Thai pediatricians' current practice toward childhood asthma

Background: Childhood asthma is a substantial health burden in Thailand. Due to a lack of pediatric respiratory specialists (pediatric pulmonologists and allergists; RS), most Thai children are cared for by general pediatricians (pediatric primary care providers (PCP)). Objectives: We investigated whether current practices of Thai pediatricians complied with asthma guidelines and compared practices (diagnosis and treatments) provided by PCP and RS. Methods: A cross-sectional study was conducted using electronic surveys including four case scenarios of different asthma phenotypes distributed to Thai pediatricians. Asthma diagnosis and management were evaluated for compliance with standard guidelines. The practices of PCP and RS were compared. Results: From 800 surveys distributed, there were 405 respondents (51%). Most respondents (81%) were PCP, who preferred to use clinical diagnosis rather than laboratory investigations to diagnose asthma. For acute asthmatic attacks, 58% of the pediatricians prescribed a systemic corticosteroid. For uncontrolled asthma, 89% of the pediatricians prescribed at least one controller. For exercise-induced bronchospasm, 55% of the pediatricians chose an inhaled bronchodilator, while 38% chose a leukotriene receptor antagonist (LTRA). For virus-induced wheeze, 40% of the respondents chose an LTRA, while 15% chose inhaled corticosteroids (ICS). PCP prescribed more oral bronchodilators (31% vs. 18%, p = 0.02), antibiotics (20% vs. 6%, p < 0.001), and antihistamines (13% vs. 0%, p = 0.02) than RS for the management of an acute asthmatic attack. Conclusions: Most of the Thai pediatricians' practices toward diagnosis and treatment of acute asthmatic attack and uncontrolled asthma conform to the guidelines. PCP prescribed more oral bronchodilators, antibiotics, and antihistamines than RS.     

Underrecognition of the Severity of Asthma and Undertreatment of Asthma in a Rural Area of Japan

Background and Aim. Revised guidelines were released in Japan in 2003 for the assessment, treatment, and management of adult asthmatics, and similar guidelines for child asthmatics were released in 2002. We reassessed the severity and possible undertreatment of asthma according to these guidelines in stable asthmatics. Methods. We reviewed medical records of 861 well-controlled asthmatic patients who, in April through June 2004 were cared for by 47 pulmonologists at 29 medical centers and 13 asthma clinics in a rural community in the San-in area of Japan. The physician obtained completed medical records about their symptoms and current treatment of the subjects, 726 adult and 135 children (aged 6 years or older) who were in stable condition and had had no exacerbations in the previous 3 months. The severity of asthma and current treatment for each patient were assessed according to the newly revised Japanese guidelines for the assessment, treatment, and management of adult and child asthmatics. Results. In adult and child asthmatics, the percentage of predicted forced expiratory volume at 1 second (FEV_1.0) was smaller and has a narrower distribution range than the percentage of predicted peak expiratory flow (PEF). When the severity of asthma was classified according to symptoms alone, 50% and 35% of those classified as mildly asthmatics patients with adults and children, respectively, had moderate to severe airflow limitation. Inhaled corticosteroids were prescribed to 90.6% of adult and 14.9% of child patients. When we compared the treatments that patients were actually receiving against the optimal treatments indexed according to a combined symptoms-FEV_1.0 classification, we found that 49% of adult asthmatics were overtreated, 21% were properly treated, and 30% were undertreated. Among children, the respective percentages were 35%, 25%, and 40%. Conclusion. In well-controlled adult and child asthmatics, the severity of asthma is poorly judged when symptoms alone are considered. We suggest that the severity of asthma should be assessed through a combination of symptoms and the measurement of FEV_1.0 during office visits. We also suggest that the proper dose of inhaled steroid needed to maintain stable conditions should be judged according to this combined symptoms-FEV_1.0 classification.     

Interprofessional Pulmocheck care pathway: An innovative approach to managing pediatric asthma care in the Netherlands

Objectives: Under-diagnosis and suboptimal asthma control in children persists. An innovative care pathway was developed by a hospital department of pediatrics with the aim to detect pulmonary problems in children and provide appropriate treatment possibilities through systematic feedback towards the referring primary care physician. Primary care physicians can use this pathway to refer children with asthma-like symptoms for a one-day assessment. Goals are to measure the usage of the pathway by primary care general practitioners (GPs), the outcomes in terms of new diagnoses of asthma, the reduction in regular referrals, generated recommendations/therapy and the adequacy of asthma follow-up. Methods: We collected all feedback letters sent to the GP concerning children who underwent the Pulmocheck in 2010, 2011 and 2012. Furthermore, all GPs, who had referred a child to the Pulmocheck in this period and that subsequently was diagnosed with asthma and was further managed in primary care, were sent a follow-up questionnaire in 2014. Results: There were 121 referrals from 51 GPs in 3 years to this pathway. In 59.5% of these referrals a new diagnosis of asthma was established. In 90.9% one or more changes in clinical management were advised. The response rate to the follow-up questionnaires was 65.7% of which 4.8% of the children with new established asthma were reviewed four times or more in the follow-up period, 17.4% two times, 65.2% once, and in 8.7% were not followed. Conclusions: The specialty pediatric asthma care pathway revealed a high number of children with newly diagnosed asthma, but was also helpful to exclude this diagnosis. However, the referral rate of GPs to this pathway was low, but in the children, that were referred several changes in the clinical management were advised and the frequency of monitoring of the children with diagnosed asthma was not in accordance with the asthma guidelines.     

TRACK as a complementary tool to GINA and NAEPP guidelines for assessing asthma control in pre-school children

Background: In this study, our goal is to evaluate the consistency between TRACK and the asthma control levels assessed according to the GINA and NAEPP guidelines in children younger than 5 years of age. Methods: Patients under 5 years old, who were followed up for recurrent wheezing for at least 1 year have been included. Parents were given the TRACK questionnaire and the control level of asthma according to GINA and NAEPP guidelines were determined by a pediatric allergist blinded to TRACK scores. Patients were classified into two groups regarding the compatibility of the control level between TRACK and both GINA and NAEPP guidelines. Results: A total of 365 questionnaires were evaluated. The TRACK cut-off point of 80 provided the most consistent balance between sensitivity and specificity for the compatibility with both GINA and NAEPP (for GINA 0.763 and 0.663, kappa?=?0.487, p?p?p?=?0.019). Conclusion: TRACK is compatible with NAEPP and GINA in majority of asthmatic children under 5 years of age. Nevertheless, there is a discrepancy between guidelines and TRACK scores; therefore, it should be used in conjunction with a detailed clinical examination in order to make a better decision for assessing the control levels and management plan.     

International survey of physician recommendation for tracheostomy for Spinal Muscular Atrophy Type I

The ethics of invasive mechanical ventilation for children with the neurodegenerative disease Spinal Muscular Atrophy Type I (SMA I) is highly debated, and wide variability in clinical outcomes exists internationally. We conducted this international survey to identify physician characteristics associated with recommendation for tracheostomy and ventilation for SMA I. A cross-sectional online survey was distributed to 1,772 pediatric pulmonologists and pediatric intensivists from online membership directories of American Thoracic Society, American College of Chest Physicians, and European Respiratory Society. Questions explored physician demographics, attitudes and experience with SMA and end-of-life care, knowledge of consensus guidelines, and recommendations for respiratory care of SMA I. A logistic regression model assessed the independent effects of physician variables on the recommendation for invasive ventilation for SMA I. A total of 367 (21%) physicians completed the survey; 82% were pediatric pulmonologists; and 16% pediatric intensivists. Seventy percent of respondents were from the U.S. Fifty percent of physicians were aware of SMA consensus guidelines. Physicians from Commonwealth countries (U.K., Canada, Australia, etc.) were less likely to recommend tracheostomy/ventilation than U.S. physicians (7% vs. 25%, P = 0.005). Logistic regression modeling identified years of experience, pediatric pulmonology specialty, agreement with a pro-life statement, and recommendation for non-invasive ventilation as predictive of recommendation for long-term invasive ventilation for SMA I. In the largest international survey on this topic, we identified regional differences in physician recommendation for invasive ventilation for children with SMA I. Our data demonstrate a need for increased awareness of consensus guidelines and further dialog about the physician role in variability of care for children with SMA I.     

Comparative Analysis of the Attitudes toward Palliative Care between Medical Oncologists and Pulmonologists

Objective In Japan, both medical oncologists and pulmonologists treat lung cancer patients; however, the difference in their attitude toward palliative care referral is unknown. Thus, we retrospectively investigated the difference in attitudes toward palliative care referral between medical oncologists and pulmonologists in Japan. Methods We retrospectively reviewed the charts of patients with thoracic malignancy who died at Shimane University Hospital between June 2011 and October 2015. We compared the patients'' demographics and medical history according to their doctor''s specialty (i.e., medical oncologist or pulmonologist). Results We identified 182 patients, among whom 90 were treated by medical oncologists and 56 by pulmonologists at the outpatient clinic. Thirty-six patients did not undergo outpatient clinic treatment. Out of 59 patients, 22 (37.3%) referred by medical oncologists, and 7 out of 36 patients (19.4%) referred by pulmonologists, were referred to palliative care specialists in the outpatient setting (p=0.107, Fisher''s exact test). The median survival time after admission to PCU was 21 (95% CI: 13-32) and 9 (95% CI: 5-15) days among the patients treated by medical oncologists and pulmonologists, respectively (p=0.128). Conclusion Medical oncologists are more likely to refer their patients to palliative care in the outpatient setting, thus enabling patients to receive longer end of life care in the PCU. Bridging the research gap regarding differences between the physicians'' attitudes toward palliative care referral may lead to patients receiving more quality palliative care.     

Is a Single Blood Eosinophil Count a Reliable Marker for “Eosinophilic Asthma?”

Purpose. In the National Heart, Lung, and Blood Institute Guidelines for the Diagnosis and Management of Asthma, the expert panel recommends that a written asthma action plan be provided for all patients with asthma. Studies evaluating the usefulness of the asthma action plan in children are limited. We aim to determine exacerbation frequency and usefulness of the asthma action plan in managing exacerbations that occur in a pediatric primary care setting. Methods. Caretakers of asthmatic children attending the general pediatric clinic in an inner‐city hospital completed a one‐page questionnaire covering topics such as asthma severity, frequency of exacerbations, and possession/usefulness of an asthma action plan. Although controversy exists over the definition of yellow and red zone exacerbations, we defined the yellow zone as symptoms that require albuterol more than three times a day or more than two nights in succession. The red zone was defined as symptoms requiring systemic corticosteroids and/or an urgent physician visit. Results. Seventy of 75 subjects completed the survey. Almost 80% of respondents carried the diagnosis of persistent asthma, whereas the remainder had intermittent asthma. Exacerbation frequency over a 3‐month period was determined. Approximately 80% of children experienced at least one yellow zone episode: 42% had one or two yellow zone episodes, and 39.6% had between three and five episodes. Sixty‐three percent of patients did not experience a single red zone exacerbation. Almost 75% (44 of 59) of subjects possessed an asthma action plan. Ninety percent (37 of 41) of respondents with action plans found the plan to be useful in managing exacerbations. Conclusion. Approximately four of every five asthmatic children seen in this primary care setting experienced a yellow zone exacerbation at least once during a 3‐month period. One third experienced at least one red zone episode. Nine of every 10 caretakers with an action plan reported the asthma action plan to be of value in managing exacerbations.     

Chinese guidelines for childhood asthma 2016: Major updates,recommendations and key regional data

Objective: With increased industrialization and urbanization in China, pediatric asthma is becoming more prevalent. Despite a growing body of evidence, there remains a significant unmet need for adequate management of childhood asthma. The Subspecialty Group of Respiratory Diseases of the Society of Pediatrics, the Chinese Medical Association, and the editorial board of the Chinese Journal of Pediatrics have recently updated the “Guidelines for diagnosis and optimal management of asthma in children,” first published in 2008. Methods: This article reviews the major updates to the guidelines and covers the main recommendations for diagnosis, assessment, and treatment of pediatric asthma in China. Key regional data on epidemiology, clinical features, disease burden, knowledge among children and parents, and risk factors including pollution are provided to contextualize the recommendations. Results: The major updates to the guidelines include: (1) A more practical definition of asthma; (2) assessment of asthma control that takes into account both current symptom control and future risk; (3) classification based on disease severity that corresponds with treatment step; (4) differentiation between difficult-to-treat and poorly controlled asthma; (5) an open-ended approach to pharmacological management; and (6) allergen immunotherapy (AIT) in mild- to moderate-persistent asthma. Conclusions: The updated “Guidelines for the diagnosis and optimal management of asthma in children (2016)” combine the latest national and international clinical evidence and experience to provide practical and reliable recommendations to Chinese clinicians.     

Double-balloon enteroscopy in the evaluation of small bowel disorders in pediatric patients

Background: The aim of the present study was to investigate the indications, clinical utility, feasibility and safety of double‐balloon enteroscopy (DBE) in the diagnosis and management of small intestinal diseases in pediatric patients. Methods: This is a retrospective analysis of pediatric patients younger than 18 years referred to Shanghai Rui Jin Hospital from May 2003 to June 2008 for investigation of suspected small bowel disorders. Demographic, clinical, procedural and outcome data were collected for analysis. Results: A total of 35 DBE were carried out in 30 children with a mean age of 13 years. Indications for DBE were obscure gastrointestinal (GI) bleeding (n = 22), chronic abdominal pain (n = 4), chronic diarrhea (n = 3), and incomplete small bowel obstruction (n = 1). DBE evidenced pathological findings in 29 patients (96.7%). DBE altered management in 90% of patients with positive findings. Follow up was obtained on all patients with a mean (range) of 40 months (14–75 months). The procedure was successful in all patients and there were no serious complications related to sedation. Conclusion: DBE is feasible and safe and has a high diagnostic yield and therapeutic impact on the diagnosis and management of small bowel disorders in selected pediatric patients.     

Pediatric acute asthma exacerbations: Evaluation and management from emergency department to intensive care unit

Objective: The goal of this report is to review available modalities for assessing and managing acute asthma exacerbations in pediatric patients, including some that are not included in current expert panel guidelines. While it is not our purpose to provide a comprehensive review of the National Asthma Education and Prevention Program (NAEPP) guidelines, we review NAEPP-recommended treatments to provide the full range of treatments available for managing exacerbations with an emphasis on the continuum of care between the ER and ICU. Data Sources: We searched PubMed using the following search terms in different combinations: asthma, children, pediatric, exacerbation, epidemiology, pathophysiology, guidelines, treatment, management, oxygen, albuterol, β₂-agonist, anticholinergic, theophylline, corticosteroid, magnesium, heliox, BiPAP, ventilation, mechanical ventilation, non-invasive mechanical ventilation and respiratory failure. We attempted to weigh the evidence using the hierarchy in which meta-analyses of randomized controlled trials (RCTs) provide the strongest evidence, followed by individual RCTs, followed by observational studies. We also reviewed the NAEPP and Global Initiative for Asthma expert panel guidelines. Results and conclusions: Asthma is the most common chronic disease of childhood, and acute exacerbations are a significant burden to patients and to public health. Optimal assessment and management of exacerbations, including appropriate escalation of interventions, are essential to minimize morbidity and prevent mortality. While inhaled albuterol and systemic corticosteroids are the mainstay of exacerbation management, escalation may include interventions discussed in this review.     

Use of lung function tests in asthmatic children is associated with lower risk of hospitalization. A Danish population-based follow-up study

Background. Asthma is the most common chronic disease in childhood. Large variations in hospitalization rates are observed and adherence to and appropriateness of guidelines are often subject of discussion. The aim was to examine if adherence to guidelines concerning use of lung function tests at time of diagnosis and during the first year after the start of medical treatment was associated with risk of hospitalization. Research Design. A Danish nationwide population-based cohort study was performed for the study period 1999–2004 using data from five nationwide registries linked by a unique personal registration number. Methods. Risk of hospitalization was examined in relation to whether asthmatic children aged 6–14 had a lung function test at the start of treatment and during the first year of follow-up and a medication ratio of controller-to-total medication of at least 0.5. Cox regression analysis was used to calculate hazard ratios (HRs) adjusted for sex, age, socioeconomic factors, care provider, and severity of disease. Results. A total of 27,193 asthmatic children were followed for at least 1 year after the start of medication. The adjusted HR for hospitalization was 0.64 (95% confidence interval: 0.55–0.74) for having had a lung function test at the start of treatment; 0.82 (0.68–1.00) for having had a lung function test during the first 6 months of follow-up; 0.67 (0.55–0.81) for having a medication ratio of at least 0.5. Children from low-income families and children aged 6–8 had an increased risk of hospitalization. Conclusion. Adherence to the guidelines concerning use of lung function test for asthmatic children was associated with a reduced risk of hospitalization. Likewise, a medication ratio of controller-to-total medication of at least 0.5 was associated with a lower risk of hospitalization.     

Update on the Management of Pediatric Chronic Hepatitis B

A primary challenge in the management of pediatric chronic hepatitis B (CHB) is the lack of established child-specific guidelines. Treatment decisions for children with CHB are extrapolated from the robust adult-focused treatment and management guidelines. However, the rationale for treating children differs from adults, and appropriate patient selection for treatment is imperative to avoid mutant virus development and an indefinite treatment course. Few approved therapies exist for children less than 10 years of age, a group who may benefit greatly from novel and effective therapeutics. It is hoped this gap will be met in the near future, as the field of CHB is rapidly evolving and new therapeutics come to market. This review focuses on the currently available pediatric data regarding treatment for CHB, and draws comparisons with adult-focused data where applicable.     

Racial and Ethnic Differences in the Use of Environmental Control Practices Among Children With Asthma

Objective. Minority children with asthma suffer a disproportionate burden of asthma morbidity. National asthma guidelines recommend use of environmental control practices (ECPs) as part of a comprehensive approach to asthma management. The purpose of this study was to examine use of ECPs among minority and nonminority children with asthma. Methods. The authors used data from the four state sample of the National Asthma Survey, a telephone survey conducted in 2003. The sample included Alabama, California, Illinois, and Texas. Parents provided responses for 2003 children ≤17 years of age with a diagnosis of asthma. The outcomes of interest were use of mattress covers, use of pillow covers, smoke avoidance, pet avoidance, and carpet removal. Univariate and multiple regression analyses were conducted to examine the rates of use of these ECPs among minority and nonminority children. Results. Black and Hispanic children with asthma were less likely to use mattress covers and pillow covers compared to white children in these four states. Smoking avoidance was less likely among black children but more likely among Hispanic children compared to white children. Both black and Hispanic children were more likely to live in a home without pets and without carpets compared to white children. Conclusions. These data illustrate that there are differences in the patterns of ECP use among minority and nonminority children with asthma in these four states. This information can help target physician counseling regarding ECP use in asthmatic children and should inform interventions to improve asthma management among minority children.     

Efficacy and safety of the combination fluticasone propionate plus salmeterol in asthmatic preschoolers: An observational study

Background: Inhaled Corticosteroids (ICS) are the cornerstone of asthma management in pediatric patients. However, in some cases, asthma is not adequately controlled on ICS alone. Long-acting beta₂-agonists (LABA) are one of the available additional therapies but their use has rarely been studied among children younger than 5 years. Objective: The aim of this observational study was to evaluate the efficacy and safety of the combination of fluticasone propionate and salmeterol (FP/SA) in asthmatic children younger than 5 years of age. Methods: A retrospective study of 796 children under the age of 5 years (2.87 ± 1.22 years, 64.2% males), who were treated with FP/SA was conducted. Hospitalization rates, frequency of wheezing, exercise induced asthma, nocturnal wheeze and drug-related side-effects were recorded through children's medical records. Results: The children had previously received short-acting β₂-agonists (73%), ICS (17%), montelukast (1%), and ICS with montelukast (2%). Mean duration of therapy with FP/SA was 12.45 ± 9.14 months. After adjusting for age, gender, and duration of treatment, a 89% reduction was recorded in annual hospitalization rates (from 27.13% before treatment to 3.01% after FP/SA therapy, p < 0.001), a 71% reduction in incidence of exercise-induced asthma (36.8% vs. after 10.6%, p < 0.001), a 81% reduction in nocturnal asthma (33.7% vs. after: 6.4%, p < 0.001), as well as in frequency of wheezing (p < 0.01),. No previous treatment carry-on effect was observed. No major drug-related side-effects occurred in the study group. Conclusions: Combination therapy (FP/SA) is well-tolerated and highly effective in asthmatic children under the age of 5 years.     

Influenza-Like Illness Responsible for Severe Exacerbations in Asthmatic Children During H1N1 Pandemic: A Survey Before Vaccination

Background. Asthma seems to be the more prevalent underlying condition in patients hospitalized for H1N1-related flu. Methods. A prospective survey was conducted during the early phase of H1N1 pandemic in France in asthmatic children before vaccination to assess whether severe exacerbations in childhood asthma are associated with influenza-like illness (ILI, the definition of H1N1-related flu in a pandemic). Eight pediatricians in primary care distributed in three localities (Paris, south suburb, and west suburb) conducted the survey (4 weeks/locality from week 36 to 47). At each visit, the pediatrician filled a questionnaire entering the information regarding asthma treatment, severe exacerbation (at least 3 days' use of systemic corticosteroids), and ILI (temperature ≥37.8°C, cough, and/or sore throat, in the absence of a known cause other than influenza) during the past 3 weeks. Results. The survey included 1155 asthmatic children (mean age [SD]: 7.5 years [4.1]); almost all visits were scheduled (99%). A severe exacerbation was recorded in 121 children [10.5%; 95% confidence interval (CI): 8.7–12.2%], which was concomitant with ILI in 20 children (16.5%; 95% CI: 9.9–23.2%), whereas 1034 children did not exhibit any exacerbation. In these latter children, 40 ILI were observed (3.9%; 95% CI: 2.7–5.0%), which constituted a significantly lesser percentage as compared with children with both exacerbation and ILI (p < .0001). This result remained significant in each locality. Overall, 60/1155 (5.2%; 95% CI: 3.9–6.5%) asthmatic children had an ILI. Conclusions. Our survey shows that severe exacerbation and ILI are strongly associated during the H1N1 pandemic in asthmatic children.     

Dietetic management of obesity and severe obesity in children and adolescents: A scoping review of guidelines

This scoping review describes current guidelines for the dietary management of pediatric obesity and severe obesity. Guidelines were identified via electronic searches of six databases, grey literature, and reference lists and included international clinical practice guidelines (n = 21), position papers (n = 5), and scientific/consensus statements (n = 2) produced by professional bodies and/or expert panels. All recommend multicomponent lifestyle interventions including diet, physical activity, and behavior modification as first‐line treatment. Most guidelines (n = 21) recommend weight loss as a treatment goal for children and adolescents with obesity and associated comorbidities or severe obesity; 15 recommend using dietary approaches. Fourteen of 28 guidelines refer to the management of severe obesity, 10 refer to dietary approaches, and seven recommend using intensive dietary approaches. Dietary approaches to weight loss focus on caloric restriction (n = 14) with some guidelines recommending very low‐energy diet (n = 4), protein‐sparing modified fast (n = 2), and very low‐carbohydrate/ketogenic diets (n = 2). A stronger evidence base is required for dietary management of pediatric obesity and severe obesity to improve consistency in future guidelines. Guidance on the use of dietary approaches, beyond caloric restriction, and in line with the growing evidence base on novel dietary approaches is required to facilitate personalized care and optimal patient outcomes.     

Step-up and step-down treatments for optimal asthma control in children and adolescents

Objective: To review therapeutic options for stepwise management of pediatric asthma in the context of this population’s unique needs such as potential effects of asthma, treatments, or both on growth and psychosocial development, and caregiver involvement. Data sources and study selection: We conducted PubMed searches to identify relevant articles then reviewed resultant articles, guidelines for asthma management in children, and articles from personal files. Results: Stepwise management of asthma, similar to adults, is recommended for children in current global and US guidelines. Treatment may be stepped up or stepped down temporarily or long-term based on response over time. Inhaled corticosteroids remain the recommended treatment for persistent childhood asthma and any potential small effects on growth are considered relatively minor compared with their benefit. Controller medication options for patients <18?years old are limited, especially for Global Initiative for Asthma Steps 2–5. The long-acting antimuscarinic antagonist tiotropium (Steps 4/5, patients aged ≥12?years) and in certain circumstances (Step 5), anti-immunoglobulin E (aged ≥6?years) and interleukin-5 antibodies (aged ≥12?years) are newer treatment options. Tiotropium is indicated in the United States and Europe for patients ≥6?years old. Stepping down treatment, which is recommended but infrequently practiced, can maintain symptom control and minimize adverse events while substantially reducing costs. Patient education and better monitoring remain important for self-management and optimum outcomes. Conclusion: A need exists to target individual treatment goals for children with asthma by using step-up and step-down approaches to maximize treatment benefits and minimize potential adverse effects.     

Asthma control and need for future asthma controller therapy among inner-city Hispanic asthmatic children engaged in a pediatric asthma disease management program (the Breathmobile program,Mobile Asthma Care for Kids Network)

Objective: To determine whether significant numbers of asthmatic children with initially rated intermittent asthma later suffer poor asthma control and require the addition of controller medications. Methods: Inner-city Hispanic children were followed prospectively in an asthma-specific disease management system (Breathmobile) for a period of 2 years. Clinical asthma symptoms, morbidity treatment, and demographic data were collected at each visit. Treatment was based upon National Heart, Lung, and Blood Institute (NHLBI) Expert Panel Report 3 asthma guidelines. Primary outcome was percentage of patients with intermittent asthma who had not well or poorly controlled asthma during subsequent visits and required controller agents. Secondary outcomes were factors associated with the maintenance of asthma control. Results: About 30.9% of the patients with initial rating of intermittent asthma had not well controlled and poorly controlled asthma during subsequent visits and required the addition of controller agents. Factors associated with good asthma control were compliance, no previous emergency room visits and previous visit during spring season. Conclusion: Asthmatic children with intermittent asthma often lose asthma control and require controller therapy. This justifies asthma guideline recommendations to assess asthma control at follow-up visits and adjust therapy accordingly.     

Clinical dysentery in hospitalized children

Background: Clinical dysenery is a severe presentation of an enteric infection. The aim of the study was to evaluate the impact of a serious bacterial etiology in clinical dysentery in hospitalized children and determine if children at high risk can be identified on the basis of clinical or laboratory parameters. Patients and Methods: A prospective study design was used. The study population included 60 children admitted to our department with clinical dysentery over a 16-month period. Fresh stool specimens were collected on days 1, 2 and 3. The clinical and laboratory data of the children were analyzed. Results: Clinical dysentery accounted for 1.7% of all pediatric hospitalizations during this period. Stool cultures were positive for Shigella ssp. In 18 children (30%), and Salmonella ssp. In 15 children (25%). Campylobacter jejuni was identified in one patient (2%). There were no significant differences in clinical characteristics or laboratory parameters between children with positive and negative stool cultures. Conclusion: 40% of the children hospitalized for clinical dysentery were eligible for antibiotic treatment. Early administration of empiric antibiotic treatment is justified in children hospitalized for clinical dysenery in Israel. Clinical or laboratory parameters were unable to differentiate those with clinical dysentery at risk of serious bacterial pathogens in stool. Received: November 11, 2001 · Revision accepted: March 13, 2002