Pediatric Asthma Management Research Articles

Parents in fragile families: the influence of parental engagement on emergency care use in children with asthma.

Current research focused on stress responsive illnesses such as asthma has identified a crucial role for families in the progression and maintenance of stress responsive illnesses. What is currently not clear is the differential effect of maternal versus paternal engagement in the management of pediatric asthma. This study explores whether or not mother, father, or the combined engagement has an effect on the management of pediatric asthma. A subsample of the Fragile Families Child and Wellbeing Study (FFCW Study) was used to examine the role of parental engagement (n = 475; 41.9% female, 58.1% male). Path analysis and actor partner interdependence modeling processes were used to examine the differential effect of mother and father engagement. A final nested model with only direct effects from the father's level of engagement proved to be the best fitting model, χ2(9) = 16.738, p = .05298, CFI = 0.995, GFI = 0.989, RMSEA = 0.043. Within this model father engagement had a moderating effect for child's emergency room (ER) use (β = -.124, p < .05). The mother's effect was best modeled as an indirect effect as this increased the father's level of engagement, but did not have a direct effect on the outcome of ER usage. This study is consistent with other studies that found that the predictability of a father's role and routine had positive health outcomes for the asthmatic child. Implications for future research and practice are identified and discussed. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Outcomes of Stepping Down Asthma Medications in a Guideline-Based Pediatric Asthma Management Program

MA Rank, ME Branda, DB McWilliams. Ann Allergy Asthma Immunol. 2013;110(5):354–358, e2 Identifying strategies to adjust medications when managing chronic diseases poses a challenge to busy practitioners, and often the opportunity is lost to step down therapy. Clinical studies suggest that many patients currently treated with combination controller medications can be successfully stepped down. Use of a multidisciplinary care management team has also been a strategy associated with success in stepping down therapy. Nonadherence represents another method of step-down. This study was performed to identify predictive factors for success in stepping down …

Newer Treatments in the Management of Pediatric Asthma

Asthma control remains a significant challenge in the pediatric age range in which ongoing loss of lung function in children with persistent asthma has been reported, despite the use of regular preventer therapy. This has important implications for observed mortality and morbidity during adulthood. Over the past decade, there has been an emergence of other treatment adjuncts, such as anti-Immunoglobulin E (IgE)-directed therapy, low dose theophylline, and the use of macrolide antibiotics, yet their exact role in asthma management remains unclear, despite omalizumab now being incorporated into several international asthma guidelines. As with many aspects of pediatric care, this is driven by a lack of appropriately designed pediatric trials. Extrapolation of data reported in adult studies may be appropriate for adolescent asthma, but is not for younger age groups, in which important pathophysiological differences exist. Novel drugs under development offer potential for benefit in the future, but to date existing data are in most cases limited to adults. Pediatric asthma also offers unique potential to prevent or modify the underlying pathophysiology. Although attempts to do so have been unsuccessful to date, advances may yet come from this approach, as our understanding about the interaction between genetics, environmental factors, and viral illness improve. This review provides an overview of the newer treatment options available for management of pediatric asthma and discusses the merits of other novel therapies in development, as we search to optimize management and improve future outcomes.

Inflammometry in pediatric asthma: A review of fractional exhaled nitric oxide in clinical practice

The burden of pediatric asthma remains high with one-third of patients being under- or overtreated because of the unique challenges in the assessment and management of childhood asthma. Until recently, there has been no point of care tool for assessing the underlying airway inflammation (i.e., inflammometry) in asthma. Recently, fractional exhaled nitric oxide (FeNO) has emerged as an important biomarker for the assessment and management of asthma. Recent evidence indicates that FeNO identifies T-helper cell type 2 (Th2)–mediated airway inflammation with a high positive and negative predictive value for identifying corticosteroid responsive airway inflammation. This article examines the evidence for FeNO as a predictor of Th2-mediated inhaled corticosteroid (ICS) responsive airway inflammation and reviews recent studies evaluating the role of FeNO, whether helpful or not, in the assessment and management of pediatric asthma. FeNO is a reliable adjunct to traditional tests in the assessment of suspected asthma. Importantly, it is useful for identifying and for excluding ICS-responsive airway inflammation. Although individual study results have varied, collectively, asthma managed using FeNO is associated with lower exacerbation rates compared with clinical algorithms alone. Finally, FeNO may be useful in identifying patients at risk for future impairment or loss of asthma control during reduction/cessation of ICS treatment. FeNO testing has an important role in the assessment of pediatric patients with suspected asthma and in the management of pediatric patients with established asthma. Additional studies will continue to define the exact role of FeNO testing in pediatric asthma.

Outcomes of stepping down asthma medications in a guideline-based pediatric asthma management program

BackgroundLittle is known about outcomes after stepping down asthma medications within an asthma management program. ObjectiveTo determine outcomes of stepping down asthma medications in a pediatric asthma management program. MethodsWe performed a retrospective study of 5- to 18-year-old children with asthma in an integrated primary care practice in the United States. Data were included on participants from March 1, 2009, until December 31, 2011. We first determined whether a child was eligible for step down and next recorded whether a step-down attempt was made and if the attempt was successful. In addition to descriptive statistics for the sample demographics and the outcomes of stepping down, univariate and multivariate analyses were performed to determine predictors of successful asthma medication step-down attempts. ResultsOf the 477 children sampled for this study, 264 (55.3%) had a guideline-eligible opportunity to step down asthma medications. An attempted step down occurred in only 89 (33.7%) of children who had guideline-eligible opportunities. A total of 166 children (34.8%) attempted a step down of asthma medication at least once (including those guideline ineligible to step down). Of children with follow-up, 96 (71.6%) of step-down attempts were successful. Time of year (any season except fall) when the step down was attempted predicted successful step down in univariate and multivariate analysis (odds ratio = 3.81; 95% confidence interval, 1.23-11.85; P = .02). Being guideline eligible for step down predicted successful step down in univariate analysis only (odds ratio = 2.51; 95% confidence interval, 1.16-5.43; P = .02). ConclusionOur findings from this sample of children participating in an asthma management program suggest that stepping down asthma medication based on National Asthma Education and Prevention Program 3 guidelines is frequently successful.

Role of Leukotriene Receptor Antagonists in the Management of Pediatric Asthma

At present, the main indications for leukotriene receptor antagonists (LTRA) in pediatric asthma are as add-on therapy to inhaled corticosteroids (ICS) and as initial controller therapy in children with mild asthma, especially those who cannot or will not use ICS.

Role of Leukotriene Receptor Antagonists in the Management of Pediatric Asthma

At present, the main indications for leukotriene receptor antagonists (LTRA) in pediatric asthma are as add-on therapy to inhaled corticosteroids (ICS) and as initial controller therapy in children with mild asthma, especially those who cannot or will not use ICS. LTRA are also useful for patients who have concomitant rhinitis, and patients with viral-induced wheeze and exercise-induced asthma. It should be noted that the benefits of LTRA therapy have been demonstrated in children as young as 6 months of age and recent clinical trials have further proven the benefits of LTRA in acute asthma exacerbations. However, considering the important pro-inflammatory effects that leukotrienes (LT) have in experimental models of asthma, it may seem surprising that LTRA treatment outcomes are not better and that in some clinical trials only a minority of patients could be classified as full responders. This could be explained by potential additional LT receptors that are not affected by LTRA. Such receptors could represent new therapeutic targets in asthma. Furthermore, progress in differentiating between asthma phenotypes that result from different pathogenic mechanisms, some of which may involve LT to a lesser degree, should lead to an improved, personalized use of LTRA for treating asthma.

1481 Trends in Paediatric Acute Asthma Management in the Republic of Ireland: A Comparison Between Community and Hospital Practice

IntroductionThe prevalence of childhood asthma in Ireland is amongst the highest in the world. We aim to compare the management of this condition by Emergency Physicians (EPs), Paediatricians and community-based...

Conditions Associated with Childhood Asthma in North Texas

Introduction. The purpose of this study was to identify significant associations between asthma diagnosis, comorbid conditions, and social problems in children. Method. This study explored data collected in a unique, regional survey of children's health in north Texas originally administered in 2009 to a random sample of 21,530 households with children from 0 to 14 years of age. Descriptive statistics were compiled for the subsample of children with asthma, associations of interest were identified, and strengths of relevant associations were calculated. Results. The prevalence of asthma in school-aged children in the target area is 19–25%, which exceeds both national and state values. Statistically significant associations were found between asthma and allergies, sleep problems, and tonsillectomy. Significant associations were identified between asthma and school absences, academic problems, and behavior problems in school. There was a significantly greater prevalence of obesity/overweight among children with asthma than without asthma. Discussion. Children with asthma are at high risk for impairment in multiple dimensions. Thorough assessment, including comprehensive medical, social, and environmental histories, is critical in management of pediatric asthma.

Montelukast versus inhaled corticosteroids in the management of pediatric mild persistent asthma.

International guidelines recommend the use of inhaled corticosteroids (ICSs) as the preferred therapy, with leukotriene receptor antagonists (LTRAs) as an alternative, for the management of persistent asthma in children. Montelukast (MLK) is the first LTRA approved by the Food and Drug Administration for the use in young asthmatic children.Therefore, we performed an analysis of studies that compared the efficacy of MLK versus ICSs. We considered eligible for the inclusion randomized, controlled trials on pediatric populations with Jadad score > 3, with at least 4 weeks of treatment with MLK compared with ICS.Although it is important to recognize that ICSs use is currently the recommended first-line treatment for asthmatic children, MLK can have consistent benefits in controlling asthmatic symptoms and may be an alternative in children unable to use ICSs or suffering from poor growth. On the contrary, low pulmonary function and/or high allergic inflammatory markers require the corticosteroid use.

Montelukast versus inhaled corticosteroids in the management of pediatric mild persistent asthma

International guidelines recommend the use of inhaled corticosteroids (ICSs) as the preferred therapy, with leukotriene receptor antagonists (LTRAs) as an alternative, for the management of persistent asthma in children. Montelukast (MLK) is the first LTRA approved by the Food and Drug Administration for the use in young asthmatic children. Therefore, we performed an analysis of studies that compared the efficacy of MLK versus ICSs. We considered eligible for the inclusion randomized, controlled trials on pediatric populations with Jadad score&gt;3, with at least 4 weeks of treatment with MLK compared with ICS. Although it is important to recognize that ICSs use is currently the recommended first-line treatment for asthmatic children, MLK can have consistent benefits in controlling asthmatic symptoms and may be an alternative in children unable to use ICSs or suffering from poor growth. On the contrary, low pulmonary function and/or high allergic inflammatory markers require the corticosteroid use.

Clinical features of a paediatric asthma population in Trinidad

Clinical features and management of paediatric asthma, highly prevalent in the Caribbean, was explored in Trinidadian children. Children (2-16 years) with acute [visiting Accident and Emergency (A&E) in the past 12 months (50.2%, 120)] or stable asthma [controlled during the previous 3 months (49.8%, 119)] were studied. There were more (P < 0.001) boys (71.5%) than girls. Asthma was associated with asthmatic mothers (48.5%), fathers (19.2%) and both parents (15.1%) (P < 0.001). Children's average age of first wheeze was 2.5 (standard deviation = 1.3) years; 30.1% were nebulized before 1 year. In the past 12 months, frequencies of A&E visits were once (20.6%), >1 (61.9%) and >3 times (26.4%) (P < 0.001). Sufferers of exacerbations showed negative logistic regression for age (-0.129, standard error = 0.039, P < 0.001) independent of gender. Acute asthmatics who suffered cough, fever and sore throat in the preceding week were respectively 15.2 [odds ratio (OR) = 15.2, 95% confidence interval (CI) = 6.8-34.0], 13.7 (OR = 13.7, 95% CI = 6.7-28.2) and 3.4 (OR = 3.4, 95% CI = 1.7-6.7) times more likely to suffer wheeze exacerbations than stable children. Most stable children (76.5%) inhaled corticosteroids with salbutamol reliever compared with 22.5% of acute asthmatics, whereas 40.8% of the latter group used salbutamol alone compared with 19.3% of stable children (P < 0.001). Childhood wheeze occurs before 3 years and is associated with maternal asthma. Cough, fever and sore throat in the previous week are strongly associated with exacerbations. Defining these associations could enhance preventive approaches to combat childhood asthma.

Adherence to national guidelines for children with asthma at primary health centres in Sweden: potential for improvement.

Although asthma is the most common chronic paediatric disease in Western Europe, the extent of adherence to guidelines for primary care management of paediatric asthma remains unclear. To evaluate adherence to national guidelines for primary care management of children with asthma. This survey involved 18 primary healthcare centres in Stockholm, Sweden. The medical records of 647 children aged 6 months to 16 years with a diagnosis of asthma, obstructive bronchitis, or cough were selected and scrutinised. 223 children with obstructive bronchitis or cough not fulfilling the evidence-based criteria for asthma were excluded, yielding a total of 424 subjects. Documentation of the most important indicators of quality as stipulated in national guidelines (i.e., tobacco smoke, spirometry, pharmacological treatment, patient education, and demonstration of inhalation technique) was examined. Only 22% (n=49) of the children 6 years of age or older had ever undergone a spirometry test, but the frequency was greater when patients had access to an asthma nurse (p=0.003). Although 58% (n=246) of the total study population were treated with inhaled steroids, documented patient education and demonstration of inhalation technique was present in 14% (n=59). Exposure to tobacco smoke was documented in 14% (n=58). This study reveals a substantial gap between the actual care provided for paediatric asthma and the recommendations formulated in national guidelines.

Trends in paediatric acute asthma management in the republic of Ireland: a comparison between community and hospital practice: Abstract G305(P) Table 1

Aims The prevalence of childhood asthma in Ireland is amongst the highest in the world. Evidence-based guidelines for the management of acute paediatric asthma have been shown to improve care in a variety of centres internationally. The authors are anecdotally aware of varying practices in management of this condition in different healthcare settings. We aim to compare the management of this condition by Emergency Physicians (EPs), Paediatricians and community-based General Practitioners (GPs). Methods A standardised online anonymous survey was conducted of senior EPs, Paediatricians and General Practitioners (GPs) in Ireland. 15% of GPs nationally were chosen using a computerised randomisation method. Those GPs for whom an email address was available were surveyed online, otherwise a postal form of the survey was sent out. Results We received 263 responses, giving a response rate (RR) of 40.6% (EP: 44/71, RR=62.0%; Paediatricians: n=69/160, RR=43.1%; GP: n=154/427, RR=36.1%). There was a significant difference between the specialities in the use of guidelines and discharge asthma action plans (table 1). Over 70% of paediatricians and EPs use spacer devices for mild and moderate attacks. 78% of GPs use spacers for mild attacks, however this drops to 38% for moderate. Paediatricians and EPs differed in their choice of first line IV bronchodilators with paediatricians choosing salbutamol (48.3%) most frequently and EPs choosing magnesium (48.3%). Whereas almost all respondents felt that severe attacks should be referred to an ED, over 85% of paediatricians and EPs felt that moderate attacks should be referred compared to 13.7% of GPs. Over 90% of all respondents would welcome a national guideline on the management of acute paediatric asthma exacerbations. Conclusion This is the first study of its kind internationally to compare management of this important and common condition across the 3 relevant specialties. The results of this survey support the development of a national guideline for acute paediatric asthma management.

Childhood asthma management guided by repeated FeNO measurements: a meta-analysis

The fraction of exhaled nitric oxide (FeNO) has gained interest as a non-invasive tool to measure airway inflammation in asthma since it reflects allergic inflammation. Recent controlled clinical studies have, however, questioned its role in the management of asthma in children. To assess the clinical value of FeNO in paediatric asthma management, a meta-analysis was performed on the controlled studies of childhood asthma management guided by repeated FeNO measurements, and relevant publications on the confounders of FeNO were reviewed. The data suggests that utilising FeNO to tailor the dose of inhaled corticosteroids in children cannot be recommended for routine clinical practice since there is a danger of excessive inhaled corticosteroid doses in children without meaningful changes in clinical outcomes. Many disease and non-disease related factors (most importantly atopy, height/age and infection) affect FeNO levels which can easily confound the interpretation.

Translating Evidence-Based Interventions Into Practice

Pediatric asthma is a multifactorial disease, requiring complex, interrelated interventions addressing children, families, schools, and communities. The Merck Childhood Asthma Network, Inc. (MCAN) is a nonprofit organization that provides support to translate evidence-based interventions from research to practice. MCAN developed the rationale and vision for the program through a phased approach, including an extensive literature review, stakeholder engagement, and evaluation of funding gaps. The analysis pointed to the need to identify pediatric asthma interventions implemented in urban U.S. settings that have demonstrated efficacy and materials for replication and to translate the interventions into wider practice. In addition to this overall MCAN objective, specific goals included service and system integration through linkages among health care providers, schools, community-based organizations, patients, parents, and other caregivers. MCAN selected sites based on demonstrated ability to implement effective interventions and to address multiple contexts of pediatric asthma prevention and management. Selected MCAN program sites were mature institutions or organizations with significant infrastructure, existing funding, and the ability to provide services without requiring a lengthy planning period. Program sites were located in communities with high asthma morbidity and intended to integrate new elements into existing programs to create comprehensive care approaches.

Improving paediatric asthma outcomes in primary health care: a randomised controlled trial

To evaluate the effectiveness of the Practitioner Asthma Communication and Education (PACE) Australia program, an innovative communication and paediatric asthma management program for general practitioners. Randomised controlled trial. General practices from two regions in metropolitan Sydney. 150 GPs, who were recruited between 2006 and 2008, and 221 children with asthma in their care. GPs in the intervention group participated in two 3-hour workshops, focusing on communication and education strategies to facilitate quality asthma care. Patient outcomes included receipt of a written asthma action plan (WAAP), appropriate medication use, parent days away from work, and child days away from school or child care. GP outcomes included frequency of providing a WAAP and patient education, communication and teaching behaviour, and adherence to national asthma guidelines regarding medication use. More patients of GPs in the intervention group reported receipt of a WAAP (difference, 15%; 95% CI, 2% to 28%; adjusted P=0.046). In the intervention group, children with infrequent intermittent asthma symptoms had lower use of inhaled corticosteroids (difference, 24%; 95% CI, -43% to -5%; P=0.03) and long-acting bronchodilators (difference, 19%; 95% CI, -34% to -5%; P=0.02). GPs in the intervention group were more confident when communicating with patients (difference 22%; 95% CI, 3% to 40%; P=0.03). A higher proportion of GPs in the intervention group reported providing a WAAP more than 70% of the time (difference, 23%; 95% CI, 11% to 36%; adjusted P=0.002) and prescribing spacer devices more than 90% of the time (difference, 29%; 95% CI, 16% to 42%; adjusted P=0.02). The PACE Australia program improved GPs' asthma management practices and led to improvements in some important patient outcomes. Australian New Zealand Clinical Trials Registry ACTRN12607000067471.

Translation of a Pediatric Asthma-Management Program Into a Community in Connecticut

MM Cloutier, DB Wakefield. Pediatrics. 2011;127(1):11–18 National Asthma Education and Prevention Program (NAEPP) guidelines have been widely disseminated, but their adoption by primary care clinicians has been problematic. This study evaluated an asthma-management program based on NAEPP guidelines. Children aged 6 months or older in Connecticut were enrolled in community pediatric offices by trained community personnel. Pediatric office health care providers and personnel in 6 Connecticut communities were trained in an asthma-management program entitled “Easy Breathing,” which …

Engagement in “My Child's Asthma”, an interactive web-based pediatric asthma management intervention

Purpose The Internet is a promising tool for delivering health behavior change programs although such interventions raise questions about participant engagement in this medium. In this study we sought to determine the characteristics of parents who engage in an Internet-based health intervention for their children (with asthma) and to distinguish parents who engage at the prescribed intervals versus those who engage less often. Methods N = 283 parents with children who had asthma were recruited and randomized to receive a web-based intervention. Participants filled out six surveys over a 6-month period asking them about demographic and clinical characteristics, outcome expectations and self-efficacy beliefs regarding asthma control for their child, and attitudes about computers and the Internet. Descriptive statistics were used to describe the population and analyze associations. Results Controller use and being adherent to this medication as well as positive outcome and self efficacy expectations were associated with increased engagement. Parents who logged on only once reported significantly less frequent use of the Internet than parents who logged on to all sessions. Discussion and conclusion The results of this study suggest that it is important to find ways to increase engagement in a web-based intervention for parents who are not yet engaging in the recommended behaviors and/or who report less positive outcome and efficacy expectations around asthma management.

To the Editors: The Asthma Control Questionnaire for children: still more questions than answers

To the Editors: Optimising control is the main goal in paediatric asthma management and reliable instruments that can help physicians to evaluate asthma control in an easy way are valuable. The article by Juniper et al. [1] provides some initial insights on the use of the Asthma Control Questionnaire (ACQ), an instrument that was originally developed for adult asthma, to assess asthma control in children. The process of developing and validating such a questionnaire is a delicate one. In 2009 Juniper [2] published a critical editorial about the consequences of even small modifications to original questionnaires and how this could …