The Influence of Variation in Type and Pattern of Symptoms on Assessment in Pediatric Asthma

Abstract

Fuhlbrigge AL, Guilbert T, Spahn J, Peden D, Davis K. Pediatrics. 2006;118:619–625 PURPOSE OF THE STUDY. To examine the asthma-related health burden in US children. STUDY POPULATION. Participants were US children (aged 4 to 18 years) with current asthma during February to May, 2004, identified in a telephone-based survey. Asthma was defined as ever having a physician diagnosis of asthma and either using current asthma medication or having asthma symptoms in the past year. METHODS. In this telephone-based study, 41 433 households were screened to provide 1089 children reporting current asthma and 801 completed interviews. Interviews were completed by parents for children 4 to 15 years old (84.6%) and the children themselves when they were 16 to 18 years old (14.6%). Symptoms, perceived level of control, activity limitation, health care use, medications, disease management, and knowledge were assessed. Global asthma-symptom burden was composed of short-term symptom burden (4-week recall), long-term symptom burden (past year), and functional impact (activity limitation) based on National Asthma Education and Prevention Program (NAEPP) guidelines. Asthma was classified on the basis of symptoms in 3 categories: mild-intermittent, mild-persistent, and moderate/severe-persistent (combined into 1 category) asthma. RESULTS. Eighty percent of the children were classified as having mild-intermittent asthma on the basis of daily symptoms; however, this percentage decreased to 64% when nighttime symptoms were considered. In contrast, on the basis of the global asthma-symptom burden, only 13% of the children were classified as having mild-intermittent disease, whereas 62% were classified as having moderate/severe disease. Of children with moderate/severe asthma, 54% reported complete asthma control despite meeting criteria for more moderate/severe-persistent disease. Asthma impact on daily activity was substantial, with 47% of the children avoiding exertion and 34% staying inside to control asthma symptoms. CONCLUSIONS. The majority of children had not achieved the goals of asthma treatment based on NAEPP guidelines. In addition, parents and their children overestimated the child's asthma control and commonly restricted activities to control asthma symptoms. REVIEWER COMMENTS. Why is there a rift between what patients or their parents perceive as their level of asthma control and their actual control measured against NAEPP-guideline goals? The level of control perceived by patients and their parents seems worse when more detailed or specific questions are asked about asthma burden. As demonstrated by this study, limitation in activity level or staying indoors are “common” methods to control asthma symptoms despite contradictory reporting that exercising and participating in outdoor activities are important to children. Unfortunately, many children are not meeting the NAEPP guidelines’ goals of removing self-imposed limitations to control a child's asthma. It is notable that this study did not account for current asthma medications that could result in underclassification of disease burden. This study provides another wake-up call that asking specific questions during patient encounters and education regarding symptom-control expectations are worthwhile, because there can be misperception of control by patients and their parents.