Asthma in children: classification and treatment

OBJECTIVES: To review concepts, classification based on severity, and long term treatment for children with asthma. METHODS: To identify precipitating factors of acute asthma attacks and classify the disease in order to establish long term treatment. RESULTS: Different plans of management according to its classification: mild, moderate and severe asthma. Antiinflammatory therapy is reserved to moderate and severe asthma. CONCLUSIONS: The identification and control of the etiologic and precipitating factors are important tasks in the management of asthma. The inhalatory route is the most appropriate to treat patients suffering from asthma. The usual drugs indicated in asthma treatment are reviewed. Precocious treatment with inhaled glucocorticosteroids is recommended by several authors.     

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.     

Asthma in children: Prevalence, treatment, and sensitization

This study compares the prevalence of asthma and sensitization in children from two Swedish regions with different climates: Göteborg on the southwest coast and Kiruna in the northern inland, north of the Arctic Circle. The 412 children of a population‐based sample, 203 in Göteborg and 209 in Kiruna, were investigated at age 7–8 and 12–13 years. Questionnaire reports and interviews were obtained from all children at 7–8 years of age, and 192 children were skin‐prick tested for common aeroallergens in Göteborg and 205 in Kiruna. At the follow‐up, 5 years later, almost all the children were re‐investigated. The prevalence of asthma, wheeze, and sensitization had increased with increasing age during the follow‐up period. The questionnaire reports revealed that the prevalence of asthma was 8.5% at 12–13 years of age. All children who in the questionnaire reported current asthma, were using asthma medication. The interviews indicated that the prevalence of a clinically significant asthma might be even higher, reaching ≈ 12%. Asthma and wheeze were as common in Göteborg as in Kiruna despite large differences in prevalence of sensitization. Sensitization, and especially sensitization to animals, was far more common in Kiruna than in Göteborg. This study shows that asthma and wheeze are increasingly prevalent even in school age children and that sensitization does not necessarily reflect the prevalence of asthma in a population.     

Predictors of medication adherence in children receiving psychotropic medication

Aim: Medication adherence is poor in many young people with chronic illness. However, little research has examined medication adherence in clinic samples of young people receiving psychotropic medication, and whether factors such as disorder or drug type influence adherence. This study aimed to examine medication adherence in children and adolescents receiving psychotropic medication. Methods: Young people receiving psychotropic medication and their caregivers were recruited from pharmacy and mental health services within a large metropolitan hospital. A brief cross‐sectional survey examined medication history, missed doses within the previous week and other clinical information. Multiple regression analysis examined whether child characteristics, drug type and regimen characteristics were associated with medication adherence. Results: Poor adherence was associated with lack of parental involvement in medication routines (P < 0.05), use of complementary medicines (P < 0.01) and difficulty remembering doses (P < 0.01). Developmental diagnoses (P < 0.05), use of antipsychotics (P < 0.05) and use of concomitant non‐psychotropic medication (P < 0.05) were predictors of good adherence. Conclusion: Encouraging parental involvement in medication routines may be a practical target for clinicians aiming to improve medication adherence in young people. Use of complementary medicines may indicate a group with a higher risk of poorer adherence.     

Minimising medication errors in children

Medical errors are a major problem in the UK and other countries. Apart from the direct expense to the healthcare system, there are great personal costs to those involved including patients, their families and staff, and public confidence is undermined. Therefore, policy initiatives have been implemented to reduce such mistakes. Medication errors are thought to be the most common type of medical errors, with the majority of studies being conducted in adults. However, recent evidence highlights the fact that medication errors are also a significant problem in the paediatric population. This paper reviews the factors contributing to paediatric medication errors, including lack of appropriate paediatric formulations, communication issues between health professionals, dose calculation mistakes and inadequate clinical practice. This review will also discuss risk reduction strategies such as electronic prescribing and computerised physician order entry (CPOE) systems which can significantly reduce paediatric medication errors in conjunction with pharmacist monitoring, improved communication and environments which promote best practice.     

Asthma in rural Bangladeshi children

Objective Although bronchial asthma causes a great deal of morbidity among children in Bangladesh, few epidemiological studies addressed this problem. The study aims to determine the prevalence of wheezing and its association with environmental and host factors. Methods A total of 1587 children aged 60–71 mth living in 50 villages in rural Bangladesh at Matlab was studied. Trained field workers interviewed caretakers of these children to diagnose wheezing using an adopted questionnaire of the International Studies of Asthma and Allergies in Childhood (ISAAC). History of pneumonia among wheezing and non-wheezing children during their childhood was obtained from the surveillance records. Results The prevalence of wheezing in the last 12 mth prior to survey was 16.1% (95% Cl: 14.3%, 18.0%), significantly higher among children who had attacks of pneumonia during their infancy compared to children who did not (23.0% vs 14.6%, p<0.0001). Risk factors associated with wheezing were pneumonia at ages 0–12m (OR= 1.50, 95% Cl 1.08, 2.10) and 13–24m (OR= 2.12, 1.46, 3.08), maternal asthma (OR=3.01, 95% Cl 2.02, 4.47), paternal asthma (OR= 3.12, 95% Cl 1.85, 5.26), maternal eczema (OR=1.81, 95% Cl 1.14, 2.87) and family income ≤ 100 US$ (OR for US$ 51–99= 1.63, 95% Cl 1.05, 2.53; OR for US$ ≤ 50= 2.12, 95% Cl 1.31, 3.44). Conclusion Our results suggest that wheezing is a significant cause of morbidity among children in rural Bangladesh. Greater efforts are needed to prevent pneumonia among children during their infancy to reduce the chances of subsequent development of wheezing.     

Asthma and obesity in children

PURPOSE OF REVIEW: Childhood asthma and obesity are significant public health problems. The prevalence of both disorders has increased considerably in the past decade. This review will highlight recent publications regarding the nature of the relationship between asthma and obesity and the clinical effects of obesity in children with asthma. RECENT FINDINGS: Most prospective studies suggest that obesity increases the risk of subsequent asthma. Possible mechanisms for the relationship between asthma and obesity include airway inflammation, mechanical changes associated with obesity, changes in airway hyper-responsiveness, and changes in physical activity and diet. Most studies suggest that obesity increases the clinical severity of asthma and decreases quality of life in children with asthma. More research is required to further define and clarify the relationship between asthma and obesity in children. SUMMARY: There are many questions and few answers regarding the relationship between asthma and obesity in children. Additional studies are needed to clarify the relationship between the two epidemics so that effective interventions can be developed to improve the health and lives of children with both asthma and obesity.     

Stimulant medication therapy in the treatment of children with attention deficit hyperactivity disorder

Despite the tremendous research advances that have increased our knowledge regarding the pharmacodynamics, clinical pharmacology, pharmacokinetics, and adverse effects of stimulant medications in the treatment of children with ADHD, our knowledge is yet incomplete. Perhaps the most central unresolved issue concerns our understanding of the pathogenesis, pathophysiology, and diagnosis of ADHD. This review has touched briefly on the controversy and confusion surrounding this issue. Although our understanding of the use of stimulant medications in this disorder is similarly incomplete, a review of the literature does allow certain conclusions to be made that are helpful to the practitioner. 1. Stimulant medications are an effective treatment modality for most children with ADHD. Short-term efficacy is well documented, and long-term outcome may be improved when stimulants are used with other therapeutic strategies. Stimulants in and of themselves are not a panacea. 2. It is impossible to predict which children will have a favorable response to stimulant medications and which children may have a placebo response. The use of individual single-blind medication trials is a practical solution to this problem and should be considered for all children who are candidates for stimulant therapy as a means for preventing overuse or inappropriate use of these medications. 3. The precise mechanism of action of stimulants is not yet completely understood, but stimulants appear to exert their therapeutic effects through their influence on multiple neurotransmitters in the catecholamine, dopamine, norepinephrine axis in the central nervous system. 4. The three major stimulants--methylphenidate, dextroamphetamine, and pemoline--appear to be equally efficacious, although methylphenidate has emerged as the most commonly used and most studied drug. Because of its potential for causing liver toxicity, pemoline has remained a second-line medication. 5. The three major stimulants appear to have somewhat different mechanisms of action so that failure of a patient to respond to one medication does not mean that he or she will not respond to another. 6. The recommended starting doses for the stimulants are 0.3 mg per kg of methylphenidate, 0.15 mg per kg of dextroamphetamine, and 37.5 mg of pemoline. There is a great deal of individual variability in dose response, so doses must be titrated for optimal effects in each child. Sustained release preparations are much more expensive than regular preparations and may be less effective. 7. There is no evidence that stimulants have any effect on ultimate adult height. 8. Although relatively uncommon, motor tics have been observed in children on stimulants, and all children on stimulants need to be carefully monitored for the development of tics. (ABSTRACT TRUNCATED AT 250 WORDS)     

Asthma management in indigenous children of a remote community using an indigenous health model

OBJECTIVE: To describe the management of asthma in children in a remote indigenous community and the delivery of subspecialist service through the indigenous health-care model. METHODOLOGY: Children referred by indigenous health-care workers were evaluated prospectively by paediatric respiratory physicians, based on a standardized protocol, at a primary health care setting at Thursday Island, Queensland. RESULTS: Forty of the 54 children referred with a provisional diagnosis of asthma did have asthma, with 30% having persistent asthma. Only 59% of parents knew the dose of the medication prescribed and 80% had minimal knowledge of the medications. In 88% of children, the management of asthma was improved by introduction of an appropriate spacer device and changing the dose and type of medications. CONCLUSIONS: The management of children with asthma in the Torres region can be improved substantially by the use of age appropriate delivery devices and medications, and improving knowledge of asthma. Specialist delivery service to remote indigenous communities can be effectively delivered in partnership with the indigenous health service. The high proportion of persistent asthma in the Torres Straits community in comparison to urbanised Australia raises issues of inequity of appropriate medical service delivery to remote indigenous communities.     

Stimulant medication treatment of target behaviors in children with autism: a population-based study

OBJECTIVE: This study provides detailed information about stimulant medication treatment for the target symptoms of hyperactivity, impulsivity, disinhibition, and inattention in children with autism. METHODS: In a previous study, 124 subjects fulfilling DSM-IV-based research criteria for autistic disorder were identified among all 0-21 year old residents of Olmsted County, MN from 1976-1997. For each of these 124 children with research-identified autism, information was abstracted on all prescribed psychopharmacological medications. RESULTS: Psychostimulants were used to treat 52.4% (N = 65) of the 124 subjects. The median total duration of psychostimulant treatment was 4.0 years. There were 398 episodes of psychostimulant treatment. Favorable responses were associated with 69.4% of treatment episodes. Of the 398 episodes of stimulant treatment, 16.8% were associated with a documented side effect. At least one side effect was experienced by 66% of the children. CONCLUSION: These results indicate that psychostimulants are commonly prescribed for children with autism, and suggest that these medications may improve the target symptoms of hyperactivity, impulsivity, disinhibition and inattention.