (3.0 vs 1.8), peer conflict (0.74 vs 0.43), and immature (2.0 vs 1.5). In multiple regression models adjusting for several important covariates, SDB remained significantly associated with total BPI scores and externalizing, internalizing, anxious/depressed, headstrong, and hyperactive behaviors. Results were consistent across SDB subscales (snoring, sleepiness). CONCLUSIONS: We found that poor sleep was independently associated with behavior problems in a large proportion of urban children with asthma. Systematic screening for SDB in this high-risk population might help to identify children who would benefit from additional intervention.

The State of Childhood Asthma: Introduction [SUPPLEMENT ARTICLES]

Malveaux, F. J. — 2009-03-01

In December 2006, the Merck Childhood Asthma Network, Inc convened a conference, "State of Childhood Asthma and Future Directions: Strategies for Implementing Best Practices." In this article, we present an overview of the conference. The other articles in this supplement were based on the conference proceedings.

Status of Childhood Asthma in the United States, 1980-2007 [SUPPLEMENT ARTICLES]

Akinbami, L. J. — 2009-03-01

Centers for Disease Control and Prevention data were used to describe 1980-2007 trends among children 0 to 17 years of age and recent patterns according to gender, race, and age. Asthma period prevalence increased by 4.6% per year from 1980 to 1996. New measures introduced in 1997 show a plateau at historically high levels; 9.1% of US children (6.7 million) currently had asthma in 2007. Ambulatory care visit rates fluctuated during the 1990s, whereas emergency department visits and hospitalization rates decreased slightly. Asthma-related death rates increased through the middle 1990s but decreased after 1999. Recent data showed higher prevalence among older children (11-17 years), but the highest rates of asthma-related health care use were among the youngest children (0-4 years). After controlling for racial differences in prevalence, disparities in adverse outcomes remained; among children with asthma, non-Hispanic black children had greater risks for emergency department visits and death, compared with non-Hispanic white children. For hospitalizations, for which Hispanic ethnicity data were not available, black children had greater risk than white children. However, nonemergency ambulatory care use was lower for non-Hispanic black children. Although the large increases in childhood asthma prevalence have abated, the burden remains large. Potentially avoidable adverse outcomes and racial disparities continue to present challenges. These findings suggest the need for sustained asthma prevention and control efforts for children.