PEDIATRICS Vol. 111 No. 5 May 2003, pp. 1046-1054
Who Gets Diagnosed With Asthma? Frequent Wheeze Among Adolescents With and Without a Diagnosis of Asthma
* Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, North Carolina
Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONAPPENDIX: ISAAC VIDEO QUESTIONSREFERENCES |
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Objective. 1) To describe the factors associated with not receiving an asthma diagnosis among children with frequent wheezing symptoms and 2) to determine risk factors for frequent wheezing in the population.
Methods. The North Carolina School Asthma Survey provided self-reported questionnaire data on respiratory health from 122 829 children ages 12 to 18 years enrolled in 499 public middle schools in North Carolina during the 1999–2000 school year. Questions from the International Survey of Allergies and Asthma in Childhood were used to estimate the prevalence of asthma and wheezing-related illness and associated factors.
Results. Factors independently associated with undiagnosed frequent wheezing versus asymptomatic children included female gender (odds ratio [OR]: 1.45; 95% confidence interval [CI]: 1.35–1.54), current smoking (OR: 2.60; 95% CI: 2.43–2.79), exposure to household smoke (OR: 1.59; 95% CI: 1.50–1.70), low socioeconomic status (OR: 1.52; 95% CI: 1.42–1.63), and African American (OR: 1.25; 95% CI: 1.15–1.34), Native American (OR: 1.35; 95% CI: 1.11-1.62), and Mexican American (OR: 1.32; 95% CI: 1.17–1.48) race/ethnicity. Urban residence showed a weak negative association (OR: 0.91; 95% CI: 0.85–0.96). A similar pattern of results was observed for analyses comparing odds of undiagnosed frequent wheeze versus diagnosed asthmatics. Report of allergies was less likely in frequent wheezers (70%) compared with diagnosed asthmatics (86%), but much higher than in asymptomatic children (36%). Thirty-three percent of children with undiagnosed frequent wheezing reported 1 or more physician visits in the last year for wheezing or breathing problems compared with 71% of children with diagnosed asthma, and 4% in asymptomatic children. The prevalence of any inhaler use in the past 12 months was 12% for undiagnosed frequent wheezers versus 78% for diagnosed asthmatics. The proportion of undiagnosed frequent wheezers with fair or poor self-rated health (23%) was slightly higher than diagnosed asthmatics (20%) and much higher than asymptomatic children (4%).
Conclusions. In one of the largest adolescent asthma surveys ever reported in the United States, undiagnosed frequent wheezing was independently associated with female gender, current smoking, exposure to household smoke, low socioeconomic status, allergies, and African American, Native American, and Mexican American race/ethnicity. Children with undiagnosed frequent wheezing were not receiving adequate health care for their asthma-like illness. Clinicians who treat adolescents should consider asking adolescents specifically about wheezing. This information may assist primary care physicians in identifying children with undiagnosed asthma in need of treatment.
Key Words: asthma • adolescents • wheezing • diagnosis • demographics • allergies
Abbreviations: ISAAC, International Survey of Asthma and Allergies in Childhood • NCSAS, North Carolina School Asthma Survey • OR, odds ratio • CI, confidence interval
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONAPPENDIX: ISAAC VIDEO QUESTIONSREFERENCES |
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Evidence exists that asthma, the most common chronic childhood disease,1 is underdiagnosed. Estimates of the proportion of children with undiagnosed asthma vary from country to country, ranging from 18% to 75%.2,3 Factors associated with the underdiagnosis of asthma or wheezing in children ages 18 and younger include female gender specifically in adolescents,4 socioeconomic status,5,6 urban residence,7 or belonging to an ethnic minority.8 Studies have been conducted in Great Britain,4,5,8 Australia,6,7 and Denmark.9 There is conflicting evidence from US studies regarding demographic factors associated with underdiagnosis of asthma, including race (African American versus white), residence (inner-city versus suburban), and gender.3,10–14
Epidemiologic research on pediatric asthma in the United States has primarily relied on either physician-diagnosed asthma or parental report of diagnosed asthma.3,14,15 This includes major analyses of national surveys (the National Health and Nutrition Examination Survey III and the National Health Interview Survey), which describe the prevalence of and burden related to asthma.16,17 However, asthma prevalence may be underestimated if based only on the diagnostic label.10 Diagnosed asthma is a case definition that is dependent not only on morbidity, but also on the patient’s or parent’s perception of symptoms, physician practice, and access to health care.18 By design, these surveys have missed a substantial proportion of the pediatric population with wheezing symptoms but no diagnosis.
To address these issues, the International Survey of Asthma and Allergies in Childhood (ISAAC) was developed and conducted in 56 countries and has allowed for a standardized evaluation of asthma-symptom prevalence in the pediatric population worldwide.19
The North Carolina School Asthma Survey (NCSAS) 1999–2000, which used an adapted ISAAC questionnaire, provided an opportunity to describe the prevalence of undiagnosed frequent wheeze (likely asthma) and associated risk factors in a population of 122 829 middle school children. The NCSAS used the rigorously validated ISAAC questionnaire including the 5 video scenes of children experiencing different types of wheezing. The feasibility of using an adapted ISAAC survey in US public middle schools has previously been reported.20 This study is distinct for several reasons compared with those previously published: 1) inclusion of large numbers of diverse groups of minority children (Native American, African-American, Latino, and Asian children); 2) simultaneous evaluation of health care utilization, medication use, and other risk factors such as allergies, active and passive smoking, and urban/rural areas, and socioeconomic status; 3) use of 2 different referent groups to represent both the clinical and public health perspective of asthma; 4) use of the internationally validated ISAAC questionnaire, which allows for identification of wheezing without diagnosis; and 5) a large population-based rather than clinic sample.
The focus of this study was to describe the factors associated with not receiving an asthma diagnosis among children with frequent wheezing symptoms and to determine risk factors for frequent wheezing in the population. Identifying characteristics associated with undiagnosed frequent wheezing would be a useful first step to help primary care physicians recognize children who may have undiagnosed asthma and need treatment. Previous research has shown that increasing physician awareness of wheezing as a marker for undiagnosed asthma may facilitate early diagnosis and intervention.3
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONAPPENDIX: ISAAC VIDEO QUESTIONSREFERENCES |
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The NCSAS was a large, population-based, cross-sectional study designed to obtain baseline surveillance data on the respiratory health of all 7th and 8th grade public school children. NCSAS was conducted as a collaborative effort between the North Carolina Department of Health and Human Services, the North Carolina Department of Public Instruction, and the Department of Epidemiology at the University of North Carolina at Chapel Hill.
NCSAS gathered baseline information on the breathing status of all children enrolled in public 7th and 8th grades—predominantly aged 13 to 14—throughout the state for the 1999–2000 school year. Urban and rural environments were included. The target population was enumerated from the North Carolina Department of Public Instruction’s 1999–2000 enrollment records and included 565 public middle schools with 192 248 children.
The questionnaire used in the survey was adapted from ISAAC,19 using both written and video symptom questions. The 13- to 14-year-old age group was chosen to reflect the period when morbidity from asthma is more common and to enable to the use of self-completed questionnaires. The video symptom sequence consisted of 5 different scenes of an adolescent experiencing the following: 1) wheezing at rest during the day, 2) wheezing after exercise, 3) waking at night by wheezing, 4) waking at night by cough, or 5) a severe wheezing attack with intercostal retractions.
Questions were added regarding health consequences of asthma, health care utilization, and environmental exposures. To standardize the administration of the questionnaire and to aid children with reading difficulties, the entire questionnaire was videotaped. A narrator read aloud 1 question at a time, with skip patterns emphasized, and the ISAAC video sequence of 5 scenes of adolescents wheezing was incorporated into the NCSAS videotape. Each school received 1 or more of the 30-minute videotapes, which were shown during homeroom, science class, or physical education class. The students were guided through the entire written questionnaire by the videotape. This method of administration was found to be feasible for statewide surveillance.20
Children reporting wheezing symptoms 1 or more times a month, during the last 12 months, without a report of physician diagnosis of asthma (hereafter referred to as undiagnosed frequent wheezers) were compared with two groups: 1) children with physician-diagnosed asthma and current wheezing symptoms, and 2) children with no wheezing symptoms in the past 12 months and no diagnosed asthma, hereafter referred to as asymptomatic children. Figure 1 and the Appendix describe categories, exclusion criteria, and video questions and responses in more detail.
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Socioeconomic status was estimated based on enrollment in the free and reduced price school lunch program. Latin American ethnicity was defined as birth origin from Central or South America, or Mexico; Mexican American ethnicity was defined as US-born with Mexican heritage. Children ages 12 to 14 years were compared with those aged 15 to 18 years. Children younger than 12 (n = 665) were excluded from the logistic regression analysis due to small numbers. Allergies were defined as self-report of allergy to 1 or more of the following: dogs, cats, dust, and grasses.
Analyses were conducted using SAS software, version 8.01 (SAS Institute, Cary NC).21 Children were categorized by type and frequency of asthma-like symptoms and physician-diagnosed asthma. Descriptive univariate statistics were calculated, followed by crude bivariate analyses comparing these groups. 
2 statistics were used to evaluate differences among groups with respect to age, race, gender, socioeconomic status, active and passive smoke exposure, health care utilization (physician visits for wheezing or other respiratory symptoms), and medication (inhaler) use.
Adjusted prevalence odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using multiple logistic regression for the outcome of undiagnosed frequent wheezing compared with 2 referent groups: 1) current physician diagnosis of asthma, and 2) lifetime absence of asthma-like symptoms and no physician-diagnosis of asthma. Independent variables in the multiple logistic regression models included age, race, gender, ethnicity, socioeconomic status, urban/rural residence (based on population density), allergies, active cigarette smoking, and exposure to household cigarette smoke.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONAPPENDIX: ISAAC VIDEO QUESTIONSREFERENCES |
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The final response rate was 66.8% (128 568/192 248) for 7th and 8th grade children enrolled in public school during 1999–2000. Response rates by school were 88% (499/565) and 99% by county (99/100). Children who participated were compared with those that did not with respect to demographic data. These data were obtained from the statistical branch of the North Carolina Department of Public Instruction. There were no significant differences among the demographic variables of socioeconomic status (enrollment in the free school lunch program), race, and gender for children who participated and those who did not (P values from
2 tests [0.66, 0.61, and 0.58, respectively]). Of the 128 568 participating children, 5739 children were excluded from the analysis because of incomplete questionnaire data. Analyses were conducted to compare the undiagnosed frequent wheezers (n = 7587) with 2 referent groups: diagnosed asthmatics (n = 12 174), and asymptomatic children (n = 64, 644). The children with mild asthma-like symptoms (n = 38 424) were excluded from additional analyses. These milder symptoms were defined as wheezing less than once per month during the last 12 months, undiagnosed wheezing before the last 12 months, or current or past cough as the only symptom all with no report of asthma diagnosis. Figure 1 provides more detail on the exclusion criteria. The values of the demographic and health care utilization variables for the excluded mild symptoms group are presented in Table 1 and Table 2 and fall between those of children with undiagnosed frequent wheezing and asymptomatic children.
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Table 1 summarizes the basic demographic variable frequencies for diagnosed current asthmatic children, children with undiagnosed frequent wheezing, and asymptomatic children who have never had wheezing or a physician diagnosis of asthma. The prevalence of undiagnosed frequent wheezing was 6% (7587/122 829).
Undiagnosed frequent wheezing was elevated in girls, children with low socioeconomic status, and cigarette smokers (59%, 45%, and 30%, respectively) compared with the asymptomatic group (47%, 30%, and 12% respectively). The proportion of children who reported allergies in the undiagnosed frequent wheezing group (70%) was comparable to the proportion of children with allergies in the diagnosed asthma group (86)% and contrasted greatly with the asymptomatic group (36%). Approximately equal proportions of girls (51%) and boys (49%) reported diagnosed asthma. Except for gender, the demographic patterns for undiagnosed frequent wheezers and diagnosed asthmatics were similar compared with the asymptomatic group—a higher prevalence among children with current smoking, any household smokers, low socioeconomic status, and reported allergies.
Differences in health care and perceived health status among undiagnosed frequent wheezers, diagnosed asthmatics, and asymptomatic children are presented in Table 2. One third of undiagnosed frequent wheezers reported 1 or more physician visit for breathing problems in the last 12 months compared with 71% of diagnosed asthmatics and 4% of asymptomatic children. The prevalence of inhaler use (in the past year) was 12% in children with undiagnosed wheezing versus 78% in diagnosed asthmatics. The proportion of undiagnosed frequent wheezers with fair or poor self-rated health (23%) was slightly higher than diagnosed asthmatics (20%) but >5 times higher than that of asymptomatic children (4%).
Adjusted ORs for the association between undiagnosed frequent wheezing and demographic factors were calculated using 2 different comparison groups: 1) diagnosed asthmatics; and 2) asymptomatic children (Table 3). Girls were 1.56 (95% CI: 1.47–1.69) times more likely than boys to be undiagnosed frequent wheezers using diagnosed asthmatics as the referent group, and 1.45 (95% CI: 1.35–1.54) times more likely using the asymptomatic referent groups. Current smoking was associated with an increased risk of undiagnosed frequent wheezing (OR: 1.65; 95% CI: 1.52–1.79) using diagnosed asthmatics as a referent group and a slightly higher (OR: 2.60; 95% CI: 2.43–2.79) using the asymptomatic referent group.
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In general, exposure to household smoke, low socioeconomic status, and Latino ethnicity were also positively associated with undiagnosed frequent wheezing, and associations were stronger in analyses with the asymptomatic comparison group. African American and Native American race were significantly associated with undiagnosed frequent wheezing only in the asymptomatic comparison. In the diagnosed asthmatic comparison, Native American, African American, Mexican American, and children of mixed or >1 race were
25% more likely to have frequent undiagnosed wheezing compared with white children, but associations were not statistically significant. Rural residence was weakly associated with increased odds of undiagnosed frequent wheezing in both comparisons. Report of allergies was positively associated with undiagnosed frequent wheeze in the comparison with the asymptomatic group (OR: 3.88; 95% CI: 3.65–4.13), but inversely associated in the comparison with the diagnosed asthmatic group (OR: 0.33; 95% CI: 0.31–0.36). |
DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONAPPENDIX: ISAAC VIDEO QUESTIONSREFERENCES |
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In an analysis of >80 000 public middle school students (12–18 years of age), we identified a number of characteristics positively associated with frequent wheezing in the absence of a physician diagnosis of asthma: female gender, current cigarette smoking, exposure to household smoke, African American, Native American, and Mexican American race/ethnicity, and low socioeconomic status. The high prevalence of allergies in the undiagnosed frequent wheezers (70%) and physician-diagnosed asthmatics (86%) compared with the asymptomatic group (36%) lends additional support to the theory that the undiagnosed frequent wheezers are likely undetected asthmatics. Our data, from one of the largest adolescent asthma surveys conducted in the United States, also provide evidence that the undiagnosed frequent wheezers may not get adequate health care and treatment for their symptoms, as illustrated by the low number of physician visits, low rate of medication use, and high proportion of children rating their health as fair or poor.
Our objectives were two-fold—first, to describe the factors associated with not receiving an asthma diagnosis among children with frequent wheezing symptoms and, second, to determine risk factors for frequent wheezing in the population. In our analyses, we included the diagnosed asthmatics as a comparison group to illustrate the similarity between frequent undiagnosed wheezers and diagnosed asthmatics, comparing children who have had access to physicians and also sought care for their symptoms, with those that perhaps have not. We observed that undiagnosed frequent wheezers were more similar to diagnosed asthmatics than to asymptomatic children with respect to allergies, self-rated health, exposure to smoking, socioeconomic status, gender, and ethnicity. However, undiagnosed wheezers had substantially lower health care utilization and medication use than diagnosed children. The comparison of diagnosed versus undiagnosed children puts the analyses in a framework familiar to the practicing clinician. The comparison of the undiagnosed frequent wheezers with a group free of respiratory symptoms represents a population-based public health perspective, identifying risk factors associated with the presence versus absence of symptoms.
Our results support those of other studies, in which girls had increased wheezing around puberty, with new and prevalent cases of asthma particularly frequent among females during adolescent years.4,22–25 For example, Castro-Rodriguez25 reported that girls who became overweight between ages 6 and 11 increased their risk of developing new asthma symptoms during puberty. In a recent study in western New York, Lwebuga-Mukasa26 reported that, of the children with suspected asthma, 57% were female. In the Bronx, New York, Crain3 found that in adolescents ages 12 to 17, the prevalence of wheeze only was 3.3 per 100 in girls compared with 2.3 per 100 in boys. Similarly, in a Midwestern city,13 girls were nearly twice as likely to report wheeze in the last year than boys (OR: 1.95; 95% CI: 1.42–2.67). Two studies in Great Britain4,38 also found that among adolescents, wheeze was significantly more prevalent in girls than boys (OR: 1.24; 95% CI: 1.18, 1.30; OR, 1.14; 95% CI: 1.08-1.20, respectively). In a study examining underdiagnosis of asthma in 495 Danish children,9 girls were 4.50 times (P = .005) as likely as boys to have undiagnosed asthma. Our findings that girls were 1.45 (95% CI: 1.35–1.54) times as likely as boys to report undiagnosed frequent wheezing versus asymptomatics, and that girls were more likely to be undiagnosed compared with boys, both of whom reported frequent wheeze (OR: 1.56; 95% CI: 1.47–1.69), corroborate the results of the published studies among children of pubertal age.
Differences in the prevalence of asthma and wheeze in the US, by race (primarily African American and white) and socioeconomic status, have been published with conflicting results.3,11,14–17,20,26–33 Schwartz et al14 found that 31% of white children and 46% of black children with frequent wheeze were diagnosed with asthma. Lwebuga-Mukasa26 found a higher prevalence of diagnosed asthma in Native American, African American, and Latino compared with white children living in New York State. Cunningham11 and Fagan13 found that African American children were more likely to be diagnosed with asthma, but had a similar prevalence of persistent wheezing compared with white children. Conversely, in a telephone survey, Crain3 reported that white children had a higher frequency of wheeze only and asthma compared with African American and Hispanic children in the Bronx, New York. Our results indicate that there was no difference in being diagnosed among African Americans and white children with frequent wheeze, but that frequent wheeze was more prevalent in African Americans than whites. However, our focus on frequent wheeze, and not the entire spectrum of wheezing, could account for the differences in findings compared with Cunningham,11 Fagan,13 and Crain.3 In addition, Crain’s study was in an urban population known nationwide for its high asthma prevalence and morbidity as well as poverty.
Others have found that, overall, children who are poor or of minority race/ethnicity are more likely to be hospitalized for asthma, are more likely to receive treatment for asthma in the emergency department, and are less likely to receive treatment according to evidence-based guidelines.30,34–37 The increased odds of undiagnosed frequent wheeze among children of lower socioeconomic status, minority race, and ethnicity observed in this analysis of the NCSAS are consistent with this published literature.
Active and passive smoking were among the factors most strongly associated with undiagnosed wheezing in our analyses for both comparisons. Environmental tobacco smoke has previously been shown to be a risk factor for childhood wheeze31,32 in the population. Siersted9 found that exposure to passive smoke was associated with undiagnosed asthma compared with diagnosed asthma (OR: 1.46; P = .005), though no information on active smoking was available. Although low socioeconomic status may also be related to parental smoking habits, we found an independent association with low socioeconomic status and frequent wheezing even after adjusting for 1 or more household smokers.
We found the report of allergies was positively associated with undiagnosed frequent wheeze in the comparison with the asymptomatic group (OR: 3.88; 95% CI: 3.65–4.13), but inversely associated in the comparison with the diagnosed asthmatic group (OR: 0.33; 95% CI: 0.31–0.36). This reflects the difference in report of allergies among the three groups: undiagnosed frequent wheezers (70%), diagnosed asthmatics (86%), and asymptomatics (36%). This finding agrees well with the international study comparing allergies among diagnosed and undiagnosed asthmatics.9 In a Danish study, Siersted9 found that children with undiagnosed asthma were much less likely to have itching eyes (OR: 0.25), serial sneezing (OR: 0.14), and watery nasal secretions (OR: 0.12) compared with diagnosed asthmatics. Allergies may facilitate a diagnosis of asthma, both by promoting contact with a doctor and by increasing the doctors’ awareness toward diagnosis.9
Our results from this US survey are comparable to international research indicating that childhood asthma is underdiagnosed and inadequately managed.3,9,36–38 Research shows the proportion of all children with asthma-like symptoms receiving a proper diagnosis ranges from 18% (2) to 75% (3), with an average estimate of 52%.2,3,9,10,14,22,38 Our study estimates 65% of children with current asthma-like symptoms are diagnosed: 11% of the sample were diagnosed asthmatics, and 6% had undiagnosed frequent wheezing.
In a study by Lowe and Burr,22 more than a quarter of adolescents reported potentially severe wheezing with no physician diagnosis of asthma in Great Britain. Of children reporting wheezing without an asthma diagnosis, only 11.5% reported bronchodilator use. The results from Lowe and Burr22 are similar to our finding that 12% of children with undiagnosed frequent wheezing used inhaled medicine. These children are likely prescribed medicine either for wheezing and not given an asthma label (eg, told it is related to allergies or a virus) or do not remember being told by a physician that they have asthma. Ortega and colleagues39 reported lower rates of prescribed asthma medicines for black and Hispanic diagnosed asthmatics compared with whites aged 12 and younger, regardless of access to care and asthma severity. The evaluation of self-reported pharmacotherapy of asthmatics by race was beyond the scope of this study.
These data are self-reported by adolescents. The ISAAC methodology has been rigorously validated with respect to the reporting of asthma-like symptoms in adolescents; ISAAC methodology using video-guided adolescent self-report of asthma agrees well with parental report of asthma as well as with physician diagnosis of asthma.44–42 The ISAAC video component was found to have a specificity of 0.87 and sensitivity of 0.75 when compared with a physician’s diagnosis of clinically active asthma as a gold standard.39 The use of a video addresses poor symptom recognition versus pencil and paper questionnaire.41 In a validation study of the ISAAC questionnaire in over 19 500 adolescents, Renzoni et al42 evaluated the agreement between parents reporting about their adolescent and adolescents self-reporting regarding a physician diagnosis of asthma; 97% of adolescents agreed with their parents in reporting that they did not have asthma. Additional research has shown that parents underestimate the presence of wheezing in their adolescent children.4,43 It would have been optimal to validate questionnaire responses with medical records in a subset of students; however, the public health budget and confidentiality limitations precluded such activities.
Information on demographics and health care is also subject to errors in recall. For example, recall may differ across these disease groups. Diagnosed asthmatics with severe asthma, who made many more physician visits for their symptoms, may underestimate the number of visits compared with the undiagnosed wheezing group. However, in this case, the conclusion would still be the same—that the undiagnosed wheezers reported fewer physician visits compared with the diagnosed asthmatics. The health care utilization questions have been validated in the United States.44
There are several major strengths of the study. First, the study sample had high levels of representation of diverse minority groups with large numbers of Native American, African American, Latino, and Asian children. Second, we also simultaneously evaluated other risk factors associated with potential differences in asthma and wheezing prevalence including medication use, allergies, active and passive smoking, and urban/rural areas, and socioeconomic status. Third, we used 2 different referent groups to represent both the clinical and public health perspective. Fourth, we used an internationally standardized and validated measurement tool, the ISAAC, which has been used in >56 countries and 450 000 children.19 This survey tool allows for proper identification of wheezing with out diagnosis. Finally, our survey sample was population-based rather than clinic-based. Much of the current literature describing undiagnosed asthma is clinic-based, limited by small sample sizes, and lacks generalizability to larger populations. Clinic-based samples include only those children with access to care or parents that seek care for their children while this population-based sample includes the range of children attending public school regardless of health care coverage.
In this analysis of a large, population-based survey of middle school children, factors associated with undiagnosed frequent wheezing were female gender, current smoking, exposure to household cigarette smoke, low socioeconomic status, allergies, and African American, Native American, and Mexican American race/ethnicity. Children with undiagnosed frequent wheezing had poorer self-rated health compared with diagnosed asthmatics and asymptomatic children. These results suggest that many children with frequent wheezing could benefit from diagnosis and treatment as part of primary care, while those with diagnosed asthma need better management to improve symptoms and quality of life.
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APPENDIX: ISAAC VIDEO QUESTIONS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONAPPENDIX: ISAAC VIDEO QUESTIONSREFERENCES |
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- Has your breathing been like this a) at any time in your life, b) if yes, has this happened in the last year, c) if yes, has this happened at least once a month?
(adolescent wheezing at a desk)
- Has your breathing been like the boy’s in the dark shirt after exercise? a) at any time in your life, b) if yes, has this happened in the last year, c) if yes, has this happened at least once a month?
(2 adolescents jogging and stop, boy with dark shirt wheezing, boy with white shirt with normal respiration after exercise)
- Have you been awakened like this at night? a) at any time in your life, b) if yes, has this happened in the last year, c) if yes, has this happened at least once a month?
(adolescent waking at night with wheezing)
- Have you been awakened like this at night? a) at any time in your life, b) if yes, has this happened in the last year, c) if yes, has this happened at least once a month?
(adolescent waking at night with coughing)
- Has your breathing been like this a) at any time in your life, b) if yes, has this happened in the last year, c) if yes, has this happened at least once a month?
(adolescent experiencing severe wheezing attack)
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ACKNOWLEDGMENTS |
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The Children and Youth Branch of the Women’s and Children’s Health Section, Division of Public Health, North Carolina Department of Health and Human Services (grant 15301013) provided support for the planning, data collection, and analyses. Glaxo Smith Kline (grant 5-58575) provided support for additional analyses and manuscript preparation.
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FOOTNOTES |
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Received for publication Jan 30, 2002; Accepted Sep 19, 2002.
Address correspondence to Karin Yeatts, PhD, MS, Department of Epidemiology, Campus Box 7435, School of Public Health, McGavran Greenberg Hall, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7435. E-mail: karin_yeatts{at}unc.edu
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