Comprehensive environmental management of asthma and pediatric preventive care

To cite this article: Roy A, Downes MJ, Wisnivesky JP. Comprehensive environmental management of asthma and pediatric preventive care. Pediatr Allergy Immunol 2011; 22 : 277–282. Indoor environmental triggers can increase asthma morbidity. National guidelines recommend comprehensive use of environmental control practices (ECPs) as a component of asthma management. The purpose of this study was to examine the association between preventive asthma care and comprehensive ECP use among children with asthma. We used data from the National Asthma Survey, including 1,921 children with asthma. Comprehensive use was defined as using at least five of eight ECPs: (i) air filter, (ii) dehumidifier, (iii) mattress cover, (iv) pillow cover, (v) pet avoidance, (vi) smoke avoidance, (vii) removing carpets, and (viii) washing sheets in hot water. Univariate and multiple regression analyses were conducted to examine the association between comprehensive use of ECPs and receipt of preventive asthma care, as measured by number of routine asthma visits in the prior year and physician advice to modify the environment. Overall, 17% (95% CI: 14–19%) of participants had comprehensive ECP use. The most commonly used practices were ‘smoke avoidance’ (85%), ‘pet avoidance’ (59%), and ‘washing sheets in hot water’ (46%). Comprehensive use of ECPs was associated with having received physician advice [odds ratio (OR) 3.1, 95% CI: 2.2–4.4] and increased asthma visits (1–2 visits: OR 1.5, 95% CI: 1.0–2.4; 3–4 visits: OR 2.2, 95% CI: 1.3–3.8; ≥5 visits: OR 2.7, 95% CI: 1.5–4.8). Only a minority of parents implement comprehensive ECPs, and receipt of preventive asthma care is associated with comprehensive use. Further research is needed to determine the factors mediating these associations in order to inform more effective asthma counseling.     

Prevalence and correlates of paediatric asthma and wheezing in a largely rural USA population

OBJECTIVE: The prevalence of asthma among children has been increasing in the United States and it is estimated that there are approximately 5 million children with asthma. This cross-sectional survey sought to estimate the prevalence of asthma and asthma symptoms and potential risk factors among children aged 16 and younger, in a largely rural population in the USA. METHODS: This study was a telephone survey of 1500 households in the South Plains/Panhandle region of Texas. Parents of children were interviewed with a response rate of 64%. Having been diagnosed with asthma by a physician and a report of wheezing in the last 12 months were used as dependent variables in multivariate logistic regressions with several sociodemographic and environmental factors as potential confounders. RESULTS: The age-adjusted prevalence of asthma and wheezing among children were approximately 15 and 18%, respectively. The prevalence of asthma was highest (20%) among children aged 11-16 (P < 0.001). Living in urban areas was associated significantly with asthma and wheezing. Non-Hispanic blacks reported significantly increased odds of asthma in their children (adjusted odds ratio (OR) = 2.04, 95%CI 1.02-4.08), whereas Mexican-Americans reported significantly reduced odds of asthma (adjusted OR = 0.48, 95%CI 0.29-0.78) and wheezing (adjusted OR = 0.58, 95%CI 0.37-0.89) in their children. The odds of asthma (adjusted OR = 1.78, 95%CI 1.09-2.92) and wheezing (adjusted OR = 2.45, 95%CI 1.52-3.95) was highest among children in the highest body mass index quartile. No significant association with pet ownership and exposure to second-hand smoke with asthma and wheezing was observed in this study. CONCLUSION: Urban residence, non-Hispanic black and Mexican-American race/ethnicity, and being overweight were significantly associated with the increased risk of asthma and/or wheezing.     

Early environmental determinants of asthma risk in a high-risk birth cohort

Environmental exposures during early life have been suggested to have the greatest impact on childhood asthma. Our aim was to evaluate the risk factors associated with asthma at age 7 yr in a high-risk cohort that participated in a randomized controlled study on the primary prevention of asthma. Indoor exposures were characterized before birth and at 2 weeks, 4, 8, 12, 18, and 24 months after birth and again at 7 yr. Nasal scrapings for respiratory viruses were done at the same intervals during the first 2 yr. At age 7, the children were assessed by a pediatric allergist and had allergy skin tests. Logistic regression analysis was undertaken to evaluate the effect of exposures on asthma for the entire cohort with adjustment for group allocation. In addition to the lower risk of asthma in the intervention group, we found a higher prevalence of asthma at age 7 for males, those having a positive history of asthma in mother, father, or older siblings, for children residing in Winnipeg and for atopic subjects. Upon adjustment for intervention group assignment and baseline factors, significant environmental risk factors during year 1 included dog ownership and respiratory syncytial viral infection detected at 12 months while maternal smoking was protective. Dog ownership was a significant risk factor in year 2, but highly correlated with dog ownership in year 1. Indoor environmental exposures during year 7 were not associated with asthma at age 7. Maternal smoking at year 7 was associated with a reduced risk of asthma at 7 yr. Early-life exposures were more important determinants than those in later years. A 'window of opportunity' exists for intervention measures to be applied.     

Indoor environmental risk factors and seasonal variation of childhood asthma

Seasonality of asthma may result from varying exposures. This cross‐sectional study was designed to examine the relationship between indoor environmental factors and seasonal childhood asthma. Study subjects were participants from the International Study of Asthma and Allergies in Childhood (ISAAC) in 2004, a population‐based surveillance, which included school children aged 6–15 yr in south Taiwan. Cases included 1725 children who experienced asthma symptoms in the past 12 months and the references consisted of 19,646 children who reportedly have no asthma history. By using a moving average and principal component analysis, asthmatic children were grouped into four asthma subtypes: winter, spring, summer/fall, and perennial. Multivariate logistic regression was used to evaluate the effect of indoor environmental factors on seasonality of childhood asthma. For all asthma prevalence, a peak occurred in the winter and a nadir appeared in summer. Contributing factors of asthma for children, regardless of seasonality, included younger age, parental atopy, maternal smoking during pregnancy, breast feeding, and perceived air pollution. After adjusted for salient risk factors, water damage was significantly associated with all subtypes of asthma. Presence of cockroaches was related to the summer/fall asthma (adjusted odds ratio [aOR] = 1.65, 95% confidence interval [CI] = 1.12–2.55). Visible mold on the walls was associated with an increased occurrence of winter and spring asthma (aOR = 1.53, 95% CI = 1.26–1.85 and aOR = 1.34, 95% CI = 1.10–1.62, respectively). Passive smoking was shown to be related to spring and summer/fall asthma. Water damage is a possible risk for childhood asthma year‐round. Cockroaches and visible mold on the walls may play essential roles for seasonality of childhood asthma in Taiwan. Plausible mechanisms and allergic effects should be further determined. Elimination of these allergens is necessary to help prevent the development of asthma.     

Dust-free bedrooms in the treatment of asthmatic children with house dust or house dust mite allergy: a controlled trial

Twenty asthmatic children with prick tests positive for house dust or house dust mites were allocated to two groups that were matched for severity. One group was provided with zippered vinyl covers for pillows, mattresses, and box springs, and instructions for making the bedroom as easy to keep clean as a hospital ward; the other group was not. At the end of a 1-month study period, there was a marked and statistically significant difference in symptoms and signs of asthma between the two groups. Those with a dust-free bedroom had fewer days on which wheezing was observed, medication was given, or an abnormally low peak expiratory flow rate was recorded. Bronchial tolerance to aerosolized histamine significantly improved in the group whose bedrooms had been modified. A dust-free bedroom diminishes bronchial irritability and is a practical and effective method for decreasing asthma in children with house dust or house dust mite allergy.     

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.     

A potential pitfall in provider assessments of the quality of asthma control.

BACKGROUND: Pediatricians elicit information about asthma control from parents to help formulate management plans. If parents of children with significant asthma symptoms inappropriately indicate good control, physician recommendations may not be optimal. We examined whether a single general question about asthma control might lead to inaccurate assessment of severity. DESIGN/METHODS: Children 3-7 years of age who met the National Heart, Lung, and Blood Institute (NHLBI) criteria for mild persistent to severe asthma were identified from 40 urban schools. A phone survey of their parents provided demographic information, symptom frequency, medication use, and general interpretation of their child's asthma control. Chi-square analyses compared the parent's general interpretation of control with demographic characteristics and measures of asthma severity. RESULTS: One hundred sixty of 224 eligible children participated in this study. Seventy-eight percent were described as in good asthma control. General assessment of asthma control did not vary by demographic characteristics. Parents were as likely to describe children with daily asthma symptoms in good control as they were to describe children with less frequent symptoms in good control. Parents were less likely to report good control in children using daily rescue medications when compared with children with less frequent medication use (65% vs 82%, P =.03), but the majority of children in both groups was described as having good control. CONCLUSIONS: Most parents underestimated the severity of their child's asthma and reported good control with their global assessment. Parents frequently reported good control even when the children had daily asthma symptoms. Pediatricians should ask about specific asthma symptoms during patient encounters because a global question about asthma control likely will result in underestimations of asthma severity.     

Environmental exposures and exhaled nitric oxide in children with asthma

OBJECTIVE: To evaluate the relation of environmental factors with exhaled nitric oxide (FENO) concentrations among asthmatic children. STUDY DESIGN: Cross-sectional analysis of 170 tobacco smoke-exposed children, ages 6 to 12 years, who have doctor-diagnosed asthma using measures of FENO, medication use, and exposures to settled indoor allergens and tobacco smoke. RESULTS: In multivariable analysis, child's age, uncarpeted flooring, not owning a cat, higher income, dust mite exposure, and being sensitized to any allergens were associated with higher FENO concentrations. Children who were sensitized to indoor allergens had an adjusted geometric mean FENO of 15.4 ppb (95% CI, 13.1, 18.2) compared with 10 ppb (95% CI, 8.2, 12.2) for unsensitized children. There was no statistically significant association of serum cotinine, hair cotinine, or reported corticosteroid therapy with FENO. CONCLUSIONS: FENO is higher among children who are sensitized to indoor allergens and exposed to dust mites. The results hold promise for the use of FENO as a tool to manage childhood asthma by using both pharmacologic and environmental treatments.     

The language of breathlessness: do families and health care providers speak the same language when describing asthma symptoms?

INTRODUCTION: Effective communication about symptoms is a critical prerequisite to appropriate treatment. Study aims were to: (a) document the symptoms that children with asthma and their parents associate with asthma, (b) identify differences between the "professional model "of asthma symptoms and the "lay model," (c) describe the family's proposed action in response to symptoms, and (d) investigate the congruence between parental assessment of "good control" and severity obtained using National Asthma Education and Prevention Program criteria. METHOD: Children with asthma and their parents (N = 228) were recruited from diverse clinical practice sites. Parents and children described symptoms they associated with an asthma exacerbation and their proposed action. Perceived asthma control was compared with a structured assessment of severity. RESULTS: One hundred and thirty-six unique symptoms were reported. While 78% of parents reported at least one standard asthma symptom, 48% also reported nonstandard asthma symptoms. Sixty-five percent of parents whose children's symptoms were consistent with severe asthma reported "good control." DISCUSSION: Improved communication about symptoms would improve asthma care. Proposed strategies include standardized screening questionnaires to assess symptoms, more frequent routine visits for children with persistent asthma, and wide dissemination of realistic goals for symptom control.     

Consistency of care with national guidelines for children with asthma in managed care

OBJECTIVE: To evaluate the consistency of pediatric asthma care with the National Asthma Education and Prevention Program Guidelines. DESIGN: Cross-sectional survey at 2 managed care organizations in the United States (winter 1997-1998). The participants were parents of children (n = 318) age 5 to 17 years with asthma. There were no interventions. The outcome measures were indicators of care in 4 domains: (1) periodic physiologic assessment, (2) proper use of medications, (3) patient education, and (4) control of factors contributing to asthma severity. RESULTS: Of 533 eligible patients with asthma, 318 (60%) parents responded; 59% of children were male, 76% were white, and 60% were aged 5 to 10 years. Deficiencies in care were identified in all care domains including, for patients with moderate and severe persistent symptoms, only 55% used long-term control medication daily, 49% had written instructions for handling asthma attacks, 44% had instructions for adjustment of medication before exposures, 56% had undergone allergy testing, and 54% had undergone pulmonary function testing. CONCLUSIONS: There are significant opportunities to improve the quality of care for children with asthma enrolled in managed care. A comprehensive approach to improving care may be necessary to address multiple aspects of care where opportunities exist.     

Effects of early intake of fruit or vegetables in relation to later asthma and allergic sensitization in school-age children

AIM: To assess the associations between nutrition supplements in infancy and later asthma and allergy in school-age children, and to explore the impact of environmental factors in early life. METHODS: Five hundred and two children underwent clinical examination, skin prick test and a second parentally completed questionnaire within 2 y of a cross-sectional questionnairebased study, including 4585 primary school children (6-16 y old) in 1994 from urban Oslo (37%), the mountainous area of Hallingdal (42%), and the industrial, coastal area of Odda (21%). The children were selected from the 1994 survey on the basis of reported diagnosed asthma (n=166), wheeze in the last 12 mo (n=155) and no asthma/no wheeze (n=181). Questions were related to nutrition and environmental exposure in early life. Possible associations between allergic sensitization or asthma at school age and exposures were estimated by logistic regression analysis, adjusting for potential confounders. RESULTS: Daily intake of fresh fruit or vegetables, but not extra vitamins or cod liver oil supplements, in infancy decreased the risk of asthma (adjusted odds ratio (aOR) 0.57 (95% confidence interval (CI): 0.37-0.88). Early supplements of cod liver oil and extra vitamins were associated with increased allergic sensitization (aOR 1.78 (95% CI: 1.03-3.07) and 1.71 (95% CI: 1.01-2.88), respectively). A significantly higher prevalence of allergic sensitization was found in children living in Hallingdal compared to Odda, while the latter children, on the other hand, had the highest prevalence of house dust mite allergy (p = 0.001 vs Hallingdal and p = 0.04 vs Oslo). CONCLUSION: The present study suggests that the early introduction of daily fresh fruit or vegetables may decrease the risk of asthma after 1 y of life, whereas allergic sensitization at school age seemed to increase with extra vitamin and cod liver oil supplements during infancy. Living area influenced allergic sensitization, with differences between coastal and inland areas.     

Racial, social, and environmental risks for childhood asthma

Unlike a number of childhood problems, it is not clear that there are racial or socioeconomic disparities in the prevalence of childhood asthma. We analyzed data from the Child Health Supplement to the 1981 National health Interview Survey, a population-based survey with information concerning 15,416 children, to address the following questions: are there racial or socioeconomic differences in rates of childhood asthma; if yes, what is the contribution of social and environmental characteristics to the observed differences? In this sample, black children were more likely to have asthma than were white children (4.4% vs. 2.5%). Racial disparities in prevalence emerged early and at all childhood ages were due to higher black rates of onset between the ages of 1 and 3 years. Poverty status, maternal cigarette smoking, large family size, smaller size of home, low birth weight, and maternal age younger than 20 years at the child's birth were all associated with increased rates of childhood asthma. When available social and environmental characteristics were controlled for using multivariate analyses, the increased risk for asthma among black and poor children was reduced to statistical insignificance. We conclude that black and poor children in the United States do have higher rates of asthma, that social and environmental factors exert substantial influences on rates of asthma, and that much of the racial and economic disparity in prevalence can be accounted for by a variety of social and environmental characteristics.     

Determinants of parental discipline practices: a national sample from primary care practices

National guidelines urge pediatricians to address discipline as part of anticipatory guidance, yet pediatricians know little about what leads parents to use different discipline approaches. Parents seen in Pediatric Research in Office Settings practices participated in an office-based survey before the well-child visit for children 2 to 11 years old (N = 2134). Parents reported using the following discipline approaches frequently: time-outs (42%), removal of privileges (41%), sent to bedroom (27%), yelling (13%), and spanking (9%). A third of parents believe their discipline approach to be ineffective. This directs the pediatric provider to help families develop effective discipline practices tailored to their context.     

Environmental factors and childhood asthma

Indoor allergens are potent triggers for acute and chronic pediatric asthma. Environmental control measures of these allergens should be considered first-line treatment measures. Allergen avoidance can produce changes in disease activity and symptoms that can be beneficial before any medical intervention is implemented. In addition to allergen avoidance, studies evaluating other exposures, such as endotoxin and diet, in the pathogenesis of asthma are in progress. Understanding the complex relationships between exposure and allergy/asthma development is vitally important to the development of potentially more effective primary and secondary prevention strategies.     

High prevalence of atopy, but not of asthma, among children in an industrialized area in North Italy: The role of familial and environmental factors – a population-based study

The prevalence of atopy and asthma, and their association with familial and environmental factors were investigated among 13- to 14-yr-old children living in Brescia, an industrialized town in North Italy. All the 1450 children attending primary school in the town were invited to participate, and 967 of them (66.7%, 493 males) provided a valid questionnaire filled in by their parents at home. We used a modified version of the questionnaire adopted in the Italian Study of Respiratory Disorders in Childhood and Environment, which is an extended version of the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire. Six hundred and twenty-eight subjects underwent skin prick test (SPT), and 308 of them (49%) were positive for at least one of the 12 allergen extracts commonly employed. Ninety-nine children (10.2%) had a physician's diagnosis of asthma - 12.4% of the males and 8.0% of the females (p = 0.03). The prevalence of wheezing in the past 12 months was 6.2%. Atopy was found in 76.8% of the subjects with, and in 45.6% of those without physician's diagnosis of asthma (p < 0.001). Analysis by multiple logistic regression showed an inverse association between physician-diagnosed asthma and female sex (odds ratio, OR = 0.5); presence of relatives in the bedroom in initial years of life (OR = 0.6); attending day care (OR = 0.4) and infant school (OR = 0.4); a positive association with parental history of wheezing (OR = 2.5) and asthma (OR = 3.8); and the child's history of asthmatic bronchitis (OR = 31.9) and atopic eczema (OR = 3.8) in the first 2 yr of life. The strength of the associations did not change when restricting the analysis to atopic asthma. In conclusion, atopy and clinical asthma among 13- to 14-yr-old adolescents are significantly associated with some familial and environmental factors, providing further support for the hygiene hypothesis. Prevalence of atopy, but not of asthma, is high in this industrialized area. The strong association found between atopy and clinical asthma suggests that atopy may play a role in causing asthma in genetically predisposed children only.     

Spacer compliance after discharge following a mild to moderate asthma attack

Aim: To assess MDIS usage in patients discharged from a children''s hospital emergency department following a mild to moderate asthma attack. Methods: Prospective observational study of 73 consecutive patients presenting to a children''s hospital emergency department with a mild to moderate asthma attack. Demographic data, whether asthma literature/written MDIS instructions were provided, and who provided MDIS instructions (either a discharge coordinator or other emergency department staff) were noted. Parents of patients were telephoned after the first week following discharge and questioned about patient improvement, MDIS use/reasons for not using MDIS, and unscheduled presentations to their local doctor or hospital. Results: Following discharge, 50/73 (68.5%) patients used MDIS exclusively (compliers), while 23/73 used nebulisers some or all of the time (non-compliers). There was no difference in patient improvement or unscheduled presentations between compliers and non-compliers. Most non-compliers 14/23 (60.9%) changed because of parental preference; ease of nocturnal nebuliser use was a possible factor. Compliance was associated with the age of the patient, spacer usage at hospital, the size of device used at hospital, and whether an information fact sheet was given. Conclusions: Most children discharged from the emergency department following a mild to moderate asthma attack continue MDIS use exclusively in the first week. MDIS compliance may be associated with knowledge, experience, and ease of spacer usage. The study shows that education for parents is crucial for MDIS compliance.     

The prehospital management of children with acute asthma

Parents of 100 children admitted sequentially to hospital with acute asthma were interviewed in order to determine the frequency of the use of asthma action plans and the intensity of prehospital treatment. The results revealed that 51% of the parents possessed some form of action plan and 84% of this group used their plan prior to the child's admission to hospital. However 79% of those children with more than two prior hospital admissions for asthma had an action plan. Bronchodilator therapy was widely used, with widespread possession of nebulizer units, but tended to be given infrequently prior to hospital admission. Steroid use in the acute attack was inadequate. Despite a concurrent national asthma campaign prehospital management was considered to be suboptimal.     

Food related asthma: a difference between two ethnic groups.

A survey of reported, food related asthma was carried out among children referred to hospital. Ninety nine replies were received from a postal questionnaire and 78 other children were interviewed personally. Both survey methods gave similar results. Symptoms from at least one item of diet were significantly more frequently reported by Asian than non-Asian children (91%:58% respectively). Ice, fizzy drinks, fried food, and nuts were incriminated significantly more often by the Asian children, but there was no difference in the prevalence of asthma associated with orange squash, milk, chocolate, or eggs. This ethnic difference could not be explained by a difference in severity of asthma. Results are presented of six Asian children who showed increased bronchial responsiveness after eating chips but not potato, thereby confirming their claim of asthma induced by fried foods. This report shows that food as a trigger of asthma is much more common than is generally accepted, particularly in Asian children.