Asthma in adolescence

Trend of Bronchial Hyperresponsiveness to Methacholine as a Cost Predictor of Mild-to-Moderate Asthma: A Twelve-Month Survey in Teenagers

Bronchial asthma is characterized by variable airflow obstruction, airway inflammation, and bronchial hyperresponsiveness (BHR) to non-specific stimuli. The role of underlying airway inflammation and of related long-lasting BHR has been suboptimally investigated in teenagers with mild-to-moderate asthma, as has the corresponding economic impact over time. The aim of the present study was to calculate the cost of mild-to-moderate atopic asthma in teenagers arising from their degree of persisting BHR over a twelve-month period.

METHODS

Patients aged 12-18 years with mild-to-moderate symptoms treated with fluticasone fumarate/vilanterol 92/22 mcg daily were retrospectively followed for 12 months. Usual spirometric parameters, BHR to methacholine (MCh), and resource consumption (visits, hospitalizations, systemic steroids and/or antibiotics courses, school days off) were assessed at recruitment (the index date) and after 6 and 12 months. Adherence to treatment was also calculated. The cost of asthma was calculated based on Italian tariffs and published papers. The trend over time in BHR and the association between response to MCh and total cost were investigated by using regression models adjusted for repeated measures.

RESULTS

106 teenagers (53 males, age 15.9 ± 1.6 years) were investigated. The annual cost of asthma proved significantly related to the BHR trend: every increment of a factor 10 in the response to MCh was associated with a saving of EUR 184.90 (95% CI -305.89 to -63.90). BHR was progressively optimized after 6 and 12 months in relation to the patients' compliance to treatment (≥70% of prescribed inhalation doses).

CONCLUSIONS

the usual spirometric parameters are largely insufficient to reflect the effects of underlying persistent inflammation in milder forms of asthma in teenagers. In terms of clinical governance, the periodic assessment of non-specific BHR is the appropriate procedure from this point of view. Non-specific BHR proves a reliable procedure for predicting and monitoring the economic impact of mild-to-moderate asthma in teenagers over time.

Parents' Experiences and Perceptions of Healthcare Transition in Adolescents with Asthma: A Qualitative Study

Adolescence marks a significant transition from pediatric to adult healthcare, and parents play critical roles in supporting their adolescents with chronic conditions through this process. However, little is known about parents' experiences, perceptions, and needs during this healthcare transition. This qualitative study explores the experiences and perceptions of parents regarding the care transition of their 16-17-year-old adolescents with asthma. Nineteen mothers participated in either a focus group or individual interviews, and a content analysis was conducted on the data. Parents expressed negative emotions and various concerns about their teens' transition readiness and asthma management. A need for early transition training for both adolescents and parents was discussed. Overall, the complexity and challenges associated with the healthcare transition of adolescents with asthma take a toll on parents, particularly when their teens are not adequately prepared to manage asthma independently. Parents need appropriate anticipatory guidance regarding the transition and skills to navigate changing roles and negotiate asthma care responsibilities with their teens. Timely interventions and support strategies for both adolescents and parents are needed to ensure the successful healthcare transition of adolescents with asthma.

Are Mid to Late Adolescents with Asthma Ready for Transition of Care? A Qualitative Study

This qualitative descriptive study explores experiences and perspectives of mid-to-late adolescents about growing up with asthma, and the roles of parents and providers as they transition. Purposeful sampling was used to recruit and enroll adolescents aged 16-20 years with asthma. Forty-one adolescents participated in a focus group or individual interview, and content analysis was conducted to analyze the data. The mean age of participants was 17.7 years, the majority (56%) of whom were Black. Themes that emerged included concerns about becoming an adult with asthma and its self-management, parental involvement, and communication with providers. Adolescents felt burdened by asthma, few considered becoming adults with asthma, and their future outlook was pessimistic with concerns related to worsening symptoms, inadequacy in symptom self-management and limitations on career choices due to asthma. Deficiencies in self-management were noted, parents still played major roles in adolescents' asthma care, and transition of care was seldom discussed with the providers. Mid-to-late adolescents with asthma are inadequately prepared for transition of care, and parents and providers insufficiently engage adolescents in the preparation. Parent, provider, and adolescent partnership is critical to achieve adolescent readiness for independence in asthma management and to ensure proper asthma care continuity post transition.

Perimenstrual Asthma in Adolescents: A Shared Condition in Pediatric and Gynecological Endocrinology

Asthma is a frequent medical condition in adolescence. The worsening of the most common symptoms perimenstrually is defined as perimenstrual asthma (PMA). The cause of PMA remains unclear, but a role for hormonal milieu is plausible. Data on PMA in adolescents are limited, and its management is not fully established. We aimed to discuss the PMA phenomenon in young females from pathophysiology to preventive strategies, focusing on the relationship with the hormonal pattern. The fluctuation of estrogens at ovulation and before menstruation and the progesterone secretion during the luteal phase and its subsequent withdrawal seem to be the culprits, because the deterioration of asthma is cyclical during the luteal phase and/or during the first days of the menstrual cycle. Conventional asthma therapies are not always effective for PMA. Preventive strategies may include innovative hormonal contraception. Even a possible beneficial effect of other hormonal treatments, including estrogens, progestogens, and androgens, as well as leukotriene receptor antagonists and explorative approach using microbial-directed therapy, is considered. The underlying mechanisms, through which sex-hormone fluctuations influence asthma symptoms, represent a challenge in the clinical management of such a distressing condition. Further studies focused on young females are mandatory to promote adolescent health.

Electronic reminders and rewards to improve adherence to inhaled asthma treatment in adolescents: a non-randomised feasibility study in tertiary care

OBJECTIVE

To test the feasibility and acceptability of a short-term reminder and incentives intervention in adolescents with low adherence to asthma medications.

METHODS

Mixed-methods feasibility study in a tertiary care clinic. Adolescents recruited to a 24-week programme with three 8-weekly visits, receiving electronic reminders to prompt inhaled corticosteroid (ICS) inhalation through a mobile app coupled with electronic monitoring devices (EMD). From the second visit, monetary incentives based on adherence of ICS inhalation: £1 per dose, maximum £2 /day, up to £112/study, collected as gift cards at the third visit. End of study interviews and questionnaires assessing perceptions of asthma and ICS, analysed using the Perceptions and Practicalities Framework.

PARTICIPANTS

Adolescents (11-18 years) with documented low ICS adherence (<80% by EMD), and poor asthma control at the first clinic visit.

RESULTS

10 out of 12 adolescents approached were recruited (7 males, 3 females, 12-16 years). Eight participants provided adherence measures up to the fourth visits and received rewards. Mean study duration was 281 days, with 7/10 participants unable to attend their fourth visit due to COVID-19 lockdown. Only 3/10 participants managed to pair the app/EMD up to the fourth visit, which was associated with improved ICS adherence (from 0.51, SD 0.07 to 0.86, SD 0.05). Adherence did not change in adolescents unable to pair the app/EMD. The intervention was acceptable to participants and parents/guardians. Exit interviews showed that participants welcomed reminders and incentives, though expressed frustration with app/EMD technological difficulties. Participants stated the intervention helped through reminding ICS doses, promoting self-monitoring and increasing motivation to take inhalers.

CONCLUSIONS

An intervention using electronic reminders and incentives through an app coupled with an EMD was feasible and acceptable to adolescents with asthma. A pilot randomised controlled trial is warranted to better estimate the effect size on adherence, with improved technical support for the EMD.

How I Do It: Transitioning Asthma Care From Adolescents to Adults

Children with asthma grow to become adults with asthma. Adolescents are not simply older children and do not automatically transform into independent adults, nor do they become proficient in self-management of their condition overnight. Adolescence is a high-risk time for many people with asthma, with increased risk of asthma-related morbidity and mortality. Children with high-risk asthma attend hospital-based asthma clinics with their parents until they reach young adulthood, and parents usually take on the significant burden of disease management on behalf of their children. Once patients are transferred to adult medical teams, many will continue to have limited knowledge about their asthma, limited understanding of how to manage their symptoms and comorbidities, and limited comprehension of how and why to take their regular medication. Adolescence is a critical time of change during which young people yearn for autonomy. Effective transition gives young people the skills and knowledge necessary to manage their health independently and provides the substrate for autonomous care, the bed rock of long-term conditions. This review focuses on the challenges of adolescent health care and provides guidance on how to take a planned, patient-centered approach to ensure each transition is effective and safe.

Asthma self-management in children: a best practice implementation project

INTRODUCTION

Asthma is one of the most common diseases in children. A self-management program can effectively improve the outcomes for children with asthma and reduce the burden on healthcare services.

OBJECTIVES

The aim of this project was to integrate the best evidence on asthma self-management with practice in a children's respiratory clinic and to improve compliance with best practice.

METHODS

Seven audit criteria were developed for the pre- and post-audit based on the best available evidence. The Joanna Briggs Institute (JBI) Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback tools were used in this project.

RESULTS

The baseline audit showed a gap between clinical practice and the best evidence. The only criterion that achieved high compliance was provision of inhaler guidance (100%). After implementation, there were substantial improvements in compliance for many criteria. Training of clinicians increased from 13% at baseline to 67% at follow-up. Education of parents improved, with specific education about asthma triggers increasing from 55% to 100%, education about warning signs from 30% to 85% and education about effective asthma treatment options from 40% to 85%. Use of written asthma action plans increased from 0% to 25%.

CONCLUSION

Strategies developed in this project were effective at providing necessary information for parents and improved the compliance with evidence. Further implementation strategies and audits are still needed to improve the use of asthma action plans and ensure they are reviewed periodically.

Managing Stigma: Young People, Asthma, and the Politics of Chronic Illness

In this article, we explore the relationship between asthma and stigma, drawing on 31 interviews with young people (aged 5-17) in Ireland. Participants with mild to moderate asthma were recruited from Traveller and middle-class settled communities. Themes derived from an abductive approach to data analysis and a critical appreciation of Goffmanesque sociology include asthma as a discreditable stigma, negative social reactions (real, imagined, and anticipated), and stigma management. Going beyond a personal tragedy model, we reflect upon macro-social structures (e.g., ethnicity, class, gender) which underlie stigma and the management of a potentially spoiled identity. This raises issues about the politics of chronic illness, embodying health identities and efforts to tackle stigma in neoliberal times.

Lost in the transition from pediatric to adult healthcare? Experiences of young adults with severe asthma

Objective: Asthma is a multifaceted disease, and severe asthma is likely to be persistent. Patients with severe asthma have the greatest burden and require more healthcare resources than those with mild-to-moderate asthma. The majority with asthma can be managed in primary care, while some patients with severe asthma warrant referral for expert advice regarding management. In adolescence, this involves a transition from pediatric to adult healthcare. This study aimed to explore how young adults with severe asthma experienced the transition process.Methods: Young adults with severe asthma were recruited from an ongoing Swedish population-based cohort. Qualitative data were obtained through individual interviews (n = 16, mean age 23.4 years), and the transcribed data were analyzed with systematic text condensation.Results: Four categories emerged based on the young adults' experiences: "I have to take responsibility", "A need of being involved", "Feeling left out of the system", and "Lack of engagement". The young adults felt they had to take more responsibility, did not know where to turn, and experienced fewer follow-ups in adult healthcare. Further, they wanted healthcare providers to involve them in self-management during adolescence, and in general, they felt that their asthma received insufficient support from healthcare providers.Conclusions: Based on how the young adults with severe asthma experienced the transition from pediatric to adult healthcare, it is suggested that healthcare providers together with each patient prepare, plan, and communicate in the transition process for continued care in line with transition guidelines.

Transition for Adolescents and Young Adults With Asthma

Asthma is a complex, heterogenous medical condition which is very common in children and adults. The transition process from pediatric to adult health care services can be a challenge for young people with chronic medical conditions. The significant changes in physical and mental health during this time, as well as the many unique developmental and psychosocial challenges that occur during adolescence can complicate and impede transition if not adequately addressed and managed. The transition period can also be a challenging time for health professionals to assess readiness for transition and manage some of the complications which are particularly common during this time, including poor adherence to therapy, smoking, drug use, and emerging mental health conditions. The natural history, presentation, symptoms, and management of asthma is often significantly different when comparing pediatric and adult practice. In addition, management in infants, toddlers, school aged children, and adolescents differs significantly, offering an additional challenge to pediatric physicians managing asthmatic children and young people. Despite these challenges, if the transition process for young people with asthma is planned and performed in a formalized manner, many of these issues can be addressed, allowing the transition to occur smoothly despite changes that may occur in medical and psychosocial domains.

Improving the global diagnosis and management of asthma in children

Asthma is the most common chronic condition in children worldwide. It affects daytime activities, sleep and school attendance and causes anxiety to parents, families and other carers. The quality of asthma diagnosis and management globally still needs substantial improvement. From infancy to the teenage years, there are age-specific challenges, including both underdiagnosis and overdiagnosis with stigma-related barriers to treatment in some cultures and in adolescents. Guidelines are increasingly evidence based, but their impact on improving outcomes has been negligible in many parts of the world, often due to lack of implementation. New thinking is needed to enable substantial improvements in outcomes. The disease varies globally and plans will need to differ for individual countries or places where region-specific barriers prevent optimal care. A wide selection of educational activities is needed, including community-targeted initiatives, to engage with families. The Paediatric Asthma Project Plan has been initiated to strengthen diagnosis and management of asthma. This encompasses a vision for the next 10–15 years, building on the knowledge and experience from previous educational projects. It will take into account the educational needs of patients, carers and healthcare professionals as well as the accessibility and affordability of medication, particularly in low and middle-income countries where the prevalence of asthma is rising more rapidly. This overview presents a first step for those involved in the diagnosis and management of childhood asthma to strengthen care for children globally.

Prevalence of asthma and associated factors among male late adolescents in Tabriz, Iran

Asthma is an important chronic disease all over the world. The aim of this study was to determine the prevalence of asthma in a population of male late adolescents and its association with some contributing risk factors in northwest of Iran. This cross-sectional study was carried out in selected high schools of Tabriz, Iran, in 2016. The asthma prevalence and patient background information were examined using a questionnaire that prepared by the ISAAC. One hundred forty-two out of 1134 subjects (12.4%) identified to have asthma, 23.3% had history of current wheeze, and 16.3% had wheezing in the previous year. Family history of asthma was present in 17.1% of the participants; prevalence of active smoking in the study subjects was 3.1%; 25.1% of all subjects had exposure to secondhand tobacco smoke and keeping pets at home was present in 9.1%. Excess weight (overweight and obesity) was positively associated with prevalence of asthma (p < 0.001). No statistically significant associations were observed between asthma and father's education level (p = 0.570), mother's education level (p = 0.584), type of birth subjects (p = 0.571), and time spent outdoors during a full day (p = 0.863). Our results suggest that family history of asthma and atopy, exposure to secondhand tobacco smoke, active smoking, amount of automobile traffic around subjects' home, and keeping pets at homes are important risk factors for asthma, while time spent outdoors, educations of parents, and delivery type (normal vaginal delivery vs. C-section) subjects are not. Therefore, decreased of exposure to some environmental risk factors could be effective to reduce rate of the prevalence of asthma and wheeze.

Approaching Current and New Drug Therapies for Pediatric Asthma

As new therapies for pediatric asthma are approved by the Food and Drug Administration, clinicians should be aware of their benefits and limitations. Accompanying these therapies are potential obstacles, including the delivery of inhaled therapies and age-specific issues regarding implementation and adherence. New insights are being added to well-established controller medications, including inhaled corticosteroids and long-acting β-agonists, while new medications previously approved in adults, including tiotropium and biologics, are now being evaluated for use in children. These drugs can be useful additive therapies to treat patients who are currently not responding to guidelines-based therapy.

Accommodating interruptions: A grounded theory of young people with asthma

AIMS AND OBJECTIVES

The aim of this study was to develop an explanatory theory on the lives of young people with asthma, issues affecting them and the impact of asthma on their day-to-day lives.

BACKGROUND

Accommodating Interruptions is a theory that explains young people's concerns about living with asthma. Although national and international asthma management guidelines exist, it is accepted that the symptom control of asthma among the young people population is poor.

DESIGN

This study was undertaken using Classic Grounded Theory.

METHODS

Data were collected through in-depth interviews and clinic consultations with young people aged 11-16 years who had asthma for over 1 year. Data were also collected from participant diaries. Constant comparative analysis, theoretical coding and memo writing were used to develop the substantive theory.

RESULTS

The theory explains how young people resolve their main concern of being restricted by Accommodating Interruptions in their lives. They do this by assimilating behaviours in balance finding, moderating influence, fitting in and assuming control minimising the effects of asthma on their everyday lives.

CONCLUSION

The theory of Accommodating Interruptions explains young people's asthma management behaviours in a new way. It allows us to understand how and why young people behave the way they do because they want to participate and be included in everyday activities, events and relationships. The theory adds to the body of knowledge on how young people with asthma live their day-to-day lives and it challenges some existing viewpoints in the literature regarding their behaviours.

RELEVANCE TO CLINICAL PRACTICE

The findings have implications for developing services to support young people in a more meaningful way as they accommodate the interruptions associated with asthma in their lives.

What do adolescents with asthma really think about adherence to inhalers? Insights from a qualitative analysis of a UK online forum

OBJECTIVE

To explore the barriers and facilitators to inhaled asthma treatment in adolescents with asthma.

DESIGN

Qualitative analysis of posts about inhaler treatment in adolescents from an online forum for people with asthma. Analysis informed by the Perceptions and Practicalities Approach.

PARTICIPANTS

Fifty-four forum participants (39 adolescents ≥16 years, 5 parents of adolescents, 10 adults with asthma) identified using search terms 'teenager inhaler' and 'adolescent inhaler'.

SETTING

Posts from adolescents, parents and adults with asthma taking part in the Asthma UK online forum between 2006 and 2016, UK.

RESULTS

Practical barriers reducing the ability to adhere included forgetfulness and poor routines, inadequate inhaler technique, organisational difficulties (such as repeat prescriptions), and families not understanding or accepting their child had asthma. Prompting and monitoring inhaler treatment by parents were described as helpful, with adolescents benefiting from self-monitoring, for example, by using charts logging adherence. Perceptions reducing the motivation to adhere included asthma representation as episodic rather than chronic condition with intermittent need of inhaler treatment. Adolescents and adults with asthma (but not parents) described concerns related to attributed side effects (eg, weight gain) and social stigma, resulting in 'embarrassment of taking inhalers'. Facilitators to adherence included actively seeking general practitioners'/consultants' adjustments if problems arose and learning to deal with the side effects and stigma. Parents were instrumental in creating a sense of responsibility for adherence.

CONCLUSIONS

This online forum reveals a rich and novel insight into adherence to asthma inhalers by adolescents. Interventions that prompt and monitor preventer inhaler use would be welcomed and hold potential. In clinical consultations, exploring parents' beliefs about asthma diagnosis and their role in dealing with barriers to treatment might be beneficial. The social stigma of asthma and its role in adherence were prominent and continue to be underestimated, warranting further research and action to improve public awareness of asthma.

Low-Income Children, Adolescents, and Caregivers Facing Respiratory Problems: Support Needs and Preferences

Burdens of poverty are often compounded by respiratory problems. This study aimed to identify the support needs and intervention preferences for low-income families facing this challenge.

DESIGN AND METHODS

Interviews were conducted in two Canadian provinces with low-income children/adolescents (n=32) diagnosed with respiratory health problems and their parents or family caregiver (n=37).

RESULTS

These vulnerable children and parents described non-supportive interactions with some health service providers and inadequate information. They reported isolation and support deficits, exacerbated by limited resources and health restrictions. Children/adolescents felt isolated and excluded and wanted to connect with peers. Group or dyadic level support, delivered by peers and health professionals, was desired. The importance of logistics to enhance accessibility and appeal of group or dyadic support interventions was clearly identified.

CONCLUSIONS

The findings of this study reveal that low-income children and their families encounter challenges to accessing support and to utilizing support resources.

PRACTICE IMPLICATIONS

Partnerships with low-income children/adolescents and family caregivers in provision of education and social support can combat isolation and ignorance. Reducing inequities for this high risk population could be achieved by providing support from experienced peers, in combination with health professional guidance, and knowledge about pulmonary health.

Medicine use and disease control among adolescents with asthma

PURPOSE

Pharmacological treatment is a cornerstone in asthma management, but there is limited evidence on how adolescents use their medication and to what extent their asthma is under control. Therefore, the aim of this study was to compare self-reported and register-based medicine use in asthmatic adolescents. Furthermore, we investigated the association between medicine use, patient characteristics, and degree of asthma control.

METHODS

Cross-sectional analyses of 331 adolescents with asthma from a population-based birth cohort linked to data from the Swedish Prescribed Drug Register. Adolescents' asthma medicine use was assessed with three approaches: self-reported medicine use, self-reported use of someone else's medicines, and dispensed medicines from pharmacies during an 18-month period. Medicine use in adolescents with and without asthma control were compared.

RESULTS

In total, 82% reported use of asthma medicines, 10 % reported use of someone else's medicines, and 62% were dispensed asthma medicines from pharmacies. Among adolescents with self-reported medicine use, 22% (n = 60) were neither dispensed medicines nor using someone else's medicines. The majority of those using someone else's medicines had also been dispensed asthma medicine (22 out of 33). Among adolescents with asthma, 176 were fully controlled and 155 were uncontrolled. Also, boys had higher odds of having asthma control than girls.

CONCLUSION

Most adolescents with asthma reported use of asthma medicines, but a considerable proportion were neither dispensed any medicines nor using someone else's medicines. Girls were less likely to achieve asthma control. It is important to combine data sources to understand medicine use among adolescents with asthma.

Impact of symptom management training among asthmatic children and adolescents on self-efficacy and disease course

PURPOSE

The study was conducted to examine the effect of a training program provided to asthmatic children/adolescents on disease course and self-efficacy.

METHODS

This prospective study consisted of both experimental and control subjects. The study population was composed of children/adolescents aged 10-18 years, who presented at Health Centers within Tokat province with asthma and who were currently using inhaler treatments. The study sample included 40 patients each in both the control and experimental groups. Asthmatic Child Information Form, Disease Evaluation Form, Peak Expiratory Flow Rate Evaluation Form and an Asthmatic Child/Adolescent Self-Efficacy Scale were used to collect data on research outcomes. Data were statistically analyzed with paired sample t-test, McNemar's test, independent samples t-test.

RESULTS

A significant increase in mean self-efficacy score was observed in the experimental group following training sessions. The experimental training was also associated with a reduction in asthma symptoms, less limitations to daily function and fewer attacks following physical activity relative to the control subjects. The children/adolescents in the experimental group were more conscious of the symptoms of asthma attacks and used preventive and rescue medications regularly, and reported fewer absences from school and fewer emergency room visits (p < 0.05). The average peak expiratory flow rate was 62.5% in the experimental group. After training, there were significant decreases in the number of attacks and the need of increasing inhaler doses in the experimental group.

CONCLUSIONS

The study results show that the training program is effective in increasing self-efficacy and improving asthma symptoms among children/adolescents. Nurses should offer the training program to support children/adolescents during asthma attacks, and encourage the development of self-efficacy.

Bullying in medically fragile youth: a review of risks, protective factors, and recommendations for medical providers

Bullying is a common child and adolescent phenomenon that has concurrent and long-term implications for victims' psychological, psychosomatic, social, and academic functioning. Youth with chronic illnesses are at increased risk for being bullied, but few studies have evaluated specific risk and protective factors for medically fragile youth. Despite recommendations by the American Academy of Pediatrics and the Society for Adolescent Medicine that pediatric health care providers should contribute to bullying prevention and intervention efforts, researchers also have yet to identify the best ways for providers to intervene with medically fragile youth. In this article, the authors review risk and protective factors for bullying among healthy samples. Then, the authors specifically address the ways in which these risk and protective factors are likely to apply to children with fragile medical conditions, and they provide summaries of extant bullying research for selected examples of medically fragile pediatric populations. Finally, the authors present recommendations for intervening with medically fragile youth and suggest several areas in which additional research is needed.

Results from a community-based trial testing a community health worker asthma intervention in Puerto Rican youth in Chicago

Abstract Objective: Puerto Rican children suffer disproportionately from asthma. Project CURA tested the efficacy of a community health worker (CHW) intervention to improve use of inhaled corticosteroids (ICS) and reduce home asthma triggers in Puerto Rican youth in Chicago.

METHODS

This study employed a behavioral randomized controlled trial design with a community-based participatory research approach. Medications and technique were visually assessed; adherence was determined using dose counters. Home triggers were assessed via self-report, visual inspection and salivary cotinine. All participants received education on core asthma topics and self-management skills. Participants in the CHW arm were offered home education by the CHW in four visits over four months. The attention control arm received four newsletters covering the same topics.

RESULTS

While most of the participants had uncontrolled persistent asthma, <50% had ICS at baseline. In the CHW arms, 67% of participants received the full four-visit intervention. In the Elementary school cohort (n=51), the CHW arm had lower odds of having an ICS (OR=0.2; p=0.02) at 12-months; no differences were seen in other outcomes between arms at any time point. The only significant treatment arm difference in the high school cohort (n=50) was in inhaler technique where the CHW arm performed 18.0% more steps correct at five months (p<0.01) and 14.2% more steps correct at 12 months (p<0.01).

CONCLUSIONS

While this CHW intervention did not increase the number of participants with ICS or reduce home asthma triggers, important lessons were learned including challenges to CHW intervention fidelity and the need for CHWs to partner with clinical providers.

Adolescents' inhaled corticosteroid adherence: the importance of treatment perceptions and medication knowledge

BACKGROUND

Studies measuring inhaled corticosteroid (ICS) adherence frequently report adherence rates below 50%. Although asthma is common in adolescents, few studies have explored determinants of ICS adherence in adolescents. The objective of this study was to examine adherence and related factors in adolescent ICS users.

METHODS

Adolescent ICS users, aged 12-18 years, were randomly recruited from a sample of 94 community pharmacies belonging to the Utrecht Pharmacy Practice Network for Education and Research to complete an online questionnaire. The survey contained questions on asthma control, self-reported adherence, medication beliefs and medication knowledge. Data were collected between April and August 2013.

RESULTS

Complete questionnaire data were received from 182 adolescents of which 40% reported to be adherent. Approximately 40% of the participants perceived strong needs, whilst only 10% was highly concerned about adverse effects regarding their ICS use. Good adherence was significantly associated with asthma control (OR: 2.1, 95% CI: 1.1-4.1). Necessity beliefs and sufficient medication knowledge were associated with better adherence (p < 0.05).

CONCLUSION

Our results suggest that by improving knowledge about asthma treatments and stimulating positive perceptions towards medicines, especially regarding the necessity of medication use, better adherence rates might be achieved.

Factors associated with concordance between parental-reported use and dispensed asthma drugs in adolescents: findings from the BAMSE birth cohort

PURPOSE

Pharmacological treatment is important in asthma care, but there are methodological challenges in measuring how drugs are used by patients. The aim of this study was to investigate the concordance between register data on dispensed drugs and parental-reported use of asthma drugs in adolescents.

METHODS

A cross-sectional study comparing data on dispensed drugs from the Swedish Prescribed Drug Register with data on parental-reported use of asthma drugs among 3 316 adolescents (age 11-14 years) in a population-based birth cohort in Sweden. Sensitivity, specificity, and positive predicted value for different time windows (3, 6, 12, 18, and 24 months) for dispensing in the register were computed. Logistic regression was used to explore factors associated with concordance.

RESULTS

The prevalence of parental-reported use of asthma drugs in the past year was 10.7% (n = 356) compared with 8.1% (n = 269) for dispensed drugs according to the register (p ≤ 0.001). The sensitivity increased with an extended time window in the register, whereas the specificity remained high up to 18 months. Although 90% of the adolescents with asthma had parental-reported use of asthma drugs, 30% of them had no such drugs dispensed in the preceding 18 months. The highest concordance was seen for adolescents with severe asthma (OR 4.6, CI 1.2-17.6).

CONCLUSIONS

An 18-month window is preferable when using dispensing data to study the use of asthma drugs. Still, many adolescents with reported drug use had not purchased any asthma drug in this period. The concordance between parental-reported use and dispensed drugs is higher for adolescents with severe asthma.

Attitudes towards medication use in a general population of adolescents

Adolescents are becoming more independently responsible for their medication regimen; therefore, adolescence is a crucial period to address medication beliefs, as many of the beliefs may persist into adulthood and can impair adherence and willingness to continue a prescribed therapy. Within this study, we aimed to explore adolescents' general perceptions towards medicines. Adolescent students attending secondary schools in the Netherlands were invited through the school's virtual learning environment to fill in an online questionnaire. Medication beliefs were assessed using the Beliefs About Medicines Questionnaire-General assessing general harm and general overuse beliefs. Within a 2-week period, 434 adolescent students responded to the questionnaire; 47.2 % thought that doctors overprescribed medication, and 20.5 % perceived medication as harmful in general. Being religious was associated with stronger harm (odds ratio (OR) 2.0, 95 % confidence interval (CI) 1.2-3.2) and overuse beliefs (OR 1.4, 95 % CI 0.9-2.1). Adolescents of native background had less concerns about overuse (OR 0.4, 95 % CI 0.2-0.8). Adolescents who actually consulted physicians had lower overuse beliefs (OR 0.6, 95 % CI 0.4-1.0).

CONCLUSION

Adolescents more strongly believe in the general overuse of medicines than in general harm. Religious and ethnic background influence medication beliefs, as does previous experiences with the health-care system. Gaining more insight in adolescent patients' medication use behavior and identifying patients at risk for negative medication beliefs associated with poor adherence in clinical practice might be a first step towards a lifelong good medication use.

Improving outcomes for underserved adolescents with asthma

BACKGROUND AND OBJECTIVE

Asthma is the most common chronic disease of childhood. Treatment adherence by adolescents is often poor, and their outcomes are worse than those of younger patients. We conducted a quality improvement initiative to improve asthma control and outcomes for high-risk adolescents treated in a primary care setting.

METHODS

Interventions were guided by the Chronic Care Model and focused on standardized and evidence-based care, care coordination and active outreach, self-management support, and community connections.

RESULTS

Patients with optimally well-controlled asthma increased from ∼10% to 30%. Patients receiving the evidence-based care bundle (condition/severity characterized in chart and, for patients with persistent asthma, an action plan and controller medications at the most recent visit) increased from 38% to at or near 100%. Patients receiving the required self-management bundle (patient self-assessment, stage-of-readiness tool, and personal action plan) increased from 0% to ∼90%. Patients and parents who were confident in their ability to manage their or their adolescent's asthma increased from 70% to ∼85%. Patient satisfaction and the mean proportion of patients with asthma-related emergency department visits or hospitalizations remained stable at desirable levels.

CONCLUSIONS

Implementing interventions focused on standardized and evidence-based care, self-management support, care coordination and active outreach, linkage to community resources, and enhanced follow-up for patients with chronically not-well-controlled asthma resulted in sustained improvement in asthma control in adolescent patients. Additional interventions are likely needed for patients with chronically poor asthma control.

Symptoms, feelings, activities and medication use in adolescents with uncontrolled asthma: lessons learned from asthma diaries

This study was to describe symptoms, feelings, activities and medication use reported by adolescents with uncontrolled asthma on their 24-hour asthma diaries. Adolescents with uncontrolled asthma (13-17 years, N=29) completed asthma diaries and audio-recorded symptom sounds for 24 hours. A variety of symptoms were reported, and the most frequently reported symptoms were coughing followed by wheezing. Most self-reported coughing and wheezing were verified by audio-recordings. Participants reported predominantly negative feelings and low levels of activities. High discordance between self-reports and medical records in medications was noted, raising a concern of poor treatment adherence in this vulnerable group.

Experiences of living with asthma - a focus group study with adolescents and parents of children with asthma

OBJECTIVE

The goal for asthma treatment is that every individual, so far as possible, shall live without symptoms and exacerbations. Patients and health care professionals sometimes have different perceptions of what is important for achieving good quality of life. This work aims to describe the experiences among adolescents as well as those of parents with young children living with asthma.

METHODS

Four focus group interviews were performed, two with parents of young children and two with adolescents. The data were qualitatively analyzed, using Systematic Text Condensation.

RESULT

Three themes relevant to the participants' experiences of living with asthma were presented; strategies, frustrations and expectations. The adolescents wanted to be like their peers and developed their own strategies for self-management of asthma, which included not always taking medication as prescribed. The parents emphasized frustration regarding not being believed, lack of understanding feelings of loneliness, or anxiety. One identified expectation was that the participants wanted to be met with competence and understanding in asthma care from health care professionals. Another expectation expressed among parents was that teachers in nursery and primary schools should have more knowledge and understanding on how to care for children with asthma.

CONCLUSION

Living with asthma leads to developing personal strategies in self-management of asthma. Moreover both parents and adolescents had expectations of being met by competent and understanding health care professionals. Developing a partnership between patients and health care professionals could be a successful way to improve the care of patients with asthma.

Using Orem's self-care model for asthmatic adolescents

PURPOSE

The aim of the study was to determine the effect of Orem's self-care model on the self-care of adolescents with asthma.

DESIGN AND METHODS

In this experimental design, adolescents with asthma (N = 80) received home visits and individualized care based on theory-guided nursing diagnoses. Patients in the experimental group were visited in their homes eight times, and those in the control group were visited two times.

RESULTS

The five self-care skills of medicine usage, peak expiratory flow meter usage, applying an asthma action plan, keeping a daily follow-up schedule, and protecting against triggering factors differed significantly between the first and last visits in the experimental group, whereas the self-care skills of adolescents in the control group did not change.

PRACTICE IMPLICATIONS

Applying Orem's self-care model increased the self-care skills of adolescents with asthma.

Time and risk preferences and the use of asthma controller medication

OBJECTIVES

We investigated the role of risk tolerance, time preference, and asthma-specific attitudes in adherence to asthma control medications.

METHODS

Students with persistent asthma completed an online survey on asthma beliefs, risk tolerance, and time preference (n = 47). The time preference questions measure the degree to which the individual discounts future outcomes and essentially prefers immediate gratification to delayed gratification. The risk tolerance questions indicate the individual's dislike of uncertainty about outcomes. We analyzed the relationship between the independent and dependent variables.

RESULTS

Feelings of embarrassment and concern about medication, as well as risk tolerance and time preference, were found to be significant predictors of adherence to control medication in the logistic regression. Analysis of probabilities associated with different profiles shows that at high rates of risk tolerance and discounting of future outcomes, the probability of adherence is near 0 regardless of asthma-specific attitudes. Asthma attitudes have a statistically significant effect for individuals with low rates of risk tolerance and time preference.

CONCLUSIONS

The risk tolerance and time preferences of the target group should be considered when designing an asthma-intervention program. Individuals who strongly prefer immediate gratification over future benefits and are willing to tolerate uncertain outcomes are unlikely to adhere to controller medication, regardless of their asthma attitudes. In contrast, efforts to affect relevant attitudes will be most fruitful for individuals with low rates of risk tolerance and time preference. However, as we cannot extrapolate these results to a larger population, we must view them with caution.

Support needs and preferences of young adolescents with asthma and allergies: "just no one really seems to understand"

The objectives of this study were to identify support needs, support resources, and support barriers for young adolescents with asthma and allergies and to describe preferences for an accessible support intervention. Adolescents (N = 57) completed a survey questionnaire. Eight young adolescents, 10 parents, and 5 older adolescents participated in separate group interviews. Young adolescents' challenges included transition to self-care, balancing restrictions with safety, social isolation, and loneliness. Young teens recommended supportive networks facilitated by older adolescent peers and wanted to meet with other young adolescents living with asthma and allergies online and share information, advice, and encouragement with them.

Impact of online support for youth with asthma and allergies: pilot study

Youth with asthma and allergies often feel isolated and different from their peers. The objective of this study was to test the impact of online social support for these youth. Three months of support was provided using weekly synchronous chat sessions. Online sessions were facilitated by trained peer mentors (older youth with asthma and/or allergies) and health professionals. Youth could also e-mail one another between chat sessions and post messages on an electronic community bulletin board. Twenty-eight adolescents across Canada participated. Social isolation and loneliness were significantly reduced. Youth reported gaining confidence and a sense of normality.

Peer-led education for adolescents with asthma in Jordan: a cluster-randomized controlled trial

OBJECTIVES

To determine the impact of a peer-led education program, developed in Australia, on health-related outcomes in high school students with asthma in Jordan.

METHODS

In this cluster-randomized controlled trial, 4 high schools in Irbid, Jordan, were randomly assigned to receive the Adolescent Asthma Action program or standard practice. Bilingual health workers trained 24 peer leaders from Year 11 to deliver asthma education to younger peers from Year 10 (n = 92), who in turn presented brief asthma skits to students in Years 8 and 9 (n = 148) and to other members of the school community in the intervention schools. Students with asthma (N = 261) in Years 8, 9, and 10 completed baseline surveys in December 2006 and 3 months after the intervention.

RESULTS

Students from the intervention group reported clinically significant improvements in health-related quality of life (mean difference: 1.35 [95% confidence interval: 1.04-1.76]), self-efficacy to resist smoking (mean difference: 4.63 [95% confidence interval: 2.93-6.35]), and knowledge of asthma self- management (mean difference: 1.62 [95% confidence interval: 1.15-2.19]) compared with the control group.

CONCLUSIONS

This trial demonstrated that the Adolescent Asthma Action program can be readily adapted to suit different cultures and contexts. Adolescents in Jordan were successful in teaching their peers about asthma self-management and motivating them to avoid smoking. The findings revealed that peer education can be a useful strategy for health promotion programs in Jordanian schools when students are given the opportunity and training.

Patient-centered care and its effect on outcomes in the treatment of asthma

Patient-centered care may be pivotal in improving health outcomes for patients with asthma. In addition to increased attention in both research and clinical forums, recent legislation also highlights the importance of patient-centered outcomes research in the Patient Protection and Affordable Care Act. However, whether patient-centered care has been shown to improve outcomes for this population is unclear. To answer this question, we performed a systematic review of the literature that aimed to define current patient-focused management issues, characterize important patient-defined outcomes in asthma control, and identify current and emerging treatments related to patient outcomes and perspectives. We used a parallel search strategy via Medline(®), Cochrane Central Register of Controlled Trials, CINAHL(®) (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO(®), complemented with a reference review of key articles that resulted in a total of 133 articles; 58 were interventions that evaluated the effect on patient-centered outcomes, and 75 were descriptive studies. The majority of intervention studies demonstrated improved patient outcomes (44; "positive" results); none showed true harm (0; "negative"); and the remainder were equivocal (14; "neutral"). Key themes emerged relating to patients' desires for asthma knowledge, preferences for tailored management plans, and simplification of treatment regimens. We also found discordance between physicians and patients regarding patients' needs, beliefs, and expectations about asthma. Although some studies show promise regarding the benefits of patient-focused care, these methods require additional study on feasibility and strategies for implementation in real world settings. Further, it is imperative that future studies must be, themselves, patient-centered (eg, pragmatic comparative effectiveness studies) and applicable to a variety of patient populations and settings. Despite the need for further research, enough evidence exists that supports incorporating a patient-centered approach to asthma management, in order to achieve improved outcomes and patient health.

Adolescents with asthma: consequences of transition from paediatric to adult healthcare

PURPOSE

A prospective follow-up of adolescents with asthma designed to identify risk factors for deterioration during and after transfer from paediatric to adult healthcare.

METHODS

Adolescents (n=150) with asthma being transferred from paediatric to adult healthcare were recruited consecutively and those with mild/moderate asthma assigned randomly to primary care or specialized care at an adult asthma clinic. Tests of pulmonary function, bronchial responsiveness and working capacity and skin prick tests were performed at the time of entry into the study and two and/or five years later.

RESULTS

Initially, 88.7% of the subjects demonstrated at least one positive skin prick test. During the five-year follow-up, FEV(1) improved, while FEV(1)/FVC remained unchanged. Bronchial hyperresponsiveness was present in 71% of the subjects at the time of inclusion and 59% five years later, while 20 developed hyperresponsiveness during this period. Poor adherence to treatment, female gender and inhalation of steroids exerted negative impacts on logPD(20). The risk for persistence of bronchial hyperresponsiveness was elevated by poor adherence and attenuated by regular exercise. The decline observed in working capacity demonstrated no correlation to the risk factors examined. Subjects with mild/moderate asthma who received primary or specialized care exhibited similar pulmonary function, responses to a histamine challenge and working capacities.

CONCLUSIONS

During a five-year follow-up of asthmatic adolescents leaving paediatric care, pulmonary function rarely deteriorated, but bronchial hyperresponsiveness persisted. Female gender and poor adherence to treatment exerted negative impact on bronchial hyperresponsiveness. Mild/moderate asthma was managed equally effectively with primary or specialized care.

Barriers to asthma self-management in adolescents: Relationships to psychosocial factors

Asthma morbidity in adolescents often results from inadequate asthma self-management. This study was to explore barriers to self-management perceived by adolescents and to examine the associations between barriers and psychosocial factors including knowledge, attitude and self-efficacy. This cross-sectional study included a total of 126 adolescents with asthma (13-20 years) representing diverse race/ethnicity groups with a wide range of socioeconomic status. Self-reported data were analyzed using descriptive statistics, factor analysis and hierarchical regression. The most frequently endorsed barrier (63%) was adolescents' unwillingness to give up "the things the doctors say I have to give up," followed by difficulty in remembering to take care of their asthma (53%), and then "trying to forget" that they have asthma (50%). Psychosocial factors accounted for 32% of the variance in total barrier perceptions. Factor analysis revealed barriers in four domains including negativity toward providers and the medication regimen, cognitive difficulty, peer/family influence and denial. Self-efficacy was found to be the most influential factor that showed strong negative associations with all four barrier subscales independent of the levels of asthma control and sociodemographic characteristics. Poor attitudes toward asthma were also associated with barriers of cognitive difficulty and social influence after adjusting for other factors. Males consistently reported higher total barriers and barriers of negativity, social influence and denial. The gender differences were not explained by psychosocial and sociodemographic factors. This study suggests that psychosocial factors are strong predictors of barriers to self-management in adolescents. Particularly, promoting self-efficacy may be beneficial in addressing the barriers. Special attention is needed to address the higher propensity for barriers in males.

Transition of care from paediatric to adult services in haematology

The need for adequate preparation for transition for young people with health care needs who require long term follow-up in the adult sector has long been recognised and is a required part of the national service framework for children. The Royal College of Paediatrics and Child Health and the Royal College of Nursing have endorsed this need for improvement in services for adolescents. In 2006 the Department of Health launched guidelines with a wealth of recommendations. Despite these initiatives only slow progress has been made (usually by enthusiasts) and much work is needed to develop good programmes in many specialties, including non-malignant haematology.

The challenge of asthma in adolescence

The adolescents with asthma are a distinct group of patients with different problems and needs compared to children and adults. Specific issues of asthma in adolescence are the variability of the clinical spectrum, the presence of particular risk factors for the persistence of symptoms, underdiagnosis and undertreatment of the disease. Refusal of the sick role, denial of symptoms, carelessness about dangerous inhalation exposure, erratic self-medication, overexertion without taking precautions against exercise-induced asthma, and a poor relationship between patients, their families, and often doctors are the main obstacles to successful management of asthma in this critical age. There are also major problems of compliance for these patients. The goal of optimal quality of life will be achieved only if the physician thoroughly understands the adolescent's needs and provides optimal care.

Assisting teens with asthma to take command

To meet and work with teenagers may be a challenge for caregivers as adolescence is a period when youths try to establish autonomy. Although asthma is an increasing problem worldwide, few studies have addressed professional caregivers' motives and actions. Therefore, the aim of this study was to describe professional caregivers' strategies in their work with teenagers with asthma. Grounded theory, inspired by Glaser, was used to uncover the phenomenon. The informants were seven professional caregivers who worked at an eight-day asthma camp for teenagers in Sweden. Participant observations and interviews were used, and the first author collected the data and participated in the activities. Findings show that professional caregivers' core concern is to assist teenagers with asthma to take command. This core concern gives rise to five strategies: showing respect, being at hand, promoting own responsibility, promoting to exceed boundaries and promoting reflections. In professional caregivers' attempt to assist teenagers to take command some differences are seen in the way they support boys and girls. One conclusion drawn from our study is that the provisional theory of 'Assisting teenagers with asthma to take command' is not only suitable for professional caregivers working at asthma camps; it may, in some degree, also be used as a source of inspiration for professional caregivers in other settings.

Not letting the disease get the upper hand over life: strategies of teens with asthma

Adolescence is a period when teens normally revolt against being dependent. For teens with asthma this period may be even more difficult to deal with, as they also have to deal with their illness. Since few studies describe this phenomenon, the aim of this study was to provide a theoretical understanding of how teens with asthma manage their everyday life in relation to their disease. A grounded theory research design, according to Glaser, was used to uncover the phenomenon. The study was undertaken at a camp for teenagers with asthma during the summer of 2003. Twelve girls and 11 boys with moderate to severe asthma participated in the study. Participant observations and interviews were used, and the first author collected the data and participated in the activities. The findings reveal a theoretical model which shows that teens' core concern is not to let the disease get the upper hand over life. To manage this core concern the teens were found to use three strategies: keeping a distance to the disease, challenging the disease and taking the disease into consideration. Boys mainly kept a distance to the disease while girls mainly kept the disease into consideration. Challenging the disease seemed to be a strategy used by both girls and boys. The teens' strategies were not studied close to their everyday life, but a conclusion drawn from our study was that the provisional theory in many respects can be transferred to their everyday life, even though further research is needed to develop this provisional theory in other settings.

Management, asthma control and quality of life in Swedish adolescents with asthma

AIM

In Sweden, paediatricians or general practitioners treat most adolescents with asthma. This study compares management, treatment goals and quality of life for adolescents aged 15-18 y in paediatric or primary care.

MATERIAL AND METHODS

A random sample of patients answered a disease-specific and a quality-of-life (MiniAQLQ) questionnaire.

RESULTS

The 146 adolescents in paediatric care had more years with asthma, better continuity of annual surveillance, higher use of inhaled steroids and a stated better knowledge of their asthma than the 174 patients in primary care. No difference could be detected in asthma control or quality of life. Of all 320 adolescents, approximately 20% had woken at night due to asthma symptoms during the last week. About 15% had made unscheduled, urgent care visits and a third had used short-acting beta-agonist relievers more than twice a week. Quality-of-life scores were high and similar in both settings.

CONCLUSIONS

Swedish adolescents with asthma are managed and treated somewhat differently in paediatric and primary care but with equal and, for the most part, satisfying results. The difference between the two settings probably reflects both differences in severity of asthma and different treatment traditions. For all adolescents, better fulfilment of goals regarding symptoms and exacerbations would be desirable, whereas a good quality of life including normal physical activity seems to have been achieved.

Paediatric asthma: overcoming barriers to an improved quality of life

Paediatric asthma has a considerable impact on both society, in terms of healthcare resources, and patients and their families, in terms of impaired quality of life. The principal goals of asthma treatment are to achieve and maintain control of symptoms. Achieving these goals may involve long-term use of appropriate medication in the form of an inhaled corticosteroid (ICS) and a long-acting ss-agonist (LABA). However, many patients with paediatric asthma are not currently achieving symptom control. The main barriers to asthma control are underuse of effective therapies, inappropriate choice of drug delivery devices and a lack of patient or parent/guardian education regarding the disease and its treatment. By addressing and overcoming these barriers to asthma control, the quality of life of patients and their families may be significantly improved.

Safety of the newer inhaled corticosteroids in childhood asthma

Inhaled corticosteroids (ICS) remain a vital part of the management of persistent asthma, but concerns have been raised about their potential adverse effects in children. This review examines the safety data on three new ICS - fluticasone propionate, mometasone, and extrafine beclomethasone in hydrofluoroalkane (HFA-134a) propellant (QVAR The use of tradenames is for product identification purposes only and does not imply endorsement. formulation) in relation to the older corticosteroids. Topical adverse effects such as thrush and dysphonia are rare, but dental erosion is a possibility with powder forms of ICS because of their low pH. Thus, it is important to stress mouth rinsing after administration and maintaining good dental hygiene to minimize this risk. Biochemical adrenal suppression can be readily demonstrated, particularly with high doses of all ICS. The clinical relevance of this was uncertain in the past, but there have now been >50 reported cases of acute adrenal crises in children receiving ICS, most of whom were on fluticasone propionate. In order to minimize the risk of symptomatic adrenal suppression, it is important to back-titrate the ICS dose and alert families of children receiving high-dose ICS of this potential adverse effect. A pediatric endocrine opinion should be sought if adrenal suppression is suspected. The older ICS cause temporary slowing of growth velocity, but the limited data available do not show any significant compromise of final adult height. The effect on growth of fluticasone propionate may not be as great as with the older ICS, but the studies have been short term and only used low doses of fluticasone propionate. There have been case reports of growth suppression in children receiving high doses of fluticasone propionate. The limited studies performed on the effect of ICS on bone mineral density in children did not show any adverse effects, but there may be an increased risk of fractures. Hydrofluoroalkane beclomethasone (QVAR) is essentially the same drug as chlorofluorocarbon beclomethasone, but with double the lung deposition owing to the smaller particle size. Thus, it could be expected that any adverse effects seen with chlorofluorocarbon beclomethasone would be the same with hydrofluoroalkane beclomethasone. However, some of the published data, particularly in adults, suggest that hydrofluoroalkane beclomethasone may be less systemically active than chlorofluorocarbon beclomethasone, even at equipotent doses. As yet, there are no long-term data on mometasone, but initial studies in adults suggest there may be less suppression of the hypothalamic-pituitary-adrenal axis, although further studies are required, particularly in children.ICS will remain a cornerstone in the management of persistent pediatric asthma, provided that the diagnosis of asthma is secure. It is very important to use ICS appropriately and to ensure the lowest possible doses are used to achieve symptom control, thus minimizing the risk of serious adverse effects.