Management of severe asthma in children

The majority of children with asthma are classified as mild/moderate and can be successfully managed with regular inhaled corticosteroids and bronchodilators. However, more than 5% of asthmatic children continue to have sub-optimal control despite apparently appropriate therapy. These children suffer significant morbidity including poor school attendance, adverse effects on family life and consume disproportionate health care resources. True therapy resistant asthma is rare in children and paediatricians should focus on ensuring the correct diagnosis, identifying and managing modifiable risk factors for difficult to control asthma before using the label severe asthma. Management of severe asthma requires a multidisciplinary approach. Symptomatic children on Step 4 (less than 5 years) or Step 5 (more than 5 years) of British Thoracic Society/SIGN Asthma Guideline or in children with diagnostic uncertainty should be referred to the local tertiary paediatric respiratory service.     

儿童哮喘缓解期维持临床控制的干预研究

目的探讨哮喘缓解期儿童伴发急性上呼吸道感染（AURI）时维持临床控制的干预措施。方法选取100例达到临床控制的哮喘儿童,随机分为观察组和对照组,均以最低剂量吸入性糖皮质激素和长效β2受体激动剂复合制剂（ICS/LABA）每晚吸入维持临床治疗。伴发AURI时均予常规处理;观察组除常规处理外同时给予早期短期升级治疗,即在维持治疗基础上每日早晨加吸等量ICS/LABA复合制剂,维持升级治疗7~10 d。两组急性发作时均根据其病情严重程度按哮喘指南诊治。治疗3、6、9、12个月后观察两组哮喘控制水平、哮喘急性发作严重程度、肺功能指标变化和不良事件发生情况等。结果治疗3、6、9、12个月各随访时间点,观察组哮喘控制率均在90%以上,对照组为80%左右,两组控制率比较差异有统计学意义（P < 0.05）。各随访时间点观察组哮喘急性发作严重程度明显低于对照组（P < 0.05）。与对照组相比,观察组肺功能大、小气道指标均明显改善（P < 0.05）。与对照组相比,观察组吸入糖皮质激素量以及对家庭生活的影响均明显减少（P < 0.05）。结论哮喘缓解期儿童伴发AURI时早期短期升级治疗可预防哮喘急性发作,提高哮喘控制率,改善肺功能。     

Parental knowledge about their asthmatic children]

A questionnaire was administered to parents of 171 asthmatic children, and their knowledge of asthma was evaluated using a quantitative score. The mean age of children was 5 yr and the mean duration of their asthma was 3 yr. Each sign of the classical triad "noisy breathing, cough, indrawing" was mentioned by two-thirds of parents. Inhaled agents perceived as triggers of asthma were: animal hair (73.7%), dust (69.6%), pollen (60.2%), tobacco (44.4%), molds (14.6%). Other triggering agents mentioned were: stress (51.5%), infections (38%), exercise (13.5%). Mothers with college or university education knew more clinical signs of an attack (P less than 0.01) and more triggering factors (P less than 0.005). Parents satisfied with previous teaching knew more threatening signs of an attack (P less than 0.01). About 80% of those that used theophylline and 49.4% of those that used inhaled beta-2-agonists knew the correct mode of administration. Parents satisfied with previous teaching had better knowledge of the side-effects of theophylline (P less than 0.005) and beta-2-agonists (P less than 0.02). 58.5% of those that used cromolyn sodium did not know the mean duration of a therapeutic trial and 15% did not use it as prophylaxis. 57.1% of those that used oral corticosteroids did not know any side-effects of the drug. About half of the parents indicated that they would like to receive more information about the causes and the appropriate treatment of asthma. It was concluded that parental teaching should focus more on environmental and therapeutic issues.     

Eosinophil cationic protein (ECP), eosinophil chemotactic activity (ECA), neutrophil chemotactic activity (NCA) and tryptase in serum before and during bronchial challenge in cat-allergic children with asthma

In order to study ECP, ECA, NCA and tryptase levels in serum in 18 cat-allergic children with asthma scrum samples were obtained before and during an allergen bronchial challenge. All children were on regular treatment with inhaled steroids (200-800 μg/day) and bronchodilators. Peak expiratory flow (PEF) was recorded twice daily for at least a week before the challenge. The baseline ECP levels were significantly higher in the children who had a baseline PEF 80-95% of pred. compared to those who had PEF >95% of pred. (mean 24. 3 μg/l and 14. 3 μg/l respectively, p <0.02). ECP in serum before the ehallenge correlated significantly to PEF in % of the expected optimal PEF obtained from the PEF curve (r= 0. 48, p <0.05). During the challenge ECA and NCA increased significantly from mean 96. 2% and 97. 9% to 122. 7% and 118. 7% (p <0.05 for both), while ECP did not change significantly, mean 20. 4 μg/l before and 17. 5 μg/l after the challenge. Tryptase levels in serum were not detectable (<0. 5 ng/ml) before or during the asthmatic attack.
We eoncludc that there are significantly raised ECP levels in serum in symptom-free asthmatic children on long-term treatment with topical steroids possibly indicating remaining airway inflammation. Acute asthma results in an increase of ECA and NCA while ECP levels seem to reflect the chronic rather than the acute phase of asthma in children.     

昆明市儿童哮喘流行病学调查分析

目的 了解昆明市儿童哮喘的流行现状、分布特征、诱发因素及治疗情况,为进一步规范哮喘患儿诊治提供依据。方法 采用随机整群抽样的方法,通过自填式问卷调查与集中调查相结合的方式进行调查。对于初筛问卷中的可疑哮喘患儿按哮喘诊断标准进行诊断,对确诊的哮喘患儿填写哮喘儿童调查表。结果 昆明市 0~14 岁儿童哮喘患病率为 1.40%,男性患病率明显高于女性（PP结论 昆明市 0~14 岁儿童哮喘的患病与年龄、性别有关。哮喘急性发作多发生在冬季、午夜及清晨,最常见的发作诱因为呼吸道感染。哮喘既往诊断与调查时最后诊断的符合率较低。糖皮质激素及支气管舒张剂吸入治疗的比例较低,而使用抗生素治疗的患儿比例则较高,需进一步规范哮喘患儿诊治方法。     

家庭环境香烟烟雾暴露对哮喘患儿疾病控制状况的影响

目的 了解家庭环境香烟烟雾暴露(ETS)与哮喘患儿疾病控制情况的关系.方法 通过病例对照研究方法,对83名ETS和80名非ETS的哮喘儿童进行为期1年的随访,比较两组患儿的儿童哮喘控制测试(childhood asthma control test,C-ACT)评分良好(＞19分)的例次,哮喘控制用药增加天数、急救用药使用天数,以及尿cotinine含量.结果 ETS患儿C-ACT＞19分802例次,占总C-ACT评分例次的80.5%;非ETS患儿 C-ACT＞9分921例次,占95.9%,两组患儿的哮喘控制状况差异无统计学意义(P＜0.05);ETS患儿的尿cotinine含量、支气管扩张剂使用天数、吸入激素增加天数、全身激素使用天数也均明显多于非ETS患儿(P均＜0.05).ETS患儿以尿cotinine含量分为重度(＞4 ng/ml)和轻度(≤4 ng/ml),其中重度ETS患儿的C-ACT＞19分例次低于轻度ETS患儿,而支气管扩张剂使用天数、吸入激素增加天数、全身激素使用天数也均明显多于轻度ETS患儿,差异均有统计学意义(P均＜0.05).结论 ETS是儿童哮喘控制不良的重要危险因素之一.     

Benefits of a school-based asthma treatment program in the absence of secondhand smoke exposure: results of a randomized clinical trial

BACKGROUND: Daily maintenance medications are recommended for all children with mild persistent to severe persistent asthma; however, poor adherence to these medications is common. OBJECTIVE: To evaluate the impact of school-based provision of inhaled corticosteroids on asthma severity among urban children with mild persistent to severe persistent asthma. DESIGN: Children aged 3 to 7 years with mild persistent to severe persistent asthma were identified at the start of the 2000-2001 and 2001-2002 school years in Rochester. Children were assigned randomly to a school-based care group (daily inhaled corticosteroids provided through the school) or a usual-care group (inhaled corticosteroids not given through school). MAIN OUTCOME MEASURE: Improvement in parent-reported symptom-free days. RESULTS: Of 242 eligible children, 184 were enrolled from 54 urban schools. Data for 180 children were available. Parents of children in the school-based care group had a greater improvement in quality of life compared with parents of children in the usual-care group (change score, 0.63 vs 0.24; P =.047); also, children in the school-based care group vs the usual-care group missed less school because of asthma (mean total days missed, 6.8 vs 8.8; P =.047) and experienced more symptom-free days during the early winter months (mean days per 2-week period, 9.2 vs 7.3; P =.02). A post hoc analysis revealed that all significant findings were produced by differences among children who were not exposed to secondhand smoke. Furthermore, among children not exposed to smoke, those in the school-based care group vs the usual-care group had more symptom-free days overall (11.5 vs 10.5; P =.046), had fewer days needing rescue medications (1.6 vs 2.3; P =.03), and were less likely to have had 3 or more acute visits for asthma (6 [13%] of 47 children vs 17 [31%] of 54 children; P =.03). CONCLUSIONS: School-based provision of inhaled corticosteroids significantly improved symptoms, quality of life, and absenteeism among urban children with mild persistent to severe persistent asthma. This effect was seen only among children not exposed to secondhand smoke.     

Use of polymerase chain reaction for detection of adenovirus in children with or without wheezing

Eighty percent of asthma attacks in children are accompanied by an upper respiratory tract viral infection. Adenovirus is one of the major viral causes of childhood bronchiolitis. As the polymerase chain reaction (PCR) is the most sensitive technique for documenting viral respiratory infections, the PCR method was performed on the throat swab samples of asthmatic children with and without wheezing to investigate the presence of the adenovirus genome in the upper respiratory tract. The frequencies of adenovirus in asymptomatic and symptomatic asthmatic patients, healthy controls and wheezy children were as follows: 33.3%, 71.4%, 37% and 62.96%, respectively. The adenovirus was detected in a significantly higher percentage in the upper airways of patients with asthma exacerbation and in children with wheezing than in patients without asthma exacerbation and in the healthy controls (p < 0.05). The frequency of adenovirus was not different between asthmatic patients receiving or not receiving inhaled corticosteroid. Adenovirus has the potential to precipitate asthma exacerbations in asthmatic patients; its frequency was not affected by the treatment of inhaled corticosteroid.     

上海市普陀区儿童喘息及哮喘流行病学调查

目的了解上海市普陀区儿童喘息和哮喘的患病状况,以及控制和治疗情况。方法整群随机抽样法抽取在普陀区10所社区卫生服务中心健康体检的婴幼儿和12所幼儿园的学龄前期儿童、3所小学及8所中学的学龄期和青春期儿童;对这些儿童和(或)其父母进行问卷调查。结果共调查11 771名儿童,其中男5 832名,女5 939名。在全体被调查者中,917名(占7.79%)有喘息或哮喘史,男性占9.34%、女性6.26%;喘息或哮喘现患率为4.21%,男性4.94%,女性3.40%,性别差异有统计学意义(P均<0.01)。无论是喘息或哮喘史,还是喘息或哮喘的现患率,均高于2000年上海市调查结果(4.52%,3.34%),差异有统计学意义(χ2=122.5、13.76,P均<0.01)。在>7岁有喘息或哮喘史的儿童中,第一次喘息发作年龄≤3岁者占55.94%。在喘息或哮喘现患儿童中,长期规范吸入糖皮质激素治疗者仅占13.51%。结论上海市普陀区,目前有喘息或哮喘史及喘息或哮喘现患率儿童的比例较2000年增加,儿童第一次喘息发作年龄小,哮喘儿童的长期规范治疗差。     

Identifying problematic severe asthma in the individual child – does lung function matter?*

Aim: Measures of lung function (usually FEV₁ <80% predicted) are used to classify asthma severity in both adults and children, despite evidence that lung function impairment is less pronounced in the paediatric asthma population. The present study assesses the relevance of lung function measurements as discriminators of severe childhood asthma. Methods: Fifty‐one school‐aged children with problematic severe asthma, 37 mild‐to‐moderate asthmatics and 29 healthy controls underwent a comprehensive clinical work‐up. Problematic severe asthma was defined in patients exhibiting poor asthma control despite high‐dose inhaled corticosteroid treatment and at least one other asthma controller drug. Mild‐to‐moderate asthmatic children used low‐dose inhaled steroids and reported minimal asthma symptoms. Results: Baseline FEV₁ values were significantly reduced in children with problematic severe asthma, yet FEV₁ <80% predicted showed a low sensitivity (41%) for discriminating severe vs. mild‐to‐moderate asthma. Receiver‐operated characteristic analysis estimated the optimal cut‐off of FEV₁ to be 90% predicted in this population (sensitivity 61%, specificity 83%). Baseline FEV₁/FVC and FEF_25–75 values were not superior to FEV₁ in discriminating problematic severe asthma, and neither exhaled nitric oxide levels nor bronchial hyperresponsiveness differentiated between the two asthmatic study populations. Conclusion: Spirometric measurements are insensitive discriminators of problematic severe asthma in childhood.     

哮喘高危婴幼儿喘息发作期病毒病原及过敏原检测分析

目的分析哮喘高危婴幼儿喘息发作期病毒病原学、过敏原分布，为喘息患儿的早期诊断与干预治疗提供帮助。方法选取2016年4月至2017年8月因喘息性支气管炎和喘息性支气管肺炎住院的135例哮喘高危婴幼儿为研究对象。采用荧光探针PCR法检测患儿鼻咽部抽吸物标本甲型流感病毒（Flu-A）、呼吸道合胞病毒（RSV）、腺病毒（ADV）、副流感病毒（PinF）、人鼻病毒（HRV）、人偏肺病毒（hMPV）、博卡病毒（HBoV）感染情况；采用ImmunoCAP技术检测患儿吸入性变应原、食物性变应原及总IgE浓度。结果 135例患儿中，鼻咽部抽吸物标本病毒检出阳性率为49.6%，各病毒检出阳性率由高到低依次为HRV 25.2%、HBoV 9.6%、RSV 8.1%、PinF 5.9%、Flu-A 3.7%、ADV 1.5%、hMPV 0.7%。HRV在1~3岁年龄组检出率高于<1岁组（P < 0.05）。过敏原筛查试验阳性率为59.3%，吸入性过敏原阳性率为44%，食物性过敏原阳性率为89%；吸入性过敏原中阳性率由高到低依次为尘螨77%、霉菌37%、花粉26%、动物皮屑9%；食物性过敏原中阳性率由高到低依次为鸡蛋白73%、牛奶68%。<1岁组吸入性过敏原阳性率大于1~3岁组（P < 0.05）；1~3岁组T-IgE水平明显高于<1岁组（P < 0.05）。病毒检出组吸入性过敏原阳性率大于病毒未检出组（P < 0.05）。第2次喘息患儿吸入性、食物性过敏原阳性率及T-IgE水平均高于第1次喘息患儿（P < 0.05）；吸入性过敏原尘螨、霉菌在第2次喘息患儿中阳性率高于第1次喘息患儿（P < 0.05）。结论早期HRV感染和吸入性过敏原阳性与哮喘高危婴幼儿喘息发生密切相关。     

Growth of asthmatic children is slower during than before treatment with inhaled glucocorticoids

Reports on the influence of inhaled glucocorticoids on growth have been controversial. We studied the growth of prepubertal asthmatic children prior to and during glucocorticoid therapy. We collected retrospectively the notes of 201 asthmatic children aged 1–11 years receiving inhaled beclomethasone dipropionate or budesonide. We calculated their height and height velocity standard deviation scores (HSDS and HVSDS, respectively) before the treatment and up to 5 years during the treatment and compared those with the growth of healthy peers. The dose of the medication was calculated and the severity of asthma was assessed. The asthmatic children grew similarly to their healthy peers before treatment with inhaled glucocorticoids: the mean HSDS was +0.02 and the mean HVSDS +0.01 for boys and -0.16 and +0.13 for girls, respectively. Growth retardation took place soon after the start of the treatment, the most profound decrease in the growth velocity (the change in the mean HVSDS from +0.05 to -0.88) occurring during the first year of treatment. The growth-retarding effect of inhaled glucocorticoids was not dose dependent. In the covariance analysis the increasing severity of asthma had a significant interaction with repeated measurements, showing more growth retardation along with more severe asthma, especially during long-term treatment. Asthma per se does not impair growth, but inhaled glucocorticoids may do so. Careful monitoring of the growth of all asthmatic children receiving inhaled glucocorticoids is necessary because the growth-retarding effect of the medication is not dose dependent. Individual sensitivity might explain the differences seen in the growth patterns of children receiving inhaled glucocorticoids.     

Internet survey of childhood asthma and use of inhaled therapy in the home in Japan

Background: The aim of the present study is to undertake a survey of childhood asthma and details of the use of inhaled therapy from mothers with asthmatic children ≤15 years old, using the Internet.
Methods: This study was done on a nationwide scale in Japan during the latter half of July 2001.
Results: Responses were obtained from 748 mothers. Four hundred and three children (53.9%) had been diagnosed with asthma when ≤2 years old and 263 children (35.2%) when 2–5 years old. Three hundred and ninety-seven children (53.1%) were in remission or had mild asthma, 295 children (39.4%) had moderate asthma, and 56 (7.5%) had severe asthma. Of 563 children who required some pharmacological treatment, 266 used inhaled therapy. One hundred and forty-four children used metered-dose inhaler (MDI), 136 used powered nebulizer, and 34 used dry powder inhaler (DPI). Of children treated with inhaled sodium cromoglycate, 63 used MDI, 129 used nebulizer solution and 23 used DPI. Of children treated with inhaled corticosteroids, 43 used MDI and six used DPI. Of children using powered nebulizer, 48 were well satisfied and 76 were slightly satisfied. More than 90% of mothers commented that this form of treatment improved the quality of life both of the asthmatic children and of the family.
Conclusion: Internet survey of childhood asthma is effective, and powered nebulizer therapy may be encouraged more acceptable by infants and young children in the treatment of asthma.     

212例儿童哮喘预后的5年随访研究

目的：探讨儿童哮喘转归和影响发病与预后的因素。方法：对随访5年以上的212例哮喘儿童资料进行回顾性分析。 结果：5年随访中,哮喘停止发作121例（57.1%）,哮喘持续91例（42.9%）。哮喘急性发作的主要诱因为呼吸道感染（71.7%）,其次是过敏原吸入（17.0%）。由呼吸道感染诱发的哮喘患儿（61.2%）较由过敏原（41.7%)或运动（26.3%）诱发者缓解率高（P＜0.05）。湿疹合并过敏性鼻炎、父母哮喘、过敏原诱发的喘息是发展成持续性哮喘的3个危险因素。结论：5年以上的随访中大部分哮喘患儿停止发作。呼吸道感染是儿童哮喘急性发作的主要诱因。由呼吸道感染诱发的哮喘转归较好。特应质及有特应质遗传背景的患儿更有可能发展成持续性哮喘。     

Assessment of use of spacer devices for inhaled drug delivery to asthmatic children

In the treatment of bronchial asthma, inhaled therapy with both bronchodilators and corticosteroids represents the basis for acute and long-term management. Drug therapy in asthma is predominantly by pressurized metered dose inhalers. The impact of treatment on the disease morbidity and mortality depends to a large extent on appropriate delivery of drug to the lungs by means of a spacer device. We performed an audit on spacer use in 200 children and showed that 99% owned a spacer, 2% owned but did not use their spacer, 11% were using a spacer which was not ideal for their age, 17% had a poor technique, and 24% were not following the recommendations given on previous visits to wash the spacer only with a soapy solution. Although physicians frequently associate poor control of asthma with inadequate doses of drugs, many factors must be considered before increasing the dose of inhaled medications to children. We should all ensure that the drugs we prescribe are delivered in the best possible manner, thus improving control of asthma, reducing side effects and offering a more cost-effective therapy.     

Reduced basal salivary cortisol in children with asthma and allergic rhinitis

Aim: Reduced basal cortisol is reported in allergic disease. We investigated if basal salivary cortisol levels were reduced in children with asthma or allergic rhinitis, controlling for inhaled corticosteroids (ICS) use. Methods: Morning and evening saliva of asthmatic children aged 7–12 years (n = 50) and that of controls (n = 52) were sampled. A total of 19 asthmatics and four controls had allergic rhinitis. Healthy children were controls without rhinitis. Of all, 14 asthmatic children used low, and 12 used moderate or high doses of ICS. Cortisol was analysed by radioimmunoassay. Results: Morning salivary cortisol median (95% CI) was lower in asthmatics (8.7 (7.1, 9.7)) compared with that in controls (10.4 (9.6, 11.8); p = 0.006), which was similar for evening cortisol levels. Regression analyses demonstrated that asthmatics using moderate or high doses of ICS had reduced morning salivary cortisol adjusted (for age and gender) odds ratio (aOR) (95% CI) (0.54 (0.37, 0.80); p = 0.002) and reduced evening cortisol aOR (0.09 (0.01, 0.6); p = 0.02) compared with that in healthy children. Asthmatics with rhinitis on no or low doses of ICS had reduced morning cortisol aOR (0.73 (0.56, 0.96); p = 0.02) compared with that in healthy children. Conclusion: Asthmatic children on moderate or high doses of inhaled corticosteroids had reduced salivary cortisol, but co‐morbidity of asthma and rhinitis was also associated with reduced cortisol levels.     

Severe asthma in children

Most childhood asthma is mild/moderate and is easily controlled with regular use of inhaled corticosteroids (ICS) and rescue bronchodilators. However, between 5% and 10% of children will have asthma that remains difficult to control despite high doses of appropriate asthma therapies. Children with ‘difficult to control’ asthma are responsible for a substantial proportion of the morbidity and health care costs associated with asthma. The recognition that not all ‘difficult to control’ asthma is ‘severe’ is perhaps the most important message for paediatricians looking after children with such asthma. Before labelling asthma as ‘severe’, factors that might make asthma difficult to control need to be identified and addressed. In the small number with genuinely severe asthma, there are a number of different subgroups or ‘phenotypes’. In the future, clearer definition of phenotypes is likely to lead to better targeting of therapy and to improved asthma control.     

Treatment preferences of adolescent patients with asthma

The study objective was to assess whether asthmatic adolescents who were regular users of inhaled corticosteroids preferred treatment with zafirlukast tablets or inhaled beclomethasone dipropionate (BDP), and, secondarily, to assess adolescents' inhaler technique and their opinions about treatment. An openlabel, randomized, twoperiod, crossover study was conducted in 18 centres (primary care to specialist asthma centres) in South Africa, the UK, Finland and the Czech Republic. One hundred and thirtytwo adolescents aged 1217 years with asthma for at least 1 year and FEV₁  75% of predicted, treated with shortacting bronchodilators and inhaled corticosteroids, entered the study. Patients received oral zafirlukast tablets (Accolate) 20 mg bd or inhaled BDP 100 or 200 µg bd, provided by a standard pressurized metereddose inhaler, for 4 weeks each. One questionnaire was used to determine preference (the primary outcome measure) and a second questionnaire was used to determine patients' likes and dislikes of treatment. Investigators also scored inhaler technique. Of 113 adolescents, 79 (70%) preferred zafirlukast compared with 31 (27%) who preferred the BDP inhaler (p < 0.001); three had no preference. Only 35 (29%) of 122 adolescents could use their inhaler correctly at study entry. Seventysix patients (65%) rated zafirlukast tablets as 'very easy' to use, compared with 35 (30%) for the BDP inhaler. Both treatments were well tolerated. This study shows that asthmatic adolescents prefer zafirlukast tablets by a ratio of 2.6:1 over inhaled BDP, and these results may have implications for improving adolescent patient compliance with asthma therapy.     

北京市哮喘儿童家长知信行问卷调查

目的 了解北京市哮喘儿童家长哮喘知信行现状及影响因素.方法 2008年8-10月,采取多中心问卷调查的方法,在北京市20家医院的哮喘专科或儿科门诊,对北京市常住居民中诊断为哮喘6个月以上的就诊患儿家长进行调查.结果 共调查390名患儿家长,有效问卷351份,回收率90.0%.接受调查的家长中,75.2%认识到哮喘的本质是气道过敏性慢性炎性疾病;54.4%的认为即使孩子处于哮喘控制状态下也只能参加轻微运动;88.4%的家长认为按照医嘱长期吸入激素对于孩子的生长发育有影响.32.5%的哮喘儿童坚持规律使用吸人激素;47.2%的哮喘患儿坚持规律使用白三烯受体调节剂;45.3%的家长在孩子哮喘急性发作时会加用抗生素,只有18.1%的家长选用速效β2受体激动剂.多因素Logistic分析显示,家长受教育程度及患儿哮喘控制状态下的复诊频率对于家长的知信行有影响(P<0.05,OR>1).结论 北京市的哮喘儿童家长对于哮喘这种疾病的认识普遍较好;家长受教育程度越高,哮喘儿童控制状态下的复诊频率越高,越有利于家长的知信行.