Childhood Asthma Management Research Articles

MAGNEsium Trial In Children (MAGNETIC): a randomised, placebo-controlled trial and economic evaluation of nebulised magnesium sulphate in acute severe asthma in children

There are few data on the role of nebulised magnesium sulphate (MgSO4) in the management of acute asthma in children. Those studies that have been published are underpowered, and use different methods, interventions and comparisons. Thus, no firm conclusions can be drawn. Does the use of nebulised MgSO4, when given as an adjunct to standard therapy in acute severe asthma in children, result in a clinical improvement when compared with standard treatment alone? Patients were randomised to receive three doses of MgSO4 or placebo, each combined with salbutamol and ipratropium bromide, for 1 hour. The Yung Asthma Severity Score (ASS) was measured at baseline, randomisation, and at 20, 40, 60 (T60), 120, 180 and 240 minutes after randomisation. Emergency departments and children's assessment units at 30 hospitals in the UK. Children aged 2-15 years with acute severe asthma. Patients were randomised to receive nebulised salbutamol 2.5 mg (ages 2-5 years) or 5 mg (ages ≥ 6 years) and ipratropium bromide 0.25 mg mixed with either 2.5 ml of isotonic MgSO4 (250 mmol/l, tonicity 289 mOsm; 151 mg per dose) or 2.5 ml of isotonic saline on three occasions at approximately 20-minute intervals. The primary outcome measure was the ASS after 1 hour of treatment. Secondary measures included 'stepping down' of treatment at 1 hour, number and frequency of additional salbutamol administrations, length of stay in hospital, requirement for intravenous bronchodilator treatment, and intubation and/or admission to a paediatric intensive care unit. Data on paediatric quality of life, time off school/nursery, health-care resource usage and time off work were collected 1 month after randomisation. A total of 508 children were recruited into the study; 252 received MgSO4 and 256 received placebo along with the standard treatment. There were no differences in baseline characteristics. There was a small, but statistically significant difference in ASS at T60 in those children who received nebulised MgSO4 {0.25 [95% confidence interval (CI) 0.02 to 0.48]; p = 0.034} and this difference was sustained for up to 240 minutes [0.20 (95% CI 0.01 to 0.40), p = 0.042]. The clinical significance of this gain is uncertain. Assessing treatment-covariate interactions, there is evidence of a larger effect in those children with more severe asthma exacerbations ( p = 0.034) and those with a shorter duration of symptoms ( p = 0.049). There were no significant differences in the secondary outcomes measured. Adverse events (AEs) were reported in 19% of children in the magnesium group and 20% in the placebo group. There were no clinically significant serious AEs in either group. The results of the base-case economic analyses are accompanied by considerable uncertainty, but suggest that, from an NHS and Personal Social Services perspective, the addition of magnesium to standard treatment may be cost-effective compared with standard treatment only. The results of economic evaluation show that the probability of magnesium being cost-effective is over 60% at cost-effectiveness thresholds of £1000 per unit decrement in ASS and £20,000 per quality-adjusted life-year (QALY) gained, respectively; it is noted that for some parameter variations this probability is much lower, reflecting the labile nature of the cost-effectiveness ratio in light of the small differences in benefits and costs shown in the trial and the relation between the main outcome measure (ASS) and preference based measures of quality of life used in cost-utility analysis (European Quality of Life-5 Dimensions; EQ-5D). This study supports the use of nebulised isotonic MgSO4 at the dose of 151 mg given three times in the first hour of treatment as an adjuvant to standard treatment when a child presents with an acute episode of severe asthma. No harm is done by adding magnesium to salbutamol and ipratropium bromide, and in some individuals it may be clinically helpful. The response is likely to be more marked in those children with more severe attacks and with a shorter duration of exacerbation. Although the study was not powered to demonstrate this fully, the data certainly support the hypotheses that nebulised magnesium has a greater clinical effect in children who have more severe exacerbation with shorter duration of symptoms. Current Controlled Trials ISRCTN81456894. The National Institute for Health Research Health Technology Assessment programme.

Effect of Inhaled Glucocorticoids in Childhood on Adult Height

HW Kelly, AL Sternberg, R Lescher; CAMP Research Group. N Engl J Med. 2012;367(10):904–912 Inhaled glucocorticoids (ICS) have been shown to have a temporary decrease in linear growth velocity in children. The effect of ICS on adult height has not been well defined. Participants (943 of 1041) in the Childhood Asthma Management Program study were enrolled between December 1993 and September 1995. They were between 5 and 13 years of …

Management of severe asthma in childhood – State of the art and novel perspectives

The majority of children with asthma have mild or moderate disease and can obtain adequate control of symptoms through avoidance of triggering factors and/or with the help of medications. There is still a group of children with severe asthma in whom symptom control is poor depending either on identifiable aggravating factors or on true therapy resistance. These children have a poor quality of life and are limited by the severity of their disease. There is a need for a staged approach to the assessment and treatment of this small but vulnerable and resource-consuming group. The current review will provide an overview of a possible standardized approach to characterize this heterogeneous group of severely sick children including some newly developed ways of assessing asthma severity and potentialities of new asthma therapies. Furthermore, the umbrella term 'problematic severe asthma' is described. The term encompasses children whose severe asthma is due to identifiable exacerbating factors, as well as children who are resistant to any conventional therapeutic approach. Characteristics of these two groups of children are described, as are possible biomarkers and current and emerging diagnostic tools for allergy evaluation. Some recent advances and future possibilities for treatment of severe asthma are also presented in this review.

Exhaled nitric oxide in childhood allergic asthma management: A randomised controlled trial

We investigated the potential yield of incorporating fractional exhaled nitric oxide (FeNO) measurements in childhood allergic asthma management. Ninety-nine children with persistent allergic asthma were included in this multicentre, single-blind, randomized controlled trial. Treatment was based on the Global Initiative for Asthma (GINA) guidelines. In the FeNO group, asthma management was also guided by FeNO measurements. Health outcomes were evaluated over a 52-week timeframe. Fewer asthma exacerbations were registered in the FeNO group. 24% of the children in the FeNO group experienced one or more exacerbations per year, compared with 48% in the clinical group (P = 0.017). The proportion of symptom-free days did not differ between groups. In the FeNO group, more months of leukotriene receptor antagonist use (median (interquartile range)) were observed: 12 (9-12) months, compared with 9 (3-12) months in the clinical group (P = 0.019). Next, the evolution of inhaled corticosteroid doses between visits 1 and 5 (median change (interquartile range)) showed a significant increase of +100 µg (0, +400) in the FeNO group and a change of 0 µg (-200, +80) in the clinical group (P = 0.016). FeNO measurements in childhood asthma management did not improve the proportion of symptom-free days, but did result in fewer asthma exacerbations associated with an increased leukotriene receptor antagonist use and an augmentation of the inhaled corticosteroid doses.

Asthma, FEF25-75, and Hospitalizations in Children.

Asthma is a common chronic pediatric respiratory disease associated with significant morbidity. Current guidelines recommend monitoring forced expiratory volume in 1 s (FEV1) as part of the assessment of asthma severity and control; however, many children with asthma have a normal FEV1 despite significant symptoms. Reduced forced expiratory flow between 25%-75% of forced vital capacity (FEF25-75) may be an important measure of asthma severity and control in children with normal FEV1. This study examines the association between FEF25-75 and asthma-related hospitalizations. Pulmonary function tests and records of 925 children ≤19 years of age seen for an initial evaluation of physician-diagnosed asthma at a community-based asthma clinic between 1999 and 2011 were reviewed. FEV1 ≥80% predicted and FEF25-75 ≥60% were considered normal. The associations between FEV1 and FEF25-75 and asthma-related hospitalizations were examined using logistic regression models. Thirteen percent (n=118) of the children were hospitalized for asthma at least once in the previous year. Fifty four percent (n=501) of the children met criteria for uncontrolled asthma symptoms. Asthma-related hospitalization was associated with reducing categories of FEF25-75, but not FEV1. Among the 693 children with normal FEV1 (≥80%), those with FEF25-75 <60% were more likely to have been hospitalized in the previous year (odds ratio 2.50, confidence interval 1.17-5.35) as compared to those with FEF25-75 ≥60% of predicted. In a diverse urban cohort of children with asthma, asthma-related hospitalization in the previous year was associated with reduced FEF25-75 even among those with normal FEV1. Our results suggest that FEF25-75 may provide important information in the assessment and management of asthma in children.

Status of diagnosis and management of children with asthma in Beijing urban area

Objective To learn the status of diagnosis and treatment as well as control level of childhood asthma in Beijing central area and to provide data for improving the prevention and management of childhood asthma in Beijing. Methods Children diagnosed as asthma in the 3rd Beijing Childhood Asthma Prevalence Survey were included in the study.Measurements of lung function, exhaled nitric oxide (eNO) were carried out in part of school-age children with asthma.Analysis of asthma diagnosis, comorbidity, medication and asthma management and asthma control level were conducted. Results Of the 497 children diagnosed as asthma in the survey, 59.4% had been previously diagnosed, 19.1%(95/497 cases) were not given a confirmed diagnosis, and 21.5%(107/497 cases) were not diagnosed of any wheezing disease.Among the previously diagnosed asthmatic children, bronchodilators and inhaled glucocorticosteroids were used in 79.0% and 46.4% of the patients respectively, while antibiotics was used in 82.4% of patients, and only 66.1%(195/295 cases) of patients underwent allergy tests.In children with asthma above 5 years old, 13.6% (53/399 cases) used peak flow meter for monitoring.In the 99 cases of asthmatic children who were followed up, wheezing was heard in 14.1% of the patients and forced expiratory volume in one second 35 ppb.In the past 1 month, 19.2%(19/99 cases) of the children used inhaled glucocorticosteroids, and 65.7% of the patients were controlled. Conclusions There were still a considerable number of asthmatic children who were not diagnosed or not treated timely or properly, even in central area of Beijing.The asthma control rate was not so high as expected, and the management of childhood asthma needs to be strengthened further. Key words: Asthma; Diagnosis; Management; Control; Child

Office-based exhaled nitric oxide measurement in children 4 years of age and older

BackgroundFractional exhaled nitric oxide (FENO) is increasingly being used in the office-based management of asthma, but data in children are limited. ObjectivesTo report FENO values in 4- to 7-year-old children with suspected asthma and characterize their relation to clinical variables and describe the relation among FENO levels, age, and sex in 4- to 18-year-old children with suspected asthma. MethodsRetrospective data in 4- to 18-year-old children (n = 825) who underwent FENO testing using the NIOX MINO device were collected and analyzed. Chart reviews were performed for the 4- to 7-year-old children (n = 75). ResultsFENO values ranged from less than or equal to 5 to 89 ppb in 75 4- to 7-year-old children and less than or equal to 5 to 300 ppb in 750 > 7 to 18-year-old children. Approximately one tenth of 4- to 7-year-old children and one third of > 7 to 18-year-old children had FENO values indicative of eosinophilic/allergic inflammation (>35 ppb). In regression analysis of the 4- to 7-year-old children, increasing age (P = .03) and asthma severity (P = .01) were associated with higher FENO levels. Atopic dermatitis was significantly associated (P = .03), whereas allergic rhinitis was marginally associated (P = .06), with higher FENO levels. Inhaled corticosteroid use was associated with lower FENO levels (P = .02). ConclusionThis study characterizes the largest cohort of 4- to 7-year-old children to undergo FENO testing in ambulatory asthma management. Correlations between FENO levels and clinical variables were consistent with established findings in older children. This preliminary real-world study suggests that FENO assessment may be feasible and useful in the office-based asthma management of children as young as 4 years.

Health professionals’ and families’ understanding of the role of individualised homeopathy in asthma management for children requiring secondary care: Qualitative findings from a mixed methods feasibility study

BackgroundThis paper draws on a mixed methods study that examined the feasibility of conducting a randomised controlled trial of individualised homeopathy plus usual care, compared to usual care alone, for children aged 7–14 with moderate to severe asthma recruited from secondary care. It draws on qualitative interviews with participants in the feasibility study that investigated families’ and professionals’ views and experiences of asthma, homeopathy and study participation. MethodsSemi-structured interviews were conducted with nine families from the homeopathy arm of the feasibility study and eight health professionals from diverse disciplines involved in the study. Data analysis was thematic, guided by the constant comparative method and questions of interest to the feasibility study. ResultsThree key themes were identified: the complexities of asthma and asthma management; the potential for homeopathy to improve asthma management; and perceptions and experiences of the research process. All participant groups agreed that asthma was a complex condition that was difficult to manage, but they voiced varied concerns and different perspectives regarding the ‘added value’ of homeopathy alongside usual care. ConclusionsThis qualitative study shows how participants in a feasibility study can hold different priorities and perspectives about an intervention for severe childhood asthma. Differences in valued outcomes that reflect holistic practice should be considered when designing future research in this field.

P196 Updating the Evidence For CPGs: The Usefulness Of RSS Feeds

BackgroundScientific knowledge is in constant evolution and even if Clinical Practice Guidelines (CPGs) get out of date in five years time, there is a lack of standardised method for an...

The value of FeNO measurement in childhood asthma: uncertainties and perspectives

Asthma is considered an heterogeneous disease, requiring multiple biomarkers for diagnosis and management. Fractional exhaled nitric oxide in exhaled breath (FeNO) was the first useful non-invasive marker of airway inflammation in asthma and still is the most widely used. The non-invasive nature and the relatively easy use of FeNO technique make it an interesting tool to monitor airway inflammation and rationalize corticosteroid therapy in asthmatic patients, together with the traditional clinical tools (history, physical examination and lung function tests), even if some controversies have been published regarding the use of FeNO to support the management of asthma in children. The problem of multiple confounding factors and overlap between healthy and asthmatic populations preclude the routine application of FeNO reference values in clinical practice and suggest that it would be better to consider an individual “best”, taking into account the context in which the measurement is obtained and the clinical history of the patient. Besides, there is still disagreement about the role of FeNO as a marker of asthma control, due to the complexity of balance among the different items involved in its determination and the lack of homogeneity in the population groups studied in the few studies conducted so far. Heterogeneity of problematic severe asthma greatly limits utility of FeNO alone as a biomarker of inflammation to optimize the disease management on an individual basis. None of the studies conducted so far demonstrated that the use of FeNO was better than current asthma guidelines in controlling asthma exacerbations. In summary, there is a large variation in FeNO levels between individuals, which may reflect the natural heterogeneity in baseline epithelial nitric oxide synthase activity and/or the contribution of other noneosinophilic factors to epithelial nitric oxide synthase activity. FeNO is a promising biomarker, but at present some limits are highlighted. We would recommend that further research can be carried out by organizing studies aimed to obtain reliable reference values of FeNO and in order to better interpret FeNO measurements in clinical settings, taking also into account the influence of genetic and environmental factors.

Effect of education on the successful management of asthmatic children

Effect of education on the successful management of asthmatic children

Effective Management of Childhood Asthma: Pediatricians Need to Go the Extra Mile!

Effective Management of Childhood Asthma: Pediatricians Need to Go the Extra Mile!

Review of the management of childhood asthma in Tasmania

To review the supply of medications to children with asthma and parent-reported management of childhood asthma in Tasmania and highlight evidence-practice gaps for future interventions. Participating pharmacies ran a software application that extracted data from dispensing records and helped to identify children with asthma. Parents of identified children were mailed a survey evaluating components of asthma management. Dispensing and survey data were analysed. A total of 939 children from 23 pharmacies were identified by the software and deemed eligible for inclusion. Surveys were received from 353 (37.6%) parents. In the past year, short-acting beta-2 agonists were supplied to 56.1% of the cohort, preventers to 76.5% (inhaled corticosteroids 52.3%; leukotriene receptor antagonists 31.3%; inhaled cromones 0.6%), long-acting beta-2 agonists (LABAs) to 25.7% and oral corticosteroids to 21.5%. Approximately half of the children receiving inhaled corticosteroids were concurrently receiving a LABA. Among children with indicators of inadequately controlled asthma, up to 73.7% of their parents reported that their asthma was adequately controlled, up to 38.2% did not possess an Asthma Action Plan, up to 36.8% were not regularly using a spacer and up to 22.8% had not received a preventer. These results indicate gaps in childhood asthma management, in particular, undersupply of preventers in high-risk patient groups, high supply of LABAs and insufficient spacer and asthma action plan usage. These areas should be targeted for interventions to improve childhood asthma management.

Does Use of Inhaled Corticosteroid for Management of Asthma in Children Make Them Shorter Adults?

The purpose of this review is to discuss the effect of daily inhaled corticosteroids (ICSs) on the height of children with asthma. The effect of ICSs on growth and height is dependent on the dose and the therapeutic index of the ICS; however, the effect on final adult height was not clear until recently. New data suggest that if growth suppression occurs with the use of ICSs in children, it is sustained, but not cumulative over the years. The observed reduction in the final adult height is small and does not outweigh the benefits of ICSs, and the growth effect may be minimized by use of newer ICSs and other approaches for management of asthma in children with mild to moderate asthma.

THU0490-HPR Development of medication assessment tools specific for rheumatoid arthritis

BackgroundMedication assessment tools,first introduced in heart failure management, are evidence-based instruments intended for the evaluation of prescribing trends and monitoring of adherence to established guidelines. To-date medication assessment tools have...

Provider Perceptions of Parent Health Literacy and Effect on Asthma Treatment Recommendations and Instructions

Little is known about how pediatric providers assess parental health literacy, how concordant they are with validated measures of health literacy, and how these perceptions may influence treatment recommendations, how instructions are given or how reliable they perceive parents to be in carrying out instructions. Two hundred and eighty-one parents of 6-12-year-old asthma patients attending a pediatric clinic visit were recruited to a cross-sectional study of health literacy and asthma outcomes. Fourteen pediatric healthcare providers participated. Parents completed surveys that included 2 measures of health literacy: the Test of Function Health Literacy in Adults (TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM). Immediately postvisit, pediatric providers completed a brief survey asking their assessment of the parent's health literacy and how it impacted treatment instructions and recommendations. Kappa statistics tested concordance; chi square and logistic regression tested associations among provider ratings, rating concordance, and demographic factors. Six providers were interviewed regarding the bases for their ratings. Providers' perceptions influenced asthma treatment recommendations (p=0.001) and how treatment instructions were given (p=0.001). Providers indicated that their perceptions were shaped by parent's verbal communication skills and patterns of past behavior related to children's asthma management. Data from 277 parents indicated that most had adequate health literacy with a lower percentage scored as adequate by the REALM versus the TOFHLA. Pediatric provider estimates of parental health literacy had low concordance with the validated measures. Providers were more likely to designate whites as adequately health literate. Pediatric asthma providers' perceptions of parents' health literacy can influence treatment recommendations and instructional practices.

G120 Knowledge and Attitudes; Essential Ingredients For Developing Co Produced Tailored Interventions For Asthma Management (MIA) in South Asian and White British Children

Childhood asthma is a chronic illness affecting quality of life and leading to higher mortality in the UK than other countries. In the UK, prescription rates for relievers and preventers...

Les hospitalisations pour asthme chez l’enfant en France, 2002–2010

Most hospital admissions for asthma exacerbation are avoidable with adequate disease management. The objective of this study was to describe admissions for asthma in children in France using data from the French nationwide hospital database. We selected admissions having either a main diagnosis of asthma or a main diagnosis of acute respiratory failure (ARF) with asthma as an associated diagnosis, occurring in children (age<15years) between 2002 and 2010 in France (excluding French Guyana). In 2010, 35,004asthma admissions and 1381cases of asthma-related ARF were recorded (crude admission rate, 30.1/10,000 children); the mean length of stay was 2days. The in-hospital lethality rate ranged from 0.01% to 0.03% depending on the year. The annual age-standardized admission rate increased between 2002 and 2010 (+2.5% per year on average in metropolitan France). In 2010, 11.8% of children admitted for asthma or asthma-related ARF were readmitted for asthma or asthma-related ARF at least once within the same calendar year, and 1.3% were readmitted within the week following admission. The proportion of children aged less than 5 years who were readmitted within the same calendar year increased between 2002 and 2010. The increase in admission and readmission rates indicates non-optimal management of asthma in children in France.

Medicaid Payment Innovations to Financially Sustain Comprehensive Childhood Asthma Management Programs at Federally Qualified Health Centers

Background. One in 7 children in the United States is diagnosed with asthma, the leading cause of chronic childhood disease. Although a manageable condition when recommended medication regimens are followed and environmental control measures implemented, asthma remains the third most common reason for hospitalization among non-newborn hospital stays. As the primary health care home to a fifth of all low-income children who are especially vulnerable to asthma, federally qualified health centers play a critical role in providing comprehensive and preventive asthma care to their pediatric patients. Many health centers rely on the asthma education and counseling services of traditional and nontraditional providers, such as clinicians and community health workers, who may or may not be certified as asthma educators, as essential elements of asthma management and control. Asthma counselors are particularly valuable for patient home assessments and tailored education and counseling that are recommended components of evidence-based asthma care. Yet sustainable reimbursement for their services is a frequent challenge. Methods. We conducted an environmental scan of innovative approaches to securing adequate Medicaid reimbursement for asthma educator services provided as part of asthma management and control. Results. We identified a number of models at the individual health center, Medicaid health plan, and Medicaid state program level for securing sustainable reimbursement for asthma educators. Whereas state-based approaches are preferable to more incremental options at the health center and health plan level, local approaches may be more feasible for some health centers. Conclusion. Asthma educators provide essential, cost-effective services as part of childhood asthma care management. This analysis identifies creative solutions for health centers and other health care organizations to consider as mechanisms for sustaining the important services of these providers.

Diagnostic accuracy of the bronchodilator response in children

The bronchodilator response (BDR) reflects the reversibility of airflow obstruction and is recommended as an adjunctive test to diagnose asthma. The validity of the commonly used definition of BDR, a 12% or greater change in FEV1 from baseline, has been questioned in childhood. We sought to examine the diagnostic accuracy of the BDR test by using 3 large pediatric cohorts. Cases include 1041 children with mild-to-moderate asthma from the Childhood Asthma Management Program. Control subjects (nonasthmatic and nonwheezing) were chosen from Project Viva and Home Allergens, 2 population-based pediatric cohorts. Receiver operating characteristic curves were constructed, and areas under the curve were calculated for different BDR cutoffs. A total of 1041 cases (59.7% male; mean age, 8.9 ± 2.1 years) and 250 control subjects (46.8% male; mean age, 8.7 ± 1.7 years) were analyzed, with mean BDRs of 10.7% ± 10.2% and 2.7% ± 8.4%, respectively. The BDR test differentiated asthmatic patients from nonasthmatic patients with a moderate accuracy (area under the curve, 73.3%). Despite good specificity, a cutoff of 12% was associated with poor sensitivity (35.6%). A cutoff of less than 8% performed significantly better than a cutoff of 12% (P = .03, 8% vs 12%). Our findings highlight the poor sensitivity associated with the commonly used 12% cutoff for BDR. Although our data show that a threshold of less than 8% performs better than 12%, given the variability of this test in children, we conclude that it might be not be appropriate to choose a specific BDR cutoff as a criterion for the diagnosis of asthma.