Asthma Morbidity In Children Research Articles

Multiple urban and asthma-related risks and their association with asthma morbidity in children.

To determine whether a multi-dimensional cumulative risk index (CRI) is a stronger predictor of asthma morbidity in urban, school-aged children with asthma, than poverty or severity alone. A total of 163 children with asthma, ages 7-15 years (42% female; 69% ethnic minority) and their primary caregivers completed interview-based questionnaires, focusing on potential cultural, contextual, and asthma-specific risks that can impact asthma morbidity. Higher levels of cumulative risks were associated with more asthma morbidity, after controlling for poverty level or asthma severity. Analyses by ethnic group and subgroup also supported the relationship between the CRI and specific indices of asthma morbidity. This study demonstrates the utility of multiple-dimensional risk models for predicting variations in asthma morbidity in urban children. Research efforts with urban families who have children with asthma need to consider the context of urban poverty as it relates to children's cultural backgrounds and specific asthma outcomes.

Addressing issues of asthma in inner-city children

For children living in the inner city, asthma tends to be more frequent and severe. Although the causes for this heightened severity of asthma are not clearly established, environmental allergens likely play a major role. To characterize, understand, and treat children with asthma living in the inner city better, the National Institutes of Allergy and Infectious Diseases of the National Institutes of Health established an Inner City Asthma Program in 1991. Over the past 15 years, 3 separate inner-city asthma research networks have been formed and funded by this institute. The work from these programs has led to important observations including evidence that environmental allergens, particularly cockroach, are important for sensitization and severity of asthma of the affected children. Furthermore, reductions in the allergen load can lead to improved asthma control. The most recent program, the Inner City Asthma Consortium, was formed in 2002 with a goal to develop immune-based therapy for children with asthma in the inner city and to determine mechanisms of these therapies as well as immunopathogenesis of asthma in these high-risk children. This article reviews these programs and how they have begun the effort to understand and treat children with asthma who live in inner cities better and what their findings mean in relationship to unique features of asthma in inner city children.

Persistent Caregiver Stress and Children's Asthma Morbidity

Persistent Caregiver Stress and Children's Asthma Morbidity

INDOOR PARTICULATE MATTER AND ASTHMA MORBIDITY IN PRESCHOOL-AGE CHILDREN

PURPOSE: Outdoor particulate matter (PM) exposure contributes to childhood asthma morbidity. Although pre-school age children are estimated to spend over 90% of time indoors, little is known about the effect of indoor PM exposure on asthmatic children. We investigated the effect of indoor PM exposure on the health of pre-school age asthmatic children.

Inner City Asthma Study: Relationships Among Sensitivity, Allergen Exposure, and Asthma Morbidity

Purpose of the Study. To describe the relationship between allergen sensitivities, allergen exposures, and asthma morbidity in children with moderate-to-severe asthma while also exploring geographic variations in indoor allergen levels. Study Population. Subjects were children aged 5 to 11 years (n = 937) from 7 inner-city and metropolitan areas across the United States participating in the Inner City Asthma Study. Methods. In a fully crossed factorial design, participants were randomly assigned to receive an allergen intervention, bimonthly feedback of the child’s health status to their primary care physicians, both interventions, or no intervention (control group, n = 234). At baseline, a clinical interview with the child’s primary caregiver (including demographics, asthma morbidity, home characteristics, and exposure to tobacco smoke) was conducted with skin-prick tests to aeroallergens. Morbidity was measured at 2-month intervals during a 24-month period. Home visits including a visual inspection and dust-sample collection (dust mite, cockroach, cat and dog dander) were conducted at baseline and every 6 months. Results. Of 1059 children tested, 94% had at least 1 positive skin test. Allergen sensitivities varied widely across the study sites, with cockroach (69%), dust mites (62%), and molds (50%) being the most predominant. Cockroach sensitivity was highest in The Bronx, New York, New York City, New York, and Dallas, Texas (81%, 79%, and 79%, respectively), whereas dust mite sensitivities were highest in Dallas and Seattle, Washington (84% and 78%, respectively). At least 30% of the subjects were allergic to cats at all sites. Cockroach levels were highest (>50% of homes) in Chicago, Illinois, New York City, The Bronx, and Dallas and were lower in Seattle and Tucson, Arizona (8% and 11% of homes, respectively). Dust mite levels were highest in Seattle and Dallas. Cockroach levels were higher in high-rise and low-rise apartments, whereas dust mite levels were higher in detached homes. No correlation was seen between animal dander and housing type. Conclusions. There were significant differences between geographic study sites and the type of indoor allergen exposure and skin-test sensitivity in this study group. Cockroach predominated in the Northeast, whereas dust mite predominated in the South and Northwest. Although most children in the study were allergic to dust mite and/or cockroaches, only the children who were sensitive and exposed to cockroach had increased asthma morbidity. Reviewer Comments. This study demonstrates the association of allergen sensitivities and exposures (particularly cockroach allergens) to increased asthma morbidity in children with moderate-to-severe asthma living in inner-city areas. Physicians can use this knowledge to identify significant risk factors in asthmatic patients, implement appropriate prevention measures (ie, environmental intervention), and more aggressive medical management to decrease the level of asthma morbidity.

Reduction in asthma morbidity in children as a result of home remediation aimed at moisture sources.

ObjectiveHome dampness and the presence of mold and allergens have been associated with asthma morbidity. We examined changes in asthma morbidity in children as a result of home remediation aimed at moisture sources.DesignIn this prospective, randomized controlled trial, symptomatic, asthmatic children (n = 62), 2–17 years of age, living in a home with indoor mold, received an asthma intervention including an action plan, education, and individualized problem solving. The remediation group also received household repairs, including reduction of water infiltration, removal of water-damaged building materials, and heating/ventilation/air-conditioning alterations. The control group received only home cleaning information. We measured children’s total and allergen-specific serum immuno-globulin E, peripheral blood eosinophil counts, and urinary cotinine. Environmental dust samples were analyzed for dust mite, cockroach, rodent urinary protein, endotoxin, and fungi. The follow-up period was 1 year.ResultsChildren in both groups showed improvement in asthma symptomatic days during the preremediation portion of the study. The remediation group had a significant decrease in symptom days (p = 0.003, as randomized; p = 0.004, intent to treat) after remodeling, whereas these parameters in the control group did not significantly change. In the postremediation period, the remediation group had a lower rate of exacerbations compared with control asthmatics (as treated: 1 of 29 vs. 11 of 33, respectively, p = 0. 003; intent to treat: 28.1% and 10.0%, respectively, p = 0.11).ConclusionConstruction remediation aimed at the root cause of moisture sources and combined with a medical/behavioral intervention significantly reduces symptom days and health care use for asthmatic children who live in homes with a documented mold problem.

Socioeconomic status and inflammatory processes in childhood asthma: The role of psychological stress

Although social environment variables such as socioeconomic status (SES) have been linked to childhood asthma, little is known about the psychobiological mechanisms underlying this relationship. The goal of this study was to investigate relationships among SES, psychological stress, and immune processes implicated in asthma. Thirty-seven children ages 9 to 18 years, physician-diagnosed with asthma, and 39 healthy children participated. Families were interviewed about chronic life stress, perceptions of threat, and SES. Blood samples were drawn from children to assess stimulated production of cytokines implicated in asthma (IL-4, IL-5, IL-13) and eosinophil counts. In children with asthma, lower SES was associated with heightened production of IL-5 and IL-13 and higher eosinophil counts (P values < .05). Lower SES also was associated with higher chronic stress and perceived threat (both groups: P values < .05). Higher levels of stress and threat perception were associated with heightened production of IL-5 and IL-13, and higher eosinophil counts in children with asthma (P values < .05). Statistical mediation tests revealed that chronic stress and threat perception represented statistically significant pathways between SES and immune processes in children with asthma (P values < .05). In healthy children, associations were in the opposite direction from the asthma group, though generally not significant. This is one of the first studies to document empirically a psychobiological explanation for the epidemiologic relationship between low SES and poor asthma outcomes. Associations among SES, psychological stress, and immune pathways suggest that the experience of stress, particularly among lower SES children, has implications for childhood asthma morbidity.

Self-Reported Moisture or Mildew in the Homes of Head Start Children with Asthma is Associated with Greater Asthma Morbidity

This study used results from a cross-sectional survey of parents of 3- to 5-year-old children with asthma to assess the frequency of self-reported home environmental conditions that could contribute to worsening asthma and examined the relationship between these factors and the child's asthma morbidity. Participants were 149 parents drawn from the two largest agencies that provide subsidized preschool childcare services in East and Central Harlem, inner-city communities with high prevalence of asthma. The sample represented 77% of eligibles determined by a validated case-identification instrument. Data were collected on demographics, symptoms, medication use, Emergency Department visits and hospitalization, and environmental conditions in the home. One or more of these home environmental conditions were reported by 92% of participants. Controlling for other environmental conditions and demographics, associations were found between self-reported presence of moisture or mildew on ceilings, walls, or windows and higher frequency of hospitalizations for breathing-related problems (OR = 3.31; 95% CI 1.62-6.75), frequent episodes of wheezing (OR = 3.25; 95% CI 1.8-6.0), and higher frequency of night symptoms due to asthma (OR = 2.19; 95% CI 1.4-3.41). Having a carpet or rug in the child's bedroom or the living room was also associated with hospitalizations (OR = 3.23; 95% CI 1.53-6.8), and male gender was marginally associated with the frequency of night symptoms (OR = 1.51; 95% CI .95-2.4). Asthma is prevalent in the Head Start population, and exposure to home environmental conditions that may worsen asthma is common in the socially disadvantaged populations served by Head Start programs.

Anti‐tumor necrosis factor‐α antibody treatment reduces pulmonary inflammation and methacholine hyper‐responsiveness in a murine asthma model induced by house dust

Recent studies documented that sensitization and exposure to cockroach allergens significantly increase children's asthma morbidity as well as severity, especially among inner city children. TNF-alpha has been postulated to be a critical mediator directly contributing to the bronchopulmonary inflammation and airway hyper-responsiveness in asthma. This study investigated whether an anti-TNF-alpha antibody would inhibit pulmonary inflammation and methacholine (Mch) hyper-responsiveness in a mouse model of asthma induced by a house dust extract containing both endotoxin and cockroach allergens. A house dust sample was extracted with phosphate-buffered saline and then used for immunization and two additional pulmonary challenges of BALB/c mice. Mice were treated with an intravenous injection of anti-TNF-alpha antibody or control antibody 1 h before each pulmonary challenge. In a kinetic study, TNF-alpha levels within the bronchoalveolar lavage (BAL) fluid increased quickly peaking at 2 h while BAL levels of IL-4, IL-5, and IL-13 peaked at later time-points. Mch hyper-responsiveness was measured 24 h after the last challenge, and mice were killed 24 h later. TNF inhibition resulted in an augmentation of these Th2 cytokines. However, the allergic pulmonary inflammation was significantly reduced by anti-TNF-alpha antibody treatment as demonstrated by a substantial reduction in the number of BAL eosinophils, lymphocytes, macrophages, and neutrophils compared with rat IgG-treated mice. Mch hyper-responsiveness was also significantly reduced in anti-TNF-alpha antibody-treated mice and the pulmonary histology was also significantly improved. Inhibition of TNF significantly reduced eotaxin levels within the lung, suggesting a potential mechanism for the beneficial effects. These data indicate that anti-TNF-alpha antibody can reduce the inflammation and pathophysiology of asthma in a murine model of asthma induced by a house dust extract.

The Canadian Asthma Primary Prevention Study: Outcomes at 2 Years of Age

Becker A, Watson W, Ferguson A, Dimich-Ward H, Chan-Yeung M. J Allergy Clin Immunol. 2004;113:650–656To determine the effectiveness of a multifaceted intervention program in the primary prevention of asthma in high-risk infants.Subjects were children (n = 549) born between October 1994 and August 1996, classified as high-risk for development of asthma on the basis of family history.A prospective, controlled clinical trial identified mothers in their third trimester of pregnancy and randomized each mother into either the multifaceted-intervention group (n = 278) or control group (n = 267). The intervention program was implemented during the first year of life and included decreasing allergen (dust mite and pet) and environmental tobacco-smoke exposure, encouraging breastfeeding, and delaying introduction of solid foods. The control group did not receive specific intervention education. Home visits conducted during the third trimester, at 2 weeks, and at 4, 8, 12, 18, and 24 months of age assessed health, demographic, and home characteristics, and dust samples were collected to quantify house dust-mite and cat-allergen levels. Infants in each group were evaluated and prick skin-tested for common food and environmental allergens at 12 months and 2 years of age. Study participants were assessed for possible asthma, probable asthma, recurrent wheeze, recurrent cough, rhinitis without colds, and atopy (defined as positive skin test to ≥1 allergen).In terms of intervention efficacy, there were significant differences in cat-allergen exposure (with no change in prevalence of pets) and day care enrollment between the groups. Asthma was characterized as the sum of possible and probable asthma diagnoses. At 2 years, 40 of 246 (16.3%) intervention children and 53 of 230 (23%) control children were classified as asthmatic. There was a significant reduction in persistent asthma (children meeting criteria for asthma at both 12 and 24 months of age), with only 4.9% of the intervention group versus 11.3% of the control group characterized as having persistent asthma. There was no difference between the groups in regard to recurrent cough and no difference in incidence in the first year of life of recurrent wheeze. However, at 2 years, there were significantly fewer children in the intervention group with recurrent wheeze (1%) versus the control group (3.5%). The prevalence of atopy at 2 years was not different between the intervention (15.6%) and control (13.7%) groups.The multifaceted intervention program, which focused on decreasing exposure in the first year of life to aeroallergens, food allergens, and environmental tobacco smoke for children deemed to be at high risk for development of asthma, was successful in significantly reducing the incidence of asthma at 2 years of age.This study demonstrates that, in infants at high risk for developing asthma, reduction in allergen exposure and environmental modifications in the first year of life can significantly affect disease development and progression. Public health programs targeting these interventions may greatly impact the increasing prevalence and morbidity of childhood asthma.

The Relationship of Caretaker Anxiety to Children's Asthma Morbidity and Acute Care Utilization

The Relationship of Caretaker Anxiety to Children's Asthma Morbidity and Acute Care Utilization

A multifaceted, home based, environmental intervention modestly reduced asthma morbidity in children with atopic asthma

Morgan WJ, Crain EF, Gruchalla RS, et al. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med 2004;351:1068–80. [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] Q In inner...

Air pollution and childhood asthma emergency hospital admissions: Estimating intra-city regional variations

In recent years childhood asthma has increased. Although the precipitants of childhood asthma are yet to be established possible contributing factors are local ambient air pollutants. This study aims to assess associations of regional ambient air pollutants on emergency department childhood asthma presentations across four regions of the city of Melbourne, Australia. Daily emergency department (ED) presentations for asthma in children were studied for the years 2000 and 2001. Estimates of local air pollutant levels were obtained using simulation modelling techniques. Generalized Additive Models were used to examine associations between combined local levels of air pollutants and childhood asthma ED presentations adjusting for seasonal variation, day of week effects, and meteorological variables. There was consistent associations between childhood ED asthma presentations and regional concentration of PM10, with a strongest association of RR = 1.17 (95% CI 1.05 to 1.31) in the central district of Melbourne. NO2 and Ozone was associated with increased childhood asthma ED presentations in the Western districts. This study suggests that regional concentrations of PM10 may have a significant effect on childhood asthma morbidity. In addition, ozone may play a role however, its effect may vary by geographical region.

The Relationship of Caretaker Anxiety to Children's Asthma Morbidity and Acute Care Utilization

Objectives: This study examined self-reported psychological distress in caretakers of inner-city children with asthma and examined its association to disease severity, as measured by day and night symptoms, and to acute care utilization for asthma. Method: We enrolled 193 English and Spanish-speaking caretakers (86% were mothers) of 2- to 12-year-olds who had at least one asthma hospitalization at a large urban medical center. They completed an interview asking about children's asthma symptoms and acute care utilization (provider visits, emergency department visits, hospitalizations for asthma) and a 29-item psychiatric symptom inventory. National guidelines criteria were used to classify asthma severity into three categories based on caretaker report of day and night symptoms in the past 4 weeks. These were: moderate-severe persistent (37%), mild persistent (27%), and mild intermittent (35%) asthma. Results: Caretakers of children who were reported as having moderate-severe persistent asthma symptoms exhibited higher anxiety than caretakers reporting milder symptoms in their children, but symptom severity was unrelated to depression, anger, cognitive disturbance, or overall distress in caretakers. Three measures of acute care utilization in the last 6 months increased with reported symptom severity, but they were not associated with caretaker distress. Conclusions: Providers treating children with asthma should consider the potential importance of caretaker reports of daily symptoms both for the child's physical functioning and for parental anxiety.

Maternal depressive symptoms and adherence to therapy in inner‐city children with Asthma

. Bartlet, S.J., Krishnan, J.A., Riekert, K.A., Butz, A.M., Malveaux, F.J. &amp; Rand, C.S. ( 2004 ) 113 , 229 – 237 . Context Little is known about how depressive symptoms in mothers affects illness management in inner‐city children with asthma.Objective The goal was to determine how maternal depressive symptoms influence child medication adherence, impact of the child's asthma on the mother, and maternal attitudes and beliefs.Methods Baseline and 6‐month surveys were administered to 177 mothers of young minority children with asthma in inner‐city Baltimore, MD and Washington, DC. Medication adherence, disruptiveness of asthma, and select attitudes toward illness and asthma therapy were measured. Six‐month data (n = 158) were used to prospectively evaluate long‐term symptom control and emergency department use. Independent variables included asthma morbidity, age, depressive symptoms and other psychosocial data.Results No difference in child asthma morbidity was observed between mothers high and low in depressive symptoms. However, mothers with high depressive symptoms reported significantly more problems with their child using inhalers properly [odds ratio (OR) 5.0, 95% confidence interval (CI) 1.3–18.9] and forgetting doses (OR 4.2, 95% CI 1.4–12.4). Depressive symptoms were also associated with greater emotional distress and interference with daily activities caused by the child's asthma, along with less confidence in asthma medications, ability to control asthma symptoms and self‐efficacy to cope with acute asthma episodes. In addition, depressed mothers reported less understanding about their child's medications and use (OR 7.7, 95% CI 1.7–35.9). Baseline asthma morbidity, maternal depression scores and family income were independently associated with asthma symptoms 6 months later, whereas medication adherence was not predictive of subsequent asthma morbidity or emergency department use.Conclusions Maternal depressive symptoms were not associated with child asthma morbidity but were associated with a constellation of beliefs and attitudes that may significantly influence adherence to asthma medications and illness management. Identifying and addressing poor psychological adjustment in mothers is important when developing a child's asthma treatment and may facilitate parent–provider communication, medication adherence and asthma management among inner‐city children.

Methods and issues in conducting a community-based environmental randomized trial*1

The environment is suspected to play an important role in the prevalence and severity of asthma in inner-city children. This paper describes the implementation and baseline data of an inner-city community-based participatory research clinical trial designed to test the effectiveness of a pollutant and allergen control strategy on children's asthma morbidity. Participants were 100 elementary-school-aged children with asthma, graduates of a school-based asthma education program in East Baltimore. The intervention for half of the randomly assigned families consisted of environmental control education, allergen-proof encasements, pest extermination, and a HEPA air cleaner at the beginning of the study. Controls received the same at the end of the study. Participants visited a clinic for questionnaires, allergy skin testing, spirometry, and blood sample at baseline and 12 months. Home environments, NO2, O3, airborne particulates, and allergens were evaluated at baseline and at 6 and 12 months. Asthma morbidity and adherence was assessed quarterly. Collaboration with the community proved very beneficial in creating a study design and procedures acceptable to an inner-city community.

Predictors of health care utilization of children with asthma in the community.

The aim of this study was to assess the pattern of use of health care services among children with asthma symptoms within the community, and assess groups at increased risk of emergency department (ED) visits or hospital admissions (HA). Using International Study of Asthma and Allergies in Childhood phase II protocol, information about asthma management and utilization of health care services was collected by parental questionnaire in a community-based random sample of 5-7- and 9-11-year-old children (n = 11,094) in Dresden and Munich. Only 11.2% of children with current wheeze did not utilize any health care facility or consultation for their asthma symptoms in the 12 months prior to survey, while 86.2%, 12.3%, and 3.6% had at least one asthma related physician's consultation, ED visits, or HA, respectively. Predictors of ED visits and HA among current wheezers were: younger age, male gender, speech-limiting wheeze, level of exposure to environmental tobacco smoke. In addition, children of low socioeconomic status were more likely to have ED visits because of their asthma. Childhood asthma is a major public health problem in Germany leading to substantial morbidity and utilization of health care services. Exposure to tobacco smoke comes out as the major modifiable risk factor related to asthma morbidity in children.

Pediatric asthma: improving management to reduce cost of care.

The economic burden of pediatric asthma is substantial, with national annual health care costs of $3 billion. Successful clinical management of asthma in children has the potential to decrease this burden by lowering the disproportionate costs of hospitalization and acute care for pediatric asthma patients. Based on increased understanding of the pathogenesis of asthma, revised guidelines were published by the National Institutes of Health in 1997 (with an update in 2002) and by the American Academy of Allergy, Asthma, and Immunology in 1999 to assist in the diagnosis and management of pediatric asthma. These guidelines emphasize the role of inflammation in asthma and recommend treatment of the underlying inflammatory process. Despite increased knowledge regarding the pathogenesis of the disease and the availability of effective anti-inflammatory agents, particularly inhaled corticosteroids, the prevalence of asthma and disease-related morbidity continues to remain high in children. Asthma interventions that include the use of guideline-recommended inhaled corticosteroid therapy and patient and caregiver education in asthma management may help to reduce asthma morbidity in children and decrease the substantial costs of pediatric asthma.

Maternal depressive symptoms and adherence to therapy in inner-city children with asthma.

Little is known about how depressive symptoms in mothers affects illness management in inner-city children with asthma. Our goal was to determine how maternal depressive symptoms influence child medication adherence, impact of the child's asthma on the mother, and maternal attitudes and beliefs. Baseline and 6-month surveys were administered to 177 mothers of young minority children with asthma in inner-city Baltimore, MD and Washington, DC. Medication adherence, disruptiveness of asthma, and select attitudes toward illness and asthma therapy were measured. Six-month data (N = 158) were used to prospectively evaluate long-term symptom control and emergency department use. Independent variables included asthma morbidity, age, depressive symptoms, and other psychosocial data. No difference in child asthma morbidity was observed between mothers high and low in depressive symptoms. However, mothers with high depressive symptoms reported significantly more problems with their child using inhalers properly (odds ratio [OR]: 5.0; 95% confidence interval [CI]: 1.3-18.9) and forgetting doses (OR: 4.2; 95% CI: 1.4-12.4). Depressive symptoms were also associated with greater emotional distress and interference with daily activities caused by the child's asthma, along with less confidence in asthma medications, ability to control asthma symptoms, and self-efficacy to cope with acute asthma episodes. In addition, depressed mothers reported less understanding about their child's medications and use (OR: 7.7; 95% CI: 1.7-35.9). Baseline asthma morbidity, maternal depression scores, and family income were independently associated with asthma symptoms 6 months later, whereas medication adherence was not predictive of subsequent asthma morbidity or emergency department use. Maternal depressive symptoms were not associated with child asthma morbidity but were associated with a constellation of beliefs and attitudes that may significantly influence adherence to asthma medications and illness management. Identifying and addressing poor psychological adjustment in mothers is important when developing a child's asthma treatment and may facilitate parent-provider communication, medication adherence, and asthma management among inner-city children.

Asthma Management Practices at Home in Young Inner‐City Children

Information on parental asthma management practices for young children is sparse. The objective of this article is to determine if specific caregiver asthma management practices for children were associated with children's asthma morbidity. Caregivers of 100 inner‐city children diagnosed with persistent asthma and participating in an ongoing asthma intervention study were enrolled and interviewed to ascertain measures of asthma morbidity, medication use, health care use (acute and primary care), and asthma management practices. Overall, asthma morbidity was high with almost two thirds of caregivers reporting their child having one or more emergency department visits within the last 6 months and 63% receiving specialty care for their asthma. Appropriate medication use was reported predominantly as albuterol and inhaled steroids (78%). However, only 42% of caregivers reported administering asthma medicines when their child starts to cough and less than half (39%) reported having an asthma action plan. There were no significant differences by asthma severity level for any asthma management practice. In conclusion, caregivers lack knowledge regarding cough as an early asthma symptom. Caregivers should be encouraged to review asthma action plans with health care providers at each medical encounter.