Steroid therapy for asthma in children

PURPOSE OF REVIEW: To highlight studies that have contributed significantly to our current knowledge of inhaled glucocorticoids in childhood asthma. RECENT FINDINGS: In 2006, three important studies were published that investigated whether inhaled glucocorticoid therapy, if started soon after the onset of asthma symptoms, could alter the subsequent course of the disease. Several studies focused on the comparative clinical efficacy of inhaled glucocorticoids to leukotriene receptor antagonists in children with mild to moderate asthma. Although the Expert Panel had recommended inhaled glucocorticoid therapy as the preferred long-term controller with persistent asthma, there were no specific studies comparing these two classes of long-term controller medications in children. Another topic of significant clinical interest was the comparative efficacy of inhaled glucocorticoid to systemic glucocorticoids in the treatment of acute asthma. The question was answered in a study published in children with mild to moderate acute asthma. Lastly, the safety of inhaled glucocorticoid therapy was also evaluated in preschool children. SUMMARY: Inhaled glucocorticoids are the preferred long-term controller for initiating treatment of persistent asthma. Early intervention with inhaled glucocorticoids achieves symptom control but does not alter the natural history of asthma. Inhaled glucocorticoids are not as effective as systemic glucocorticoids for managing acute asthma exacerbations.     

Update on National Asthma Education and Prevention Program pediatric asthma treatment recommendations

The National Asthma Education and Prevention Program (NAEPP) published an update on selected topics from the 1997 Guidelines for the Diagnosis and Management of Asthma and provided new evidence-based recommendations for asthma treatment. Selected topics on the long-term management of asthma in children addressed the efficacy of inhaled corticosteroids (ICSs) compared with other asthma medications (i.e., as-needed beta(2)-adrenergic agonists and other controllers) in mild and moderate persistent asthma and the safety of long-term ICS use. The effects of early intervention with ICSs on asthma progression also were evaluated. An important new aspect of the treatment update entails the recommendation of ICSs as the controller medication of choice for all severities of persistent asthma in children. Additionally, on the basis of studies in adults, the Expert Panel suggested that long-acting beta(2)-adrenergic agonists are now the preferred adjunct to ICSs in children with moderate or severe persistent asthma. Based on long-term data in children, ICS therapy was deemed safe in terms of growth, bone mineral density, ocular effects, and hypothalamic pituitary adrenal axis function. Although members of the NAEPP Expert Panel determined that the effects of early intervention with ICSs on decline in lung function have not been adequately studied, they found that the effects on asthma control were substantial.     

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.     

Sodium cromoglycate therapy in wheezing infants: preliminary evidence of beneficial outcome at early school age

BACKGROUND: In order to affect the natural course of childhood wheezing and asthma, anti-inflammatory therapy is often prescribed for young wheezing children, but there is lack of long-term follow-up data. METHODS: Eighty-two of the original 100 children, hospitalized for wheezing under the age of 2 years in 1992-1993, were re-examined at school age in 1999. The children had participated in an open, randomized, parallel-group trial including a 4-month intervention with inhaled sodium cromoglycate (SCG) or budesonide (BUD). The baseline data, including data on atopy, eosinophilia and viral etiology, were prospectively collected on admission. RESULTS: At early school age (median 7.2 years), asthma was present in 33 (40%) children. There was less asthma in the original SCG (21%) than in the control group (54%) (OR 0.23; 95% CI 0.07-0.77). The figure was 46% in the BUD group. When the analyses were performed separately for atopic and non-atopic infants, the difference was significant only among atopics. The lowered risk for asthma in the SCG group remained significant in the multivariate logistic regression analysis when adjusted for age, sex and atopy, and further when adjusted for earlier episodes of wheezing and respiratory syncytial virus identification. However, after adjustment for blood eosinophilia, the significance was lost, albeit the risk for asthma remained low (OR 0.21; 95% CI 0.04-1.12). A sensitivity analysis, which was done by including the six drop-outs of the SCG group as unfavorable and the 12 drop-outs of other groups as favorable outcomes in the model, did not change the direction of the result (OR 0.70; 95% CI 0.26-1.89). CONCLUSIONS: An early SCG intervention in infants hospitalized for wheezing was associated with a lowered risk for early school-age asthma, especially in infants with evidence of atopy.     

Current concepts in asthma treatment in children

PURPOSE OF REVIEW: The purpose of this review is to present current literature related to the management of childhood asthma. RECENT FINDINGS: Persistent asthma is now considered an inflammatory airways disease. Inhaled corticosteroids are recognized as the preferred long-term control medication. New classes of medications have been introduced during the last 5 years, including leukotriene modifiers, long-acting beta-adrenergic agonists, combination inhaled corticosteroids with long-acting beta-adrenergic agonists, and anti-IgE. Research is also being directed to understand the early onset of asthma. SUMMARY: Management of childhood asthma is now being directed to early recognition and early intervention. Recent updates in the asthma guidelines prompt clinicians to consider intervention with antiinflammatory therapy, preferably inhaled corticosteroids, in children who have frequent asthma exacerbations and a risk profile for persistent asthma. In children with persistent asthma, inhaled corticosteroids are recognized as the preferred antiinflammatory therapy. Health care systems that have adapted this approach have recognized the benefits of reduced hospitalizations and urgent care visits. Continued research is needed to identify asthma at a very early stage so that interventions can be directed to interrupting the development of this disease.     

Underuse of controller medications among children with persistent asthma in the Ohio medicaid population: evolving differences with new medications.

BACKGROUND: Despite innovations in asthma care, morbidity and mortality have increased significantly. Underuse of controller medications is a major contributor to increased morbidity and mortality. OBJECTIVE: To determine the extent of underuse of asthma controller medications among Ohio Medicaid children and to determine if there are racial differences in controller medication claims. METHODS: We conducted a retrospective analysis of Ohio Medicaid claims data. The source data included all institutional, medical service, and pharmacy claims for fee-for-service patients between January 1, 1997, and December 31, 2001. We identified children with persistent asthma using Health Employer Data Information System criteria. The primary outcome was a controller medication claim. We used multivariable logistic regression to identify risk factors for underutilizing asthma controller medications and applied generalized estimating equations to account for repeated measures. RESULTS: The proportion of children with claims for a controller medication increased from 53% in 1997 to 67% in 2001. Although there were no racial differences in medication claims in 1997, a smaller proportion of African American children had a claim for a controller medication in 2001 (64.8% vs 67.8%, P < .001). Leukotriene antagonists (LTAs) were driving this difference. Individuals residing in urban areas were significantly less likely to have claims for LTAs when compared with those who resided in nonurban areas. CONCLUSIONS: Overall use of asthma controller medications among Ohio Medicaid children was poor. There was a widening racial difference in controller medication claims over the 5-year study. Regional differences in LTA claims were driving this racial difference.     

Tests to assess symptoms of gastroesophageal reflux in infants and children

In studying antireflux medications, we may use tests for assessing symptoms of gastroesophageal reflux to establish or confirm a diagnosis of reflux disease and to evaluate whether study subjects are improving with therapy. Symptom assessment questionnaires need to be validated, results need to be reproducible, and the outcome variables measured need to be clinically relevant. Other outcomes for clinical trials include measures of esophagitis: histologic (morphometric) measures in infants and endoscopic and histologic visualization in older children. Intraesophageal pH monitoring studies may be useful for obtaining pharmacodynamic data.     

Beyond the guidelines: fatal and near-fatal asthma

While asthma is extremely common, fatal and near fatal asthma is rare and often preventable if there is early recognition of symptom progression and appropriate intervention. In the past decade, asthma mortality has progressively declined in association with the widespread use of inhaled corticosteroids and asthma care plans. Management of life threatening asthma requires patient education to ensure the proper use of medications and to enable the patient to recognize when additional therapy for poorly controlled asthma is required. There is some evidence that suggests that the overly aggressive use of asthma medications when treating a severe exacerbation may contribute to morbidity. Because of the risks of air trapping and barotrauma associated with partial airway obstruction, it is best to avoid mechanical ventilation if possible but when this is used, low tidal volumes, longer exhalation times, and permissive hypercarbia can minimize these risks. There is the promise that a better understanding of asthma immunology and severe asthma "phenotypes" will lead to better prevention and therapy.     

Feasibility of high-resolution,low-dose chest CT in evaluating the pediatric chest

Thin-section, high-resolution (1.0/1.5 mm thick slices), low-dose chest CT scans were performed in 55 infants and children. The studies were carried out with 1-and 2-s scan (data acquisition) times using a high-resolution (bone) algorithm. Although there was some motion artifact, the studies provided valuable information for evaluating diffuse parenchymal lung disease. The thin slices provided finer detail and more diagnostic information than images representing thicker sections. Most studies were performed using between 40 and 80 mAs. It is estimated that the patients' radiation exposure was 20% that of conventional high-resolution CT (HRCT) and 57% that of routine chest CT. Diagnostic HRCT scans can be obtained in infants and young children without the need for suspended respiration or specialized ultrafast CT scanners.     

Day-to-day management of asthma.

Asthma remains a major cause of morbidity and an occasional cause of mortality in children despite greatly increased knowledge of its pathophysiology and newer improved medications. Management of asthma requires consideration of the two components of airway obstruction, spasm of bronchial smooth muscle and inflammation resulting in mucosal edema and mucous secretions. The pharmacologic alternatives include medications that relax bronchial smooth muscle, prevent the release of mediators that induce bronchospasm and inflammation and anti-inflammatory corticosteroids that can reverse or prevent the inflammatory component of asthma. Therapeutic decisions in asthma also require consideration of the clinical pattern of disease which can be classified as intermittent, seasonal allergic or chronic. Therapeutic strategies for the use of pharmacologic agents include intervention measures for reversal of acute symptoms and maintenance measures to prevent symptoms. While all patients need available intervention measures to reverse acute symptoms when present, only those patients with prolonged periods of symptomatology, i.e. seasonal allergic or chronic, require pharmacologic agent for maintenance therapy. When evaluation identifies environmental factors as clinically important precipitants of asthma, appropriate environmental manipulation offers a potentially useful nonpharmacologic approach to therapy. The use of injections of allergenic extracts in selected patients with appropriate inhalant allergen sensitivity offers an immunologic approach for decreasing symptoms in patients with a predominant inhalant allergic component to their disease. Success in the treatment of asthma requires careful consideration of health care delivery. Available measures, when appropriately delivered to the patients when needed, have been convincingly demonstrated to greatly decrease morbidity.     

Asthma medication use and disease burden in children in a primary care population

BACKGROUND: Children with persistent asthma underuse controller medications and overuse relievers. A better understanding of the appropriateness of regimens, medication adherence, and adequacy of asthma control is needed. OBJECTIVES: To describe use of asthma medications and disease burden in children with persistent asthma, to determine whether use of controllers and relievers is consistent with national guidelines, and to estimate adequacy of asthma control. DESIGN: Cross-sectional cohort study. SETTING: Forty-two primary care practices participating in 3 regions of the United States. PARTICIPANTS: Parents of 638 children aged 3 to 15 years with asthma. MAIN OUTCOMES MEASURES: Asthma symptom-days, use of reliever and controller medications, and adequacy of asthma control, ascertained by face-to-face questionnaire. RESULTS: The mean age was 9.4 years, and 59.9% were boys. In the preceding 2 weeks, two thirds (67.5%) of subjects had 0 to 4 symptom-days, 15.8% had 5 to 9 symptom-days, and 16.6% had 10 to 14 symptom-days (percentages do not total 100 because of rounding). One third (32.6%) of children using relievers had high levels of use. One third (34.3%) of children using controllers used them 4 or fewer days per week. Among children with some evidence of persistent disease (use of controllers, excess symptoms, or excess reliever use), almost two thirds (64.3%) were inadequately controlled. This group consisted both of children reportedly using controllers less than recommended and those reporting not receiving controller medication at all. CONCLUSIONS: In this insured population, inappropriate reliance on relievers and nonadherence to controllers were common. Inadequate asthma control was common regardless of whether controllers were prescribed.     

Diagnosing Asthma in Young Children: Current Research & Recommendations

Asthma is the leading pediatric chronic illness in the United States, and there has been a steady increase in the incidence of asthma in children younger than 6 years of age. Early intervention for asthma decreases morbidity, controls health care costs, and may even preserve lung function. Asthma is difficult to diagnose in young children and is under-diagnosed in this population. It is important for primary care nurse practitioners to diagnose asthma in young children in a timely manner so that therapy can be initiated. This article reviews current recommendations for diagnosing asthma in young children and highlights new and promising diagnostic tools for asthma.     

Can asthma education improve the treatment of acute asthma exacerbation in young children?

Acute exacerbation of asthma requires timely and appropriate treatment. Young children are completely reliant on others in this respect. This paper aims to evaluate the effectiveness of staff asthma education programs in ensuring correct treatment for young children experiencing asthma exacerbations in formal care. A systematic review was undertaken of studies focusing on staff asthma education in relation to pharmacological treatment of acute asthma exacerbation. Three randomised controlled trials and seven uncontrolled pre‐ and post‐test intervention studies were included for review. Asthma education was found to increase staff knowledge and confidence in managing asthma. There was a distinct lack of staff performance testing and studies undertaken in the pre‐school setting. Staff asthma education appears effective in increasing asthma knowledge; however, utility of this measure is limited with respect to staff performance in treating acute asthma exacerbation. Further studies evaluating asthma education through performance are needed.     

Patterns of quick-relief and long-term controller medication use in pediatric asthma

OBJECTIVES: To simultaneously examine adherence to long-term controller and quick-relief medications and to contrast patterns of medication use in children with asthma. STUDY DESIGN: Cross-sectional, 1-month follow-up study conducted with 75 children ages 8 to 16 years diagnosed with persistent asthma and prescribed quick-relief and long-term controller medications by metered dose inhaler. Participants were a subsample of a larger adherence study. The primary outcome measure was adherence to both medications as measured by electronic monitoring devices. A classification framework for contrasting adherence patterns between medication classes was developed to identify cases for individual analysis. RESULTS: High levels of nonadherence to long-term controller medications (median = 46% of prescribed doses taken) and variable patterns of quick-relief medication use (range = 0 to 251 doses over the month) were documented, whereas consistent relationships between patterns of medication use across both classes were not found. Individual cases identified by the classification scheme illustrated the complexity and clinical utility of contrasting adherence patterns. CONCLUSIONS: Monitoring long-term controller medication adherence may be more predictive of morbidity than quick-relief medication use, except in outlier cases in which monitoring both medication types may be valuable for clinical and empirical purposes.     

The role of inflammation in childhood asthma

The role of inflammation in adult asthma is well known, involving a cascade of immunological stimulation in which mast cells and eosinophils play pivotal roles. However, the assessment of airway inflammation in children is more difficult as the invasive methods used in adults cannot ethically be used for this purpose alone. Nevertheless, limited data from studies using invasive methodology, and studies using novel non-invasive techniques such as sputum induction and nitrous oxide exhalation, are improving knowledge. The immunopathology in childhood asthma appears to mirror that in adult sufferers. The inflammatory processes are evident at an early age in wheezing infants who later develop asthma, and there are different "wheezing phenotypes" in children with atopic asthma or viral associated wheeze. The mechanisms underlying childhood asthma are dependent not only on increased numbers of inflammatory cells in the airways, but also increased activation of these cells. In vitro data have shown that corticosteroids can inhibit the secretion of proinflammatory compounds from alveolar macrophages, suggesting a potential important role for these agents in halting the development of asthma. Techniques for measuring inflammation in infants need to be refined, in order to provide increased knowledge and accurate monitoring of the disease. It is hoped that this will enable the development of early interventions to minimise the impact of asthma in infants who are identified as being susceptible.