Providers underestimate symptom severity among urban children with asthma

BACKGROUND: Guidelines recommend that children with mild persistent to severe persistent asthma receive maintenance anti-inflammatory medications. However, providers may not be aware of the severity of their patients' symptoms. The underestimation of severity may contribute to poor adherence to asthma care guidelines. OBJECTIVES: To describe the use of preventive medications among a group of urban children with mild persistent to severe persistent asthma and to evaluate the degree to which their health care providers are aware of their asthma severity. DESIGN: Children (ages 4-6 years) from urban schools in Rochester, NY, were eligible if their parents reported mild persistent to severe persistent asthma symptoms. Each child's health care provider was asked to assess the child's asthma severity and use of medications based both on their knowledge of the child and review of the medical record. Parent and provider assessments were compared. Bivariate and regression analyses were used to identify factors associated with concordant classifications of asthma severity. RESULTS: Ninety children with parent-defined mild persistent to severe persistent asthma participated (64% boys, 67% black, 73% receiving Medicaid). Only 40% of the children were described accurately by their providers as having mild persistent to severe persistent asthma, and only 50% of the total had been prescribed maintenance medications. Thirty-six percent of families reported that their child used maintenance medications daily. In contrast, most of the children who were classified by their provider as having mild persistent to severe persistent asthma were prescribed a maintenance medication (83%), and 58% used them daily. Sociodemographic characteristics and asthma severity were not associated with provider accuracy. CONCLUSIONS: Most children in this study were not accurately classified by their providers as having mild persistent to severe persistent asthma and had not been prescribed maintenance medications. When providers were aware of their patient's asthma symptoms, most of the children were prescribed maintenance medications. Attempts to improve adherence to asthma guidelines should take into consideration provider underestimations of asthma severity.     

Nocturnal asthma symptoms and poor sleep quality among urban school children with asthma

ObjectiveThe aim of this study was to describe nocturnal asthma symptoms among urban children with asthma and assess the burden of sleep difficulties between children with varying levels of nocturnal symptoms.MethodsWe analyzed baseline data from 287 urban children with persistent asthma (aged 4–10 years) enrolled in the School-Based Asthma Therapy trial; Rochester, New York. Caregivers reported on nocturnal asthma symptoms (number of nights/2 weeks with wheezing or coughing), parent quality of life (Juniper’s Pediatric Asthma Caregivers Quality of Life Questionnaire), and sleep quality by using the validated Children’s Sleep Habits Questionnaire. We used bivariate and multivariate statistics to compare nocturnal asthma symptoms with sleep quality/quantity and quality of life.ResultsMost children (mean age, 7.5 years) were black (62%); 74% had Medicaid. Forty-one percent of children had intermittent nocturnal asthma symptoms, 23% mild persistent, and 36% moderate to severe. Children's average total sleep quality score was 51 (range, 33–99) which is above the clinically significant cutoff of 41, indicating pervasive sleep disturbances among this population. Sleep scores were worse for children with more nocturnal asthma symptoms compared with those with milder symptoms on total score, as well as several subscales, including night wakings, parasomnias, and sleep disordered breathing (all P < .03). Parents of children with more nocturnal asthma symptoms reported their child having fewer nights with enough sleep in the past week (P = .018) and worse parent quality of life (P < .001).ConclusionsNocturnal asthma symptoms are prevalent in this population and are associated with poor sleep quality and worse parent quality of life. These findings have potential implications for understanding the disease burden of pediatric asthma.     

School functioning of US children with asthma.

Data from the 1988 US National Health Interview Survey on Child Health, a nationally representative cross-sectional survey, were used to determine national estimates of school outcomes (grade failure, learning disabilities, and suspension/expulsion) and mean number of absences for children with asthma (CWA) compared to well children without current health conditions. Families indicated that 536 (4.9%) of the 10,362 survey children in grades 1 through 12 had had asthma in the previous 12 months. Families reported 18% of CWA vs 15% of well children had grade failure, 9% of CWA vs 5% of well children had learning disabilities, and 5% of CWA vs 6% of well children had been expelled or suspended. Children with asthma averaged 7.6 school days absent compared with 2.5 days for the well group. Multiple logistic regression was used to compare the odds of grade failure, learning disabilities, and suspension/expulsion among CWA and well children, overall and stratified by income. Similar methods were used to assess the role of health status among asthmatic children. After adjustment for demographic factors, CWA had similar risks of grade failure and suspension/expulsion, but 1.7 times the risk of learning disability compared with well children. Also, among families with incomes below $20,000, CWA had twice the odds of grade failure compared with well children. For asthmatic children, reported health status was an important predictor of learning disability. Ten percent of CWA were reported to be in fair-poor health. After adjustment for demographic factors, those in fair-poor health were twice as likely to have a reported learning disability compared with those in good-excellent health.(ABSTRACT TRUNCATED AT 250 WORDS)     

School readiness

School readiness includes the readiness of the individual child, the school's readiness for children, and the ability of the family and community to support optimal early child development. It is the responsibility of schools to be ready for all children at all levels of readiness. Children's readiness for kindergarten should become an outcome measure for community-based programs, rather than an exclusion criterion at the beginning of the formal educational experience. Our new knowledge of early brain and child development has revealed that modifiable factors in a child's early experience can greatly affect that child's learning trajectory. Many US children enter kindergarten with limitations in their social, emotional, cognitive, and physical development that might have been significantly diminished or eliminated through early identification of and attention to child and family needs. Pediatricians have a role in promoting school readiness for all children, beginning at birth, through their practices and advocacy. The American Academy of Pediatrics affords pediatricians many opportunities to promote the physical, social-emotional, and educational health of young children, with other advocacy groups. This technical report supports American Academy of Pediatrics policy statements "Quality Early Education and Child Care From Birth to Kindergarten" and "The Inappropriate Use of School 'Readiness' Tests."     

School readiness among children with behavior problems at entrance into kindergarten: results from a US national study

The impact of behavior problems on kindergarten readiness is not known. Our objective was to estimate the association between behavior problems and kindergarten readiness on a US national sample. In the US educational system, kindergarten is a natural point of entry into formal schooling at age 5 because fewer than half of the children enter kindergarten with prior formal preschool education. Parents of 1,200 children who were scheduled to enter kindergarten for the first time and were members of the Harris Interactive online national panel were surveyed. We defined behavior problems as an affirmative response to the question, “Has your child ever had behavior problems?” We validated this against attention deficit hyperactivity disorder diagnosis, scores on a reliable socioemotional scale, and child’s receipt of early intervention services. We used linear, tobit, and logistic regression analyses to estimate the association between having behavior problems and scores in reliable scales of motor, play, speech and language, and school skills and an overall kindergarten readiness indicator. The sample included 176 children with behavior problems for a national prevalence of 14% (confidence interval, 11.5–17.5). Children with behavior problems were more likely to be male and live in households with lower income and parental education. We found that children with behavior problems entered kindergarten with lower speech and language, motor, play, and school skills, even after controlling for demographics and region. Delays were 0.6–1 SD below scores of comparable children without behavior problems. Parents of children with behavior problems were 5.2 times more likely to report their child was not ready for kindergarten. Childhood behavior problems are associated with substantial delays in motor, language, play, school, and socioemotional skills before entrance into kindergarten. Early screening and intervention is recommended.     

Missed opportunities for influenza vaccination among children with asthma.

Influenza vaccination is recommended for children with moderate to severe asthma. However, most children with asthma are not vaccinated, in part because many do not make an office visit during the vaccination time period. We studied 247 urban children with asthma to determine the maximum number that could have been vaccinated during a medical visit to a clinic or emergency department. One hundred thirty-nine patients (56%) had at least one visit during the study period. Sixty-five patients (26%) received the influenza vaccination; 74 patients (30%) did not receive the vaccination despite being seen in the clinic or emergency department. One-half of the missed vaccination opportunities at the clinic occurred during nonacute visits. Influenza vaccination rates could be substantially improved by efforts to increase primary care visits during the vaccination time period and to minimize missed vaccination opportunities.     

Adverse asthma outcomes among children hospitalized with asthma in California

OBJECTIVE: To use administrative data to determine whether adverse asthma outcomes for pediatric asthma hospitalizations are related to specific clinical and nonclinical patient characteristics. DESIGN: Cross-sectional study. SETTING: All pediatric (0 to 17 years of age) asthma-related hospital discharges, 1986 to 1993, in California. PATIENTS: A total of 113 974 eligible patients with asthma-related discharges. MAIN OUTCOME MEASURE: Adverse asthma outcomes (intubation, cardiopulmonary arrest, and death). RESULTS: Adverse asthma outcomes occurred in 0.48% of subjects. The frequency of adverse asthma outcomes increased during the 1990s compared with 1986. After controlling for differences in gender, age, specific comorbid conditions, year, race, and insurance type, adverse asthma outcomes were more likely to occur in the 5- to 11-year-old group (odds ratio [OR]: 1.39; 95% confidence interval [CI]: 1.13-1.69) and in the 12- to 17-year-old group (OR: 4.48; CI: 3.20-6.21) compared with those children in the 0 to 4-year-old age group. Asian Pacific-American children were more likely (OR: 1.59; CI: 1.24-2.59) than were white children to experience an adverse asthma outcome. Children who had a secondary diagnoses of pneumonia (OR: 1.54; CI: 1. 19-2.00) also were more likely to experience an adverse asthma outcome. The odds of an adverse outcome increased progressively after 1986, becoming significant after 1989. Gender and insurance type were not associated with increased odds of experiencing an adverse asthma outcome. CONCLUSIONS: Adverse asthma outcomes among hospitalized children are increasing in the 1990s and are associated with specific clinical and nonclinical patient characteristics.     

Influenza vaccination among children with asthma in medicaid managed care.

OBJECTIVE: To describe influenza vaccination rates and identify risk factors for missing vaccination among children with asthma in managed Medicaid. METHODS: As part of a longitudinal study of asthma care quality, parents of children aged 2-16 years with asthma enrolled in Medicaid managed care organizations in Massachusetts, Washington, and California were surveyed by telephone at baseline and 1 year. We evaluated influenza vaccination rates during the follow-up year. RESULTS: The study population included 1058 children with asthma. The influenza vaccination rate was 16% among all children with asthma and 21% among those with persistent asthma. Children with persistent asthma (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.36-0.79) and those who had been hospitalized during the follow-up year (OR 0.29, 95% CI 0.11-0.76) were less likely to miss vaccination.Children older than 9 years (OR 1.66, 95% CI 1.13-2.46) and children of parents with less than a high school education (OR 2.29, 95% CI 1.05-5.03), compared with a college degree, were at risk for missing vaccination. Among children with persistent asthma, older children (OR 1.65, 95% CI 1.01-2.69) and children of parents with less than a high school education (OR 4.13, 95% CI 1.43-11.90) were more likely to miss influenza vaccination. CONCLUSIONS: Our findings suggest that interventions directed toward older children and families with lower educational levels may help improve influenza vaccination rates among this high-risk group. The low overall vaccination rate highlights the need for improvement in this important component of asthma care quality for all children with asthma.     

Allergens in urban schools and homes of children with asthma

To cite this article: Permaul P, Hoffman E, Fu C, Sheehan W, Baxi S, Gaffin J, Lane J, Bailey A, King E, Chapman M, Gold D, Phipatanakul W. Allergens in urban schools and homes of children with asthma. Pediatr Allergy Immunol 2012: 23: 543-549. ABSTRACT: Background: Most studies of indoor allergens have focused on the home environment. However, schools may be an important site of allergen exposure for children with asthma. We compared school allergen exposure to home exposure in a cohort of children with asthma. Correlations between settled dust and airborne allergen levels in classrooms were examined. Methods: Settled dust and airborne samples from 12 inner-city schools were analyzed for indoor allergens using multiplex array technology (MARIA). School samples were linked to students with asthma enrolled in the School Inner-City Asthma Study (SICAS). Settled dust samples from students' bedrooms were analyzed similarly. Results: From schools, 229 settled dust and 197 airborne samples were obtained. From homes, 118 settled dust samples were obtained. Linear mixed regression models of log-transformed variables showed significantly higher settled dust levels of mouse, cat and dog allergens in schools than homes (545% higher for Mus m 1, estimated absolute difference 0.55?μg/g, p?相似文献   

Medication use and health care contacts among symptomatic children with asthma.

OBJECTIVE: Asthma morbidity and mortality continue to increase despite the availability of improved therapies. Little is known about the degree to which children with asthma use medications and health care services during symptomatic periods. This study documents prospectively the use of medications and health care contacts among children with active asthma symptoms. METHODS: Children age 6--19 years from 11 primary care settings in upstate New York were eligible for this study if they had 3 or more asthma-related medical visits during the prior year. We collected extensive information on asthma symptoms, medication use, and contacts with health care providers from biweekly phone interviews and daily diaries during a 3-month period. Symptoms were evaluated as the average number of symptomatic days per week. We tabulated the proportion of children using anti-inflammatory medications and having health care contacts according to the frequency of their symptoms during this 3-month period. Chi-square and regression analyses were used. RESULTS: One hundred sixty-five children participated (67% White, 24% Black, 9% Other). Sixty-five percent of the children in this sample had an average of more than 2 symptomatic days per week or more than 2 symptomatic nights per month during the 3-month study period and thus had mild persistent to severe asthma. Among these children, 25% received prednisone, and 46% reported the use of an inhaled maintenance medication during the monitoring period. Ten percent of children in this sample experienced an average of 6 or more symptomatic days per week during the study period. Among these highly symptomatic children, only 19% received prednisone, and 56% used a maintenance medication. Further, the proportion of children having contact with a health care provider during this 3-month period was 50% or less, even among the children experiencing the most frequent asthma symptoms. There were no differences in the proportion of children with health care contacts, prednisone use, or maintenance anti-inflammatory use among different gender or race categories or with different insurance types or places of residence. CONCLUSIONS: Even among children experiencing almost daily asthma symptoms, inadequate anti-inflammatory therapy is common, and few contacts with health care providers occur. These children are silently suffering at home and likely are experiencing preventable morbidity.     

School holidays and admissions with asthma.

The admission rate for asthma at a children''s hospital was studied over an 11 year period. Admissions varied unpredictably over periods of a few days, but there was a repeated yearly pattern of peaks and troughs with an interval of several weeks. The short term variation could be attributed to chance effects alone, excluding any important role for short term influences--for example, weather changes--in precipitating asthma admissions. There was a definite association between the longer term variation and school holidays. The admission rate fell during holidays and there were two or more peaks during terms. The pattern is consistent with a largely viral aetiology for asthmatic attacks throughout the year. We postulate that school holidays disrupt the spread of viral infections in a community, with synchronisation of subsequent attacks. Travel during holidays may facilitate acquisition of new viral strains by the community.     

Gender differences in the association of overweight and asthma morbidity among urban adolescents with asthma

Asthma and obesity disproportionately affect US African-American youth. Among youth with asthma, obesity has been associated with poor control. The impact of gender on this association is unclear. We examined these relationships in a sample of urban, African-American adolescents with asthma. Questionnaires were used to identify high school students with asthma, and to examine the association of body mass index (BMI) to asthma morbidity, by gender. Of 5967 students completing questionnaires, 599 (10%) met criteria for asthma and 507 had data sufficient for inclusion in further analyses (46% male, mean age = 15.1 yr). Univariately, BMI > 85th percentile was significantly related only to reported emergency department visits (ED) and school days missed for any reason, Odds Ratio (95%Confidence Interval) = 1.7(1.1–2.7), p  =  0.01 and 1.8(1.1–3.0), p  =  0.01, respectively. A significant gender-BMI interaction (p   <   0.05) was observed in multivariate models for ED visits, hospitalizations and school days missed for asthma. In gender-specific models, adjusted Risk Ratios for BMI > 85th and ED visits, hospitalizations, and school days missed because of asthma were 1.7(0.9–3.2), 6.6(3.1–14.6) and 3.6(1.8–7.2) in males. These associations were not observed in females. Gender modifies the association between BMI and asthma-related morbidity among adolescents with asthma. Results have implications for clinical management as well as future research.     

Underuse of controller medications among Medicaid-insured children with asthma

BACKGROUND: National guidelines recommend daily use of controller medications for children with persistent asthma. Although studies suggest low rates of controller use, little is known about predictors of underuse among low-income children in whom asthma morbidity is greatest. OBJECTIVES: To determine the frequency of underuse of controller medications among Medicaid-insured children in a variety of managed care arrangements, and to examine demographic factors and processes of asthma care associated with underuse. DESIGN: Cross-sectional telephone survey of parents of children and adolescents aged 2 to 16 years with asthma, insured by Medicaid, and enrolled in 1 of 5 managed care plans. The main outcome was parent-reported underuse of controllers among children with persistent asthma. Survey items included demographic factors and reports of specific processes of care. Current symptom level was determined by recall of the number of days with symptoms in the previous 14 and by the Physical Function Score of the American Academy of Pediatrics (AAP) Child Health Status Assessment for Asthma. Logistic regression was used to identify factors independently associated with underuse. RESULTS: The response rate was 66%, with 1648 children included in the analysis; 1083 were classified as having persistent asthma. Of these, 73% were underusers of controller therapy, with 49% reporting no controller use and 24% reporting less than daily use. A multivariate model that adjusted for age, managed health care organization, and AAP Physical Function Score found that black (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.4) or Latino (OR, 2.2; 95% CI, 1.3-3.8) race were associated with underuse and that parental education beyond high school was protective (OR, 0.6; 95% CI, 0.4-0.8). Having a primary care physician (OR, 0.4; 95% CI, 0.2-0.8), written action plan (OR, 0.5; 95% CI, 0.4-0.7), or a follow-up visit (OR, 0.5; 95% CI, 0.4-0.8) and having seen an asthma specialist (OR, 0.5; 95% CI, 0.4-0.7) were associated with lower rates of underuse. CONCLUSIONS: Underuse of controller medications among Medicaid-insured children is widespread. Racial minorities and children whose parents are less educated are at higher risk for underuse. Patients who have received action plans or had follow-up visits or specialty consultations are less likely to be symptomatic underusers of controller medications.     

Atopy,asthma, and antibodies to Ascaris among rural and urban children in Kenya

OBJECTIVE: The purpose of this study was to evaluate differences in the relationship between asthma and immune responses to allergens in children living in rural and urban areas of Kenya. STUDY DESIGN: Children (mean age, 11 years) from Kabati (n = 136), a rural village, and Thika (n = 129), a small town, were studied by skin testing and serum immunoglobulin E (IgE) and immunoglobulin G (IgG) antibody measurement. Asthma was evaluated by symptoms, as well as spirometry before and after vigorous exercise to test for exercised-induced bronchospasm (EIB). School children from a study performed in Atlanta, Georgia, were used for comparison of anthropometric and immunologic results. RESULTS: Compared with the urban area of Kenya, children living in the rural area had a lower percentage of body fat, smaller and fewer skin test responses to allergens, a higher prevalence of IgE antibodies to Ascaris (67% vs 26%) and 10-fold higher total IgE. In the urban area of Kenya, there was a strong correlation between EIB and atopy determined both by IgE antibodies (P =.02) and skin tests (P =.002). By contrast, in the rural area, none of the 13 children with EIB were skin-test positive (vs 13/109 of children without EIB). CONCLUSIONS: Among the rural children, there was no association between immune responses to allergens and airway-related symptoms or reactivity. The association between asthma and atopy seen in the town of Thika may represent an important step in the increase in asthma seen both in urban Africa and in the West.