Pediatric health-care providers may be unaware of how best to partner with their patients’ schools to create asthma-friendly environments in which patients’ asthma health needs are communicated clearly, school heath staff are empowered and equipped to react to asthma exacerbations appropriately, and school personnel reinforce asthma health maintenance messages with families.After completing this article, readers should be able to: More than 5.5 million school-age children in the United States are diagnosed as having asthma. (1) This equates to almost 1 in 10 school-age children, making asthma the most common chronic childhood condition in the country. More than half of all children with a diagnosis of asthma have at least 1 asthma exacerbation each year. Particularly concerning, rates of pediatric asthma deaths have been increasing. In 2018, 156 children aged 5 to 17 years died of asthma. Non-Hispanic black children have a 6 times greater mortality rate from asthma complications than Hispanic white children and a 7 times greater rate than non-Hispanic white children. (1) Deaths that occur outside the clinical setting account for 13% of all asthma deaths in children.Asthma can affect a child’s academic attendance and education. Children with asthma miss more school than those without asthma and are at greater risk for missing more than 10 school days per year, a degree of absenteeism that may put them at risk for grade retention. (2)(3) Almost half of all students with asthma miss at least 1 day of school each year due to related symptoms, accounting for 13.8 million lost days. (4) Absences occur most frequently during colder months, among students with persistent rather than intermittent asthma, and among students attending a school with a part- versus full-time nurse on staff. (3)(5) Studies suggest that 1 of the peak times for ambulance-treated pediatric asthma exacerbations is around 1 pm (ie, in the middle of the school day), further underscoring the importance of school factors in contributing to students’ asthma outcomes. (6)A recent policy statement from the American Academy of Pediatrics highlights the importance of coordination of care between community-based pediatricians and other child health-care providers (hereafter referred to collectively as pediatricians) and school health staff. (7) This review article focuses on the role of pediatricians in supporting and contributing to high-quality school-based asthma management. By gaining an understanding of the challenges that schools face in promoting asthma wellness, and of how to partner with students, families, school nurses, and school staff to overcome these challenges, pediatricians can help ensure that their patients with asthma are safe, healthy, and primed to learn.The Centers for Disease Control and Prevention (CDC) Healthy Schools and the CDC’s National Asthma Control Program (NACP) have developed strategies to guide school personnel and other stakeholders in creating asthma-friendly schools. (8) Asthma-friendly schools are defined as environments that are safe for children with asthma and have policies and practices in place that support children and their caregivers in managing their asthma. The NACP recommends multiple evidence-based strategies to address asthma in schools, including supporting students in asthma self-management, educating school staff and caregivers, improving school air quality, linking students to medical providers for asthma health maintenance, allowing students to self-carry quick-relief medication (such as albuterol), and having schools stock a supply of albuterol for communal student use.In interventional studies, school-based asthma management programs have typically involved a combination of interventions designed to improve schools’ ability to identify students with asthma and assess their level of symptom control, educate high-risk students on disease management, link students to primary care providers, and/or develop protocols for managing asthma emergencies. (9)(10)(11)(12) School-based asthma interventional trials have achieved varying levels of success in terms of improving students’ quality of life and reducing their number of hospitalizations and emergency department visits. Results suggest that strong partnerships among schools, families, and health-care providers are key to programmatic success, and limitations in available resources for program implementation are a primary barrier. (12)Note that interventional trials are typically conducted in relatively highly resourced school settings with engaged stakeholders. Depending on local context, the level of medical support that can be provided to students at any given school may be very different. Although US federal laws mandate that all children have access to health services at school, individual states determine the minimum qualifications for school nurses, which may or may not include a baccalaureate degree, nursing certification, registered nursing license, and minimum amount of experience. (13) States also regulate which activities, such as administering medications, can be performed only by a registered nurse versus a licensed practical nurse. Although the American Academy of Pediatrics strongly endorses a minimum of 1 full-time registered nurse in every school, this standard is not always met. (14) Access to school nurses has been associated with improvements in chronic disease management, including reduced frequency of asthma exacerbations and absenteeism due to asthma. (14) Nonetheless, only 63% of schools have full-time nursing coverage, 19% have part-time coverage, and 18% have no nursing coverage. (15) Approximately 80% of public schools have support from a registered nurse, either full- or part-time, whereas among private schools the percentage is much lower at 35%. In addition to nurses, nearly 1 in 5 schools use volunteers, and nearly 3 of 4 schools use teachers or school staff to supplement nursing activities, including performing health promotion education.Most assessments of barriers to asthma care management at school have exclusively included schools with nurses on staff. Presumably schools without nursing staff experience even greater obstacles to the provision of quality care to students. In a survey of school nurses that sampled from a national database, 78% of respondents reported that albuterol was available at their school. (16) However, because most schools do not stock albuterol for communal student use, it is unclear how many of the respondents were simply reporting that at least 1 student at their school had access to a personal supply of albuterol brought from home. (17) In another survey of nurses from 36 predominantly urban schools in Alabama, respondents collectively reported that only 14% of students with asthma had an albuterol inhaler at school. (18) Another survey of 126 nurses from a different urban school district found that nearly three-quarters of the respondents agreed that “asthma is one of the biggest health problems I deal with among students in my school,” and “most of the kids who have to be dismissed early because of asthma symptoms could go back to class if they had an inhaler at school.” (19) These results underscore the perceived impact of asthma on student health and suggest that some asthmatic children with mild symptoms and no inhaler are being sent home, leading to higher rates of absenteeism.Beyond limited access to albuterol, school nurses have also reported that their efforts to manage students’ asthma are hampered by inadequate nurse staffing and time, limited support from school administrators, and challenges in communicating with parents and pediatricians. Other barriers cited by school nurses include a lack of knowledge about asthma management guidelines among students, parents, teachers, school personnel, pediatricians, and school nurses, as well as a lack of appreciation for school nurses’ expertise. (20)Pediatricians’ efforts to partner with schools on asthma management should begin with self-evaluation to determine whether personal clinical practice adheres to guidelines for asthma diagnosis and management. In 2007, the National Heart, Lung and Blood Institute’s National Asthma Education and Prevention Program (NAEPP) established age-based criteria for the classification of asthma based on patients’ level of risk for severe exacerbation and degree of daily impairment. (21) In 2020, the NAEPP published focused updates across 6 topic areas to the original guidelines. (22).Assessing asthma risk involves considering all of a child’s significant asthma exacerbations in the preceding year, and assessing asthma impairment involves considering all of the child’s daily symptoms in the past 2 to 4 weeks. Risk and impairment are used to classify a child’s asthma severity (intermittent, mild persistent, moderate persistent, and severe persistent) and control (well controlled, not well controlled, or very poorly controlled). The NAEPP guidelines provide standardized recommendations for therapy initiation, escalation, and de-escalation based on the child’s risk and impairment classification at the time of the assessment. For more details on asthma diagnosis and management, see the article “Asthma” in the November 2019 issue of Pediatrics in Review and the 2007 and 2020 NAEPP recommendations. (21)(22)(23)NAEPP guidelines emphasize the importance of patient and family education regarding asthma diagnosis, symptom recognition, and management. Pediatricians should provide families with asthma self-management education at the time of diagnosis and reinforce key messages routinely at follow-up visits. Messages should be tailored to a child’s level of comprehension and developmental stage to encourage engagement. Proper use of inhalers should be repeatedly reviewed using the teach-back method, with parents and older children demonstrating their ability to administer medication. Asthma education initiated in the medical home should establish concepts and language that transcend care setting.Beyond following evidence-based guidelines in caring for individual patients with asthma, pediatricians can also leverage the functionality of their electronic medical record system to optimize asthma management on a practice or population level. Specifically, pediatricians can use medical record search tools to identify their at-risk patients and patients with asthma who have had gaps in care (eg, missed appointments or lack of prescription for an indicated controller medication).Guidelines dictate that all patients with asthma have an asthma action plan that is individualized. The written asthma action plan provides individualized instructions and a roadmap for education at school to reinforce appropriate medication use by families. The treatment plan should be developed through a joint decision-making process among the pediatrician, the patient, and the patient’s family. Input from a child’s school nurse may also be helpful for proper execution of the plan at school. Coordinating educational messages via the asthma action plan and other health records shared with school health staff allows the pediatrician to be sure that families receive consistent advice across care settings.Key elements of the asthma action plan include the following (24): Many pediatricians and school systems have adopted asthma action plans with these important components. These plans often use a stoplight format designating green, yellow, and red zones to indicate the actions needed when a child is doing well, should be monitored for worsening symptoms, or requires emergency medical intervention, respectively. Helpful asthma action plan examples in English and Spanish are available for download from the American Lung Association website. (25) Of note, some schools and school districts only accept their own, approved asthma action plan as the official form authorizing school health staff to administer asthma medication to students.A 2012 survey of 1,412 health-care providers (including adult-focused health-care providers and mid-level providers) found that only 16.4% of primary care providers “almost always” gave asthma action plans to patients, and 17.6% “never” gave them to patients. (26) A 2013 CDC survey found that only half (50.8%) of parents of a child aged 0 to 17 years with asthma recalled ever having received an asthma action plan. (27)Giving an asthma action plan to a family at medical visits does not guarantee that the form reaches school health staff. Manual delivery of asthma action plans to the school nurse by families has not been found to be reliable. (28) Faxing or mailing forms to the school are other options but require accurate school information and appropriate labeling of documents because they contain protected health information that should not be shared with non–health personnel at the school. Sharing of medical forms using electronic medical record interfaces, portals, and direct secure messaging should be explored as options for communicating with schools as these tools become more widely available.Communication between pediatricians and school health staff must comply with federal privacy laws governing the exchange of protected health information. Local school districts and health organizations may have additional regulations. Misconceptions regarding the requirements of these laws and regulations pose a barrier to effective care coordination across sectors.The Health Insurance Portability and Accountability Act (HIPAA) is a US federal law that protects the privacy of patient health information held by “covered entities.” (29) Pediatricians are considered covered entities, and thus, signed parental consent for the disclosure of a child’s protected health information by the pediatrician is required; however, there are exceptions. The exchange of protected health information with other health-care providers for treatment purposes is one of those exceptions permitting pediatricians to discuss a student’s medications and plan for the provision of care with the student’s school health staff without the written authorization of the student’s parent. (30)The Family Educational Rights and Privacy Act (FERPA) is a US federal law that protects the privacy of students’ personal records held by educational agencies or institutions that receive federal funds under programs administered by the US Secretary of Education. (31) School health records are maintained as part of the students’ educational records and are, therefore, governed by FERPA, not HIPAA. Under FERPA, school health staff is not allowed to disclose information in a student’s educational record to any party outside the school without written consent from parents. As such, school health staff can request documents and forms from the pediatrician but may not share information about asthma symptoms and medication use at school, absenteeism, or school performance without parental authorization. (32) In other words, HIPAA allows the pediatrician to communicate with the school nurse regarding the child’s health without written consent. However, FERPA requires parental consent for the school nurse to share any educational record information, including student health data, with the pediatrician.Bidirectional health information exchange between pediatricians and school health staff is a key component of creating an asthma-friendly school. Obtaining parental consent for this exchange needs to be standard procedure and, ideally, should be documented in the asthma action plan. Supplementary consent documents or treatment orders can also be used. Beyond the asthma action plan, standardized forms or documents to facilitate communication between school health staff and pediatricians can be used to streamline information exchange, particularly for children with poorly controlled asthma and/or chronic absenteeism due to asthma. Such a form may include space to document details about a student’s hospital admissions, emergency department visits, urgent care visits, school health suite visits, school days missed, whether the student has an asthma action plan and medication at school, and how both health-care parties prefer to exchange documents in the future. A standardized form may also include a place to document parental consent to permit bidirectional communication between the school and the pediatrician if consent is not already captured in the asthma action plan.In 2004, the US Congress passed the Asthmatic Schoolchildren’s Treatment and Health Management Act, which gives states preference for certain sources of federal funding if they enact local laws requiring schools to permit students to access their asthma medications during the school day. (33) Complying states must require public schools to authorize students to self-carry and self-administer asthma medication if 1) a health-care provider prescribed the medication for use during school hours; 2) the student demonstrates to the health-care provider and school nurse (if available) the skill level necessary to use the medication; 3) the health-care provider has written a treatment plan guiding medication use and asthma management (ie, an asthma action plan); and 4) the student’s parent or guardian has submitted to the school the asthma action plan and any other documents required by the school related to liability. Per the Act, students must have immediate access to their asthma medication while 1) at school; 2) at school-sponsored activities, including sporting events; and 3) traveling to or from school or school-sponsored activities. The asthma action plan, any other related documents, and backup medication, if provided to the school, must all be kept in a location at school to which the student and staff have immediate access in case of emergency. The medication authorization can apply only to the school for which it was granted, and it must be renewed by the parent each school year.All states and the District of Columbia now have albuterol self-carry laws for students. Nonetheless, states differ in the amount of detail included in their local laws. Those with less-detailed legislation rely on individual schools and school systems to determine the specific policies used to implement the mandate. It has been found that schools and school systems often create policies that add restrictions beyond what is minimally required. (34) For example, school systems may require the submission of extra forms beyond the asthma action plan. They may dictate that backup medication must be new and unopened, or accompanied by the asthma action plan at the time it is received rather than working with families to collect all the necessary items piecemeal. These policies effectively limit the number of asthmatic students with access to lifesaving treatment at school. Local variation in medication access rules can also cause confusion for parents and pediatricians in terms of knowing what items need to be submitted for which school.There are multiple prerequisite steps for a student to have access to a personal supply of quick-relief medication at school: Depending on when parents initiate the process and the time it takes for all the steps to be completed, a student may not gain access to albuterol at school until the winter or spring. In such cases, it is helpful for the pediatrician to alert the family that the process will need to be repeated again in the fall for the new school year.Access to albuterol remains low despite every state passing laws allowing students access to their self-supplied asthma medications at school. (18)(19) As a result, the NACP, professional organizations such as the National Association of School Nurses, and advocacy groups such as the American Lung Association all maintain the position that schools should stock albuterol inhalers for students who experience asthma symptoms or emergencies at school and lack access to their own medication. (8)(35)(36) In addition to the inhalers, schools need spacers to ensure effective delivery of medication. School policies and procedures need to minimize any contagion risk related to the use of medications and delivery devices.Most successful legislative efforts to enact so-called stock albuterol policies for schools have been modeled on existing stock epinephrine laws. (37) Currently, all states and the District of Columbia allow or require schools to stock epinephrine. In contrast, fewer than 20 states have passed laws or provided guidelines for stock albuterol in schools, and legislative efforts at the federal level have not been successful thus far. Important considerations for creating and implementing stock albuterol policies include the following: Toolkits and recommendations are available to help guide efforts to enact stock albuterol policies and programs, including from the American Lung Association (https://www.lung.org/), the National Association of School Nurses (https://www.nasn.org/home), and state agencies that have succeeded in such efforts. (35)(38)(39)(40)Some early adopters of stock albuterol policies have found promising results. For example, the state of Missouri enacted its stock albuterol legislation in 2012. Data collected in the 2013–2014 school year revealed that 981 students received stock albuterol, with 86% of those students returning to the classroom. (41) A low-income urban district in Arizona saw a 20% reduction in 911 calls and a 40% reduction in medical transports to the emergency department after implementing a stock albuterol policy that delivered 222 albuterol doses to 55 children at 22 schools. (42)Importantly, establishing a stock albuterol program does not replace the necessary components for the appropriate clinical diagnosis and management of asthma, such as effective communication between pediatricians and school health staff, use of an asthma action plan, and ongoing asthma self-management education for patients and families. Rather, stock albuterol should be viewed as 1 important tool among many in the toolbox for creating asthma-friendly school settings.Daily use of inhaled corticosteroids, with or without concomitant long-acting beta2-agonist (LABA) therapy depending on age and asthma severity, is recommended for many children who meet the NAEPP’s definition of having persistent asthma. (21) add Ref: National Asthma Education and Prevention Program Expert Panel. 2020 Focused Updates to the Asthma Management Guidelines. National Heart Lung and Blood Institute; December 2020. Poor adherence to prescribed use of a daily inhaled corticosteroid as a controller medication among children with persistent asthma is associated with lower quality of life and increased frequency of asthma exacerbation, sleep disruption, and school absence. (21)(43) Nonetheless, mean adherence among children with their prescribed inhaled corticosteroid regimen is likely less than 50%. (44)(45)(46) The school nurse may be an underused resource for achieving asthma control for students with persistent asthma, poor adherence to an inhaled corticosteroid regimen, and high asthma morbidity. In addition to providing outreach to families to educate them about the need for improved asthma control, school nurses may administer daily inhaled corticosteroid medication to students.To implement school-based asthma controller therapy, the pediatrician prepares an asthma action plan with separate directions for inhaled corticosteroid use (with or without LABA) on school days versus weekends to be shared with the student’s family and school nurse. On school days, the student reports to the health suite on morning arrival. Medication that would typically be dosed twice daily is instead administered all at once by the school nurse. On weekends and on other days that school is not in session, students or parents administer morning and evening doses of the controller medication at home.Challenges to widespread adoption of school-based asthma controller therapy are primarily logistical. School-based asthma controller therapy is possible only at schools with an onsite nurse authorized to administer medications. In addition, insurance plans must be willing to cover the cost of dispensing 2 controller medication units at a time. Although most will cover only 1 unit per month without previous administrative review, some will authorize the dispensing of a second unit for school use for children with a history of high health-care utilization for asthma exacerbations. Last, school nurses and parents must be able to maintain an open line of communication because the parent must supply the school nurse with a new controller medication unit each month. Pediatricians can advise parents that the major US pharmacies offer free delivery of medications, and parents can arrange for deliveries to go directly to the school. Medication delivery to the school needs to be pre-approved and coordinated with school staff. Given all the obstacles, school-based asthma controller therapy is most practically reserved for students with very poor asthma control who are at high risk for morbidity. In such cases, it can be well worth the upfront effort necessary to arrange for school-based asthma controller therapy because multiple trials have demonstrated it to be associated with fewer daytime and nighttime symptoms, a greater total number of days without any symptoms, and decreased albuterol use and frequency of urgent care visits. (47)
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