McLean DE, Bowen S, Drezner K, et al. Arch Pediatr Adolesc Med. 2004;158:244–249
Purpose of the Study.
To determine the prevalence of asthma among a population of homeless children.
A total of 740 children whose families entered 3 family shelters in New York City, New York, from June 1998 to September 1999, representing 75% of all children entering these shelters.
On entry into the shelters, the investigators attempted to screen children with a 1-page, 11-item survey that included questions about daytime and nighttime symptoms, previous diagnosis of asthma, current medications, use of an emergency department for respiratory symptoms, and demographic characteristics. The asthma-symptom questions were coded to allow for staging as outlined in nationally recognized guidelines. The validity of the screening instrument was assessed by comparing the screening results of 117 children with a clinical assessment by a pediatrician or pediatric nurse practitioner. With this assessment, the sensitivity of the screening instrument was 77%, and the specificity was 92%.
The prevalence of asthma in the children who were screened was 39.8%, with 26.9% having a prior physician diagnosis of asthma and 12.9% having no prior diagnosis but symptoms consistent with moderate to severe asthma. Furthermore, 50.3% of these children had current symptoms consistent with mild intermittent to severe asthma. Of those children who were <5 years old, 34.2%, 9.8%, 30.1%, and 25.9% had current symptoms consistent with mild intermittent, mild persistent, moderate, and severe asthma, respectively. Of those children who were ≥5 years old, 45%, 17%, 18%, and 20% had current symptoms consistent with mild intermittent, mild persistent, moderate, and severe asthma, respectively. Of those children with a prior physician diagnosis of asthma, the percentage of patients receiving anti-inflammatory treatment was 4%, 11%, 16%, 28%, and 20% for patients with no symptoms and current symptoms consistent with mild intermittent, mild persistent, moderate, and severe asthma, respectively. Finally, 48.6% of children with current asthma symptoms consistent with severe asthma visited an emergency department in the last year for respiratory symptoms, whereas 54.9% of severe asthmatics (and 68% of mild persistent asthmatics) with a prior physician diagnosis of asthma visited an emergency department in the last year for respiratory symptoms.
The data suggest that the routine use of a screening instrument for asthma would identify many at-risk children, an essential first step to providing them with appropriate medical care. Another remarkable finding is the low rate of use of anti-inflammatory medication even among severe asthmatics. This finding, taken along with the high rate of use of emergency department care for respiratory symptoms, provides evidence for a high rate of undertreatment of asthma among homeless children.
This study, which provides evidence for a surprisingly high rate of asthma among homeless children, as well as undertreatment with anti-inflammatory medication and overuse of the emergency department, should be viewed by health care providers as a call to action. The medical system seems to have failed these children, and new approaches to their care are worth considering, such as routine screening for asthma, regular visits with primary care providers, and education of caregivers about asthma.