Poor asthma control in children: evidence from epidemiological surveys and implications for clinical practice

Parents' Beliefs about Medicines and Their Influence on Inhaled Corticosteroid Adherence in Children with Asthma

The most widespread chronic condition observed amid children globally is asthma. Only half of children with asthma adhere to their prescribed inhaled corticosteroids (ICS) therapy. Parents' emotions and perspectives regarding asthma have an impact on inhalation corticosteroid adherence. The participants in this study were 148 parents of children with asthma, with the aim to redintegrate their beliefs about medicines in general and specifically of ICS and the impact on ICS adherence in children with asthma. Children were mostly male (66.9%), older than five years (58.8%), parents were female, mean age 38, employed, and with a history of consumption of some form of corticosteroids. Parents' answers show that 50% of them disagreed with the statement that medicines are addictive, and 90% agree that medicine helps many to live better. A percentage of 77.7% of parents acknowledge that their child's health relies on inhaled corticosteroids (ICS), and 86.5% of parents agree that these medications safeguard their child from worsening health. Most of the parents (93.2%) adhere to the guidelines and instructions of the doctor. In summary, parents who hold the belief that medicines are neither overused nor harmful tend to exhibit a higher adherence. Furthermore, those with elevated adherence levels express lower levels of concern regarding the use of inhaled corticosteroids (ICS) in their children's asthma therapy.

The external validation of the asthma prediction tool in the French ELFE cohort

BACKGROUND

Existing predictive scores for early identification of children at high risk of developing asthma include invasive procedures, and hence have limited utility in a primary care setting. The Leicestershire respiratory cohort (LRC) has developed a noninvasive asthma prediction tool (APT) for children with promising results. We aimed to perform its external validation in the French general population Étude Longitudinale Française depuis l'Enfance (ELFE) cohort.

METHODS

Predictive scores were determined at Age 1 and the primary outcome of asthma was defined as parental reporting of "asthma ever or "wheezing in the past 12 months" at Age 5. Logistic regression was used to calculate the odds ratio (OR) and performance measures, and discriminative performance was reported using the receiver operating curve and area under curve (AUC). Calibration was assessed using Hosmer-Lemeshow goodness-of-fit test and visualized with a calibration plot. Overall performance was determined using Brier scores.

RESULTS

Of the 10,689 children analyzed: 84.9% were at low, 13.1% medium, and 2% at high risk of developing asthma at Age 5. Children in the medium-risk category were three times more likely to develop asthma (OR = 3.3, 95% confidence interval [CI] = 2.97-3.78) whereas 13 times more likely in the high-risk category (OR = 13.8, 95% CI = 10.2-18.8). The tool's AUC was comparable: LRC 0.74 versus ELFE 0.68; as were the Brier scores LRC 0.16 versus ELFE 0.14. The tool's performance was robust to changes in inclusion criteria and outcome definitions.

CONCLUSIONS AND RELEVANCE

Results of the present study and previous validation studies performed in high-risk populations provide a comprehensive measure of the effectiveness of the APT, providing encouragement for its application by general practitioners.

Heterogeneous Condition of Asthmatic Children Patients: A Narrative Review

Currently, asthma represents the most common chronic disorder in children, showing an increasingly consistent burden worldwide. Childhood asthma, similar to what happens in adults, is a diversified disease with a great variability of phenotypes, according to genetic predisposition of patients, age, severity of symptoms, grading of risk, and comorbidities, and cannot be considered a singular well-defined disorder, but rather a uniquely assorted disorder with variable presentations throughout childhood. Despite several developments occurring in recent years in pediatric asthma, above all, in the management of the disease, some essential areas, such as the improvement of pediatric asthma outcomes, remain a hot topic. Most treatments of the type 2 (T2) target phenotype of asthma, in which IL-4, IL-5, and IL-13 modulate the central signals of inflammatory reactions. Although, there may be an unresolved need to identify new biomarkers used as predictors to improve patient stratification using disease systems and to aid in the selection of treatments. Moreover, we are globally facing many dramatic challenges, including climate change and the SARS-CoV2 pandemic, which have a considerable impact on children and adolescent asthma. Preventive strategies, including allergen immunotherapy and microbiome evaluation, and targeted therapeutic strategies are strongly needed in this population. Finally, the impact of asthma on sleep disorders has been reviewed.

Pharmacogenomics and Pediatric Asthmatic Medications

Asthma is a respiratory condition often stemming from childhood, characterized by difficulty breathing and/or chest tightness. Current treatment options for both adults and children include beta-2 agonists, inhaled corticosteroids (ICS), and leukotriene modifiers (LTM). Despite recommendations by the Global Initiative for Asthma, a substantial number of patients are unresponsive to treatment and unable to control symptoms. Pharmacogenomics have increasingly become the front line of precision medicine, especially with the recent use of candidate gene and genome- wide association studies (GWAS). Screening patients preemptively could likely decrease adverse events and therapeutic failure. However, research in asthma, specifically in pediatrics, has been low. Although numerous adult trials have evaluated the impact of pharmacogenomics and treatment response, the lack of evidence in children has hindered progress towards clinical application. This review aims to discuss the impact of genetic variability and response to asthmatic medications in the pediatric population.

The Role of Education, Monitoring, and Symptom Perception in Internet-Based Self-management Among Adolescents With Asthma: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Internet-based self-management programs improve asthma control and the asthma-related quality of life in adults and adolescents. The components of self-management programs include education and the web-based self-monitoring of symptoms; the latter requires adequate perception in order to timely adjust lifestyle or medication or to contact a care provider.

OBJECTIVE

We aimed to test the hypothesis that adherence to education and web-based monitoring and adequate symptom perception are important determinants for the improvement of asthma control in self-management programs.

METHODS

We conducted a subgroup analysis of the intervention group of a randomized controlled trial, which included adolescents who participated in the internet-based self-management arm. We assessed the impacts that attendance in education sessions, the frequency of web-based monitoring, and the level of perception had on changes in asthma control (Asthma Control Questionnaire [ACQ]) and asthma-related quality of life (Pediatric Asthma Quality of Life Questionnaire) from baseline to 12 months after intervention.

RESULTS

Adolescents who attended education sessions had significant and clinically relevant improvements in asthma control (ACQ score difference: -0.6; P=.03) and exhibited a nonsignificant trend of improvement in asthma-related quality of life (Pediatric Asthma Quality of Life Questionnaire score difference: -0.45; P=.15) when compared to those who did not adhere to education. Frequent monitoring alone did not improve asthma control (P=.07) and quality of life (P=.44) significantly, but its combination with education did result in improved ACQ scores (difference: -0.88; P=.02). There were no significant differences in outcomes between normoperceivers and hypoperceivers.

CONCLUSIONS

Education, especially in combination with frequent web-based monitoring, is an important determinant for the 1-year outcomes of asthma control in internet-based self-management programs for adolescents with partly controlled and uncontrolled asthma; however, we could not establish the effect of symptom perception. This study provides important knowledge on the effects of asthma education and monitoring in daily life.

Are we overcoming our inability to have pediatric patients properly use inhaled corticosteroids by inappropriately escalating their therapy?

OBJECTIVE

To perform a narrative review to describe and discuss potential methods and strategies for effectively assessing and dealing with poor adherence and/or misuse of inhalers in difficult-to-treat pediatric asthmatic patients.

DATA SOURCES

Articles available in electronic databases, published from inception to April 2021.

STUDY SELECTIONS

Relevant articles in the literature that discuss and analyze potential methods and strategies for effectively assessing and dealing with poor adherence and/or misuse of inhalers in difficult-to-treat pediatric asthmatic patients.

RESULTS

Validated self-reported questionnaires, weighing inhaler canisters, and pharmacy records might be the most suitable methods for assessing adherence to inhaled controller therapy in clinical practice. Additionally, validated instruments could be used as an objective measurement of the adequacy of inhaler technique. Finally, empathy and a true and strong physician-parent/patient partnership have a more powerful influence on adherence than almost any other factor, and they are probably the most cost-effective methods not only for detecting poor adherence to controller therapy but also for dealing with and improving it.

CONCLUSIONS

Failure to detect or effectively handle nonadherence and/or inhaler misuse in a patient with uncontrolled asthma can mislead clinicians into thinking that the patient is nonresponsive to the original less-intensive therapy, resulting in unneeded dosage increases and/or escalation of controller therapy to more costly medications, in some cases reaching the level of biologic therapy.

An approach to the management of children with problematic severe asthma

Children with poor asthma control despite high levels of prescribed treatment are described as having problematic severe asthma. Most of these children have steroid sensitive disease which improves with adherence to daily inhaled corticosteroids and after having removed modifiable factors like poor inhalation technique, persistent adverse environmental exposures and psychosocial factors. These children are described as having “difficult-to-treat asthma” while children with persistent symptoms despite above-mentioned factors having been addressed are described as having “severe therapy-resistant asthma”. In this review, we will describe the 6-step approach to the diagnosis and management of a child with problematic severe asthma adopted by The Royal Brompton Hospital (London, UK). The role of a multidisciplinary team is crucial for identification and treatment of modifiable factors and comorbidities in order to avoid invasive examinations and useless pharmacological treatments. The current knowledge on add-on therapies will be discussed.

Medical Neglect as a Contributor to Poorly Controlled Asthma in Childhood

Child maltreatment, including medical neglect, is a frequent contributor to the development of asthma as well as a barrier to its proper management. This article aims to review the role of medical neglect as a contributor to poor asthma control. Medical neglect can present as failure of the caretaker to recognize severe asthma symptoms in a child, non-adherence to medical management, failure to prevent chronic exposure to allergens or tobacco smoke, poor child nutrition leading to obesity, and allowing a young child to manage his/her illness without supervision. This article will explore the different factors leading to medical neglect (as illustrated by two cases) and suggest possible interventions aiming to prevent emergency department visits, hospitalizations, and asthma-related deaths.

Expiratory variability index (EVI) is associated with the severity of acute bronchial obstruction in small children: A proof-of-concept study

BACKGROUND

Lung function testing in small children is cumbersome. However, reduced variability of tidal breathing recorded using impedance pneumography (IP) during sleep was recently found to be a potential objective marker of wheeze in children aged 1-5 years. We aimed to investigate how an acute bronchial obstruction (BO) and its severity, and recovery thereof reflect in expiratory variability index (EVI).

METHODS

EVI was measured using a wearable IP system (Ventica®) during sleep in 40 healthy controls (aged 1.5-5.9 years) and 30 patients hospitalized due to acute BO (aged 1.3-5.3 years). In healthy controls, EVI was measured for 1-3 nights at their homes. Patients were measured for several nights during hospitalization, as practically feasible, and at home 2 and 4 weeks post-discharge.

RESULTS

We received 79 EVI results from 39 controls and 139 from 30 patients. 90% had previous BO episodes, 30% used asthma controller medication before and 100% after hospitalization. Compared to controls, EVI was significantly lower during hospitalization (P < .0001) having significant correlation with number of days to discharge (r = -.38, P = .004). At 2 or 4 weeks post-discharge, EVI was not significantly different from the controls (P = .14, P = .49, respectively). EVI was significantly associated with chest auscultation findings (P = .0001) being 17.5 (4.9) (median, IQR) with normal auscultation, 15.6 (7.4) in those with prolonged expiration and 11.4 (6.8) in those with wheeze and/or rales and crackles.

CONCLUSIONS

EVI was found to be a sensitive, objective marker of acute BO, showing strong association with changes in clinical status in wheezy children aged 1-5 years.

Maternal common mental disorder over time and asthma control: The role of social support

BACKGROUND

Despite therapeutic advances, asthma prevalence remains high. Psychosocial factors, including maternal mental disorders, may be involved. This study aims to evaluate the association of maternal common mental disorders (CMDs) and their change over time with asthma morbidity in the child and to observe the effect of social support on this association.

METHODS

This prospective study involved 189 dyads of mothers and their asthmatic children aged between 2 and 14 years, assisted in specialized outpatient clinics. We measured the association of maternal CMD evolution (absent, maintained, or improved over time) with asthma control and visits to the emergency department (ED) due to asthma attacks through Poisson regression analysis. We further stratified the sample according to social support levels to identify a possible effect of this variable on the association of maternal psychological symptoms with asthma morbidity.

RESULTS

Compared with mothers who maintained CMD over time, maternal CMD absence had a protective effect on the occurrence of visits to the ED (RR: 0.45; 95% CI: 0.26-0.79) and maternal CMD improvement was associated with lower risk of uncontrolled asthma in the child (RR: 0.60; 95% CI: 0.37-0.97). There was a stronger association of maternal CMD improvement with asthma control in the child only for the stratum of mothers with high social support in its three dimensions (affective-social interaction, emotional-informational, and material dimensions).

CONCLUSIONS

Maternal CMD absence and improvement over the study period were protective factors for uncontrolled asthma in the child, mainly in the presence of high social support.

Reduced expiratory variability index (EVI) is associated with controller medication withdrawal and symptoms in wheezy children aged 1-5 years

BACKGROUND

Lung function testing is an essential part of diagnostic workup and monitoring of asthma, but young children are lacking easy, routine testing methods. However, recent discoveries show reduced tidal breathing variability measured using impedance pneumography (IP) at home during sleep as a sign of airway obstruction. In this study, we assessed (a) the discriminative capacity of expiratory variability index (EVI) between healthy controls and young children with recurrent wheeze on-and-off controller medication, (b) association between EVI and parentally perceived obstructive symptoms (need for bronchodilator) and (c) measurement success rate.

METHODS

We included 68 patients (aged 1.0-5.6) and 40 healthy controls (aged 1.0-5.9 years). The patients were prescribed a three-month inhaled corticosteroid (ICS) treatment due to recurrent obstructive bronchitis. We measured EVI using IP at home at the end of the treatment (0W) and 2 (2W) and 4 (4W) weeks after ICS withdrawal.

RESULTS

EVI was higher in controls than in patients, and significant within-patient reduction occurred at 4W as compared to 2W or 0W. Area under curve of the ROC curve (controls vs all patients) at 4W was 0.78 (95% CI 0.70-0.85). Children who were administered bronchodilator by parental decision had lower EVI than those without bronchodilator need at 4W, but not at 0W or 2W. Patients with parent-reported airway infection, but no bronchodilator need, had normal EVI. Measurement success rate was 94%.

CONCLUSION

EVI was lower in patients than in controls and it reduced further after controller medication withdrawal, especially in the presence of parentally perceived wheeze symptoms. This technique shows a significant potential for routine lung function testing of wheezy young children.

The impact of care management for high-risk pediatric asthmatics on healthcare utilization

INTRODUCTION

From 2011 to 2015, a series of quality improvement interventions were developed that targeted pediatric persistent asthmatics that included recalls for those overdue for care and access to specialist care. The objective of this study was to assess the impact on urgent care and emergency department visits and hospitalizations from enrollment into at least one intervention during the time period.

METHODS

Persistent asthmatics were identified through electronic medical records, with patients having an asthma designation containing "persistent," asthma control containing "poor", and asthma risk being "high risk." Asthma utilization events were identified for these patients between January 1, 2011, and June 30, 2015 using ICD-9 diagnosis codes. Evaluation focused on differences in utilization for patients before and after receiving interventions through the use of logistic regression for each utilization outcome.

RESULTS

The interventions were delivered to 1060 children out of a total of 2046 identified as having the persistent asthmatic criteria. The intervention group consisted of 389 (36.7%) moderate persistent asthmatics and 643 (60.7%) mild persistent asthmatics, with 976 (92.1%) identifying as a minority. Analysis of 60692 months of data showed patients who received the intervention were less likely to visit the urgent care (OR [0.80, 0.96]) or be hospitalized (OR [0.37, 0.75]) than those who did not receive any interventions. Adjustment for provider referral into the interventions resulted in slight changes for both hospitalizations (OR [0.38, 0.79]) and urgent care (OR [0.68, 0.94]).

CONCLUSION

Children receiving interventions were less likely to be hospitalized or visit urgent care clinics.

Influence of contextual factors on quality of primary care in children with asthma

OBJECTIVE

Asthma is a common chronic disease among children, quality assurance is thus important. Adherence to pre-specified quality indicators of practice guidelines could be used to assess the quality of asthma care. The aim was to estimate which contextual factors that had an influence on the primary health care centres (PHCs) adherence to the quality indicators as stated in the practice guidelines.

METHOD

A pragmatic cross-sectional study was performed comprising 14 PHCs in Sweden. Included contextual factors were socio-demographic characteristics, organizational characteristics, and indicators regarding engagement in asthma care. Documentation on adherence to the quality indicators was retrieved from the medical health care records. Quality indicators included documentation of history of allergy and risk factors, diagnostics and patient support performed, and pharmacological treatment. To score adherence, a composite quality indicator (CQI) was computed for each PHC. A multivariable regression analysis was performed by orthogonal projection to latent structures (OPLS). By this analysis, the relationship between the result variable (CQI) and 26 pre-specified contextual factors was assessed.

RESULTS

There was a wide variation of CQI between the PHCs. The OPLS analysis identified that 10 of the contextual factors influenced CQI. The most pronounced influences were found in more time scheduled for asthma care, a lower age-limit for performing spirometry, a lower duty-grade for general practitioners, and a higher activity at asthma educational seminars. We found no influence of socio-demographic contextual factors.

CONCLUSION

We found that some of the contextual factors at the PHCs influenced the quality of performed care. Evidence-based care in paediatric asthma may thus be presumed to be facilitated by allocating time, by improving interprofessional collaboration, and by creating structures and opportunities for commitment to asthma care.

Wireless Wearable Ultrasound Sensor on a Paper Substrate to Characterize Respiratory Behavior

Respiratory behavior contains crucial parameters to feature lung functionality, including respiratory rate, profile, and volume. The current well-adopted method to characterize respiratory behavior is spirometry using a spirometer, which is bulky, heavy, expensive, requires a trained provider to operate, and is incapable of continuous monitoring of respiratory behavior, which is often critical to assess chronic respiratory diseases. This work presents a wireless wearable sensor on a paper substrate that is capable of continuous monitoring of respiratory behavior and delivering the clinically relevant respiratory information to a smartphone. The wireless wearable sensor was attached on the midway of the xiphoid process and the costal margin, corresponding to the abdomen-apposed rib cage, based on the anatomical and experimental analysis. The sensor, with a footprint of 40 × 35 × 6 mm³ and weighing 6.5 g, including a 2.7 g battery, consists of three subsystems, (i) ultrasound emitter, (ii) ultrasound receiver, and (iii) data acquisition and wireless transmitter. The sensor converts the linear strain at the wearing site to the lung volume change by measuring the change in ultrasound pressure as a function of the distance between the emitter and the receiver. The temporal lung volume change data, directly converted from the ultrasound pressure, is wirelessly transmitted to a smartphone where a custom-designed app computes to show volume-time and flow rate-volume loop graphs, standard respiratory analysis plots. The app analyzes the plots to show the clinically relevant respiratory behavioral parameters, such as forced vital capacity (FVC) and forced expiratory volume delivered in the first second (FEV₁). Potential user-induced error on sensor placement and temperature sensitivity were studied to demonstrate the sensor maintains its performance within a reasonable range of those variables. Eight volunteers were recruited to evaluate the sensor, which showed the mean deviation of the FEV₁/FVC ratio in the range of 0.00-4.25% when benchmarked by the spirometer. The continuous measurement of respiratory behavioral parameters helps track the progression of the respiratory diseases, including asthma progression to provide alerts to relevant caregivers to seek needed timely treatment.

Gaps in health insurance coverage and emergency department use among children with asthma

Background: Gaps in health insurance coverage may complicate asthma management and increase emergency department (ED) use. Using two nationally-representative surveys, we characterize the prevalence of coverage gaps among children with asthma, and describe their association with ED visits in this population. Methods: De-identified data were obtained from the 2016 National Survey of Children's Health (NSCH) and National Health Interview Survey (NHIS). Among children with asthma, we classified coverage over the past year as: (1) continuous private, (2) continuous public, (3) gap in coverage, and (4) continuously uninsured. The primary outcome was all-cause ED visits in the past year (both surveys). Secondary outcomes included unmet health care needs (NSCH), asthma-related ED visits or hospitalizations (NHIS) and asthma exacerbations (NHIS). Results: The analysis included 3739 (NSCH) and 854 (NHIS) children with asthma, representing a population of 5.5 million children in the US. Estimated prevalence of coverage gaps was 5% in the NSCH and 3% in the NHIS. On multivariable ordinal logistic regression using NSCH data, coverage gaps were associated with increased all-cause ED use (OR = 2.5; 95% CI: 1.3, 4.7, p = 0.005), compared to continuous private coverage. Further analysis confirmed higher odds of unmet health care needs, asthma exacerbations, and asthma-related ED visits among children with coverage gaps. Conclusions: Children with asthma who experience insurance coverage gaps have increased ED use, possibly related to poorer access to appropriate health care. Protecting insurance coverage continuity may reduce ED use and improve clinical outcomes in this population.

Applying UK real-world primary care data to predict asthma attacks in 3776 well-characterised children: a retrospective cohort study

Current understanding of risk factors for asthma attacks in children is based on studies of small but well-characterised populations or pharmaco-epidemiology studies of large but poorly characterised populations. We describe an observational study of factors linked to future asthma attacks in large number of well-characterised children. From two UK primary care databases (Clinical Practice Research Datalink and Optimum Patient Care research Database), a cohort of children was identified with asthma aged 5–12 years and where data were available for ≥2 consecutive years. In the “baseline” year, predictors included treatment step, number of attacks, blood eosinophil count, peak flow and obesity. In the “outcome” year the number of attacks was determined and related to predictors. There were 3776 children, of whom 525 (14%) had ≥1 attack in the outcome year. The odds ratio (OR) for one attack was 3.7 (95% Confidence Interval (CI) 2.9, 4.8) for children with 1 attack in the baseline year and increased to 7.7 (95% CI 5.6, 10.7) for those with ≥2 attacks, relative to no attacks. Higher treatment step, younger age, lower respiratory tract infections, reduced peak flow and eosinophil count >400/μL were also associated with small increases in OR for an asthma attack during the outcome year. In this large population, several factors were associated with a future asthma attack, but a past history of attacks was most strongly associated with future attacks. Interventions aimed at reducing the risk for asthma attacks could use primary care records to identify children at risk for asthma attacks.

A past history of asthma attacks in young children is a strong predictor for future attacks and should be factored into treatment regimes. Childhood asthma attacks take considerable toll on sufferers and their carers, yet risk factors for future attacks are unclear. David Price at the Observational and Pragmatic Research Institute in Singapore and co-workers searched UK primary care databases to find at least two years’ worth of consecutive data on children with asthma aged 5 to 12. The team analyzed data from 3,776 children. Their results showed that past attacks are the strongest predictor for future attacks; of 638 patients who experienced more than one asthma attack during the first year, 240 (38%) had attacks in the second year. Other risk factors included reduced peak flow, lower respiratory tract infections and younger age.

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.

Perceptions and Practices in Parents of Saudi Children with Asthma: A Cross-Sectional Survey

OBJECTIVE

To acquire more precise data on perceptions and practices adopted by Saudi parents of asthmatic children regarding asthma and its management.

METHODS

A cross-sectional study was conducted through 2015 on 292 parents of children (aged 3-15 years) with asthma visiting the outpatient clinics and the emergency departments (ED) of two tertiary care medical centers in Riyadh city, using a self-administered questionnaire.

RESULTS

Out of 292 parents who participated in this study, 60.2% reported that their children had previously difficulty in sleeping at night due to an asthma attack. The majority (70.4%) of parents was worried about adverse effects of inhaled corticosteroids, and 58.8% of participants were worried about other inhaler adverse effects, whereas 29.0% believed that their child would develop a dependency on asthma medications. Around 82% reported visiting the pediatric emergency department for asthma treatment and 61.2% of participants reported going to the routine physician follow-up visits. Family income was significantly associated with parental concerns about the adverse effects of inhaled medications and corticosteroids as well as drug dependency (p = 0.044, p = 0.033, and p = 0.001, respectively). One hundred and seventy (57%) of the children used inhaled β-agonists while only 39 (13.3%) were using inhaled corticosteroids.

CONCLUSIONS

Participated parents had misperceptions regarding the use of asthma medications and thus adopted ineffectual practices in its management. Therefore, to enhance asthma care and compliance in children, it is essential to develop different comprehensive parental education programs.

Concordance among children, caregivers, and clinicians on barriers to controller medication use

OBJECTIVE

While much research has addressed asthma medication adherence, few have combined quantitative and qualitative data, and none has addressed the triad of child, caregiver, and clinician simultaneously. This study assessed, with mixed methods, barriers to medication adherence within this triad.

METHODS

We conducted interviews with publicly-insured children with asthma, their caregivers, and their primary-care clinicians. Children (7-17 years) had been prescribed daily inhaled corticosteroids and visited the ED for asthma (past year). Participants answered open-ended and survey questions, rating suggested barriers to medication use (never vs. ever a barrier). McNemar's tests compared report of barriers by each group (children, caregivers, clinicians), and assessed concordance within triads.

RESULTS

Fifty child-caregiver dyads participated (34 clinicians). Children (40% female; median age 10 years) had mostly non-Hispanic black (90%) caregivers with less than or equal to high-school education (68%). For barriers, children and clinicians were more likely than caregivers to report medications running out. Clinicians were also more likely to cite controllers being a "pain to take" (vs. children) and forgetfulness (vs. caregivers) (all p < .05). There was a lack of within-triad concordance regarding barriers to adherence, especially regarding medication running out, worrying about taking a daily medication, and medication being a pain to take. Qualitative data revealed themes of competing priorities, home routines, and division of responsibility as prominent contributors to medication adherence.

CONCLUSIONS

There was significant disagreement among children, caregivers, and clinicians regarding barriers to daily use of asthma medications. To tailor asthma management conversations, clinicians should understand family-specific barriers and child-caregiver disagreements.

Efficacy and safety of tiotropium in school-age children with moderate-to-severe symptomatic asthma: A systematic review

BACKGROUND

Recently published data support the benefits and safety of the once-daily (OD) long-acting anticholinergic tiotropium bromide bronchodilator for the treatment of uncontrolled moderate-to-severe asthma in adults and adolescents. However, its role for the treatment of school-age asthmatics has not yet been clearly defined. The aim of this systematic review was to assess the efficacy and safety of tiotropium Respimat^® in children aged 6-11 years with moderate-to-severe symptomatic asthma.

METHODS

Randomized, placebo-controlled trials were included. Primary outcomes were peak forced expiratory volume in 1 s measured within 3 h post-dosing) [FEV_{1 (0-3 h)} ] and trough FEV₁ measured at the end of the dosing interval.

RESULTS

Three studies (more than 900 patients) were selected. Tiotropium was associated with significant improvements in FEV₁ peak (mean change from baseline) by 102 mL (P<.0001) and trough by 82 mL (P<.0001) compared with placebo. Tiotropium 5 μg dose presented a trend (statistically non-significant) toward a greater bronchodilation in comparison with 2.5 μg dose. Tiotropium significantly increased the rate of the Asthma Control Questionnaire (ACQ-7) responders compared with placebo (82.2% vs 75.4%, number needed to treat for benefit [NNTB]=15) and significantly decreased the number of patients with at least one exacerbation in comparison with placebo (29.1% vs. 39.8%, with a NNTB of 10). There were no significant differences in rescue medication use, withdrawals, and adverse events.

CONCLUSIONS

OD tiotropium Respimat^® is efficacious and well tolerated as an add-on to inhaled corticosteroids plus one or more controller medications in school-age symptomatic asthmatics.

Examining Profiles of Family Functioning in Pediatric Asthma: Longitudinal Associations With Child Adjustment and Asthma Severity

Objective

Identify profiles of functioning in families of children with asthma and examine whether profile membership predicts subsequent child mental and physical well-being.

Methods

Primary caregivers and children ( N  = 1,030) from the Childhood Asthma Management Program completed questionnaires assessing family functioning and child adaptation at five time points. Asthma severity was also assessed via spirometry.

Results

Latent profile analyses identified a four-profile solution as best fitting the data: cohesive, permissive, controlling/disengaged, and controlling/enmeshed families. Distal outcome analyses using Bolck-Croon-Hagenaars techniques suggested that children from families that were more cohesive had fewer internalizing and externalizing symptoms. These associations remained stable across time. Family profiles did not differ with regards to child asthma severity.

Conclusion

Results highlight the importance of looking beyond the effects of distinct components of family functioning and instead using pattern-based approaches. Recommendations for incorporating screenings and services for families in pediatric care settings are provided.

Mometasone furoate (MF) improves lung function in pediatric asthma: A double-blind, randomized controlled dose-ranging trial of MF metered-dose inhaler

OBJECTIVES

Mometasone furoate (MF), delivered via dry-powder inhaler (DPI) QD in the evening (PM), is a treatment option for pediatric patients with asthma. We evaluated MF delivered via a metered-dose inhaler (MDI), in children ages 5-11 years with persistent asthma.

METHODS

This was a 12-week double-blind, double-dummy, placebo-controlled trial. Pateints were randomized to the following treatments: MF-MDI 50 mcg BID, MF-MDI 100 mcg BID, MF-MDI 200 mcg BID, MF-DPI 100 mcg QD PM, and placebo. The primary analysis assessed MF-MDI doses versus placebo, on the change in %-predicted forced expiratory volume in one second (FEV₁ ) from baseline to week-12; a secondary analysis compared MF-MDI 50 mcg BID versus MF-DPI 100 mcg QD PM. Adverse events (AEs) were monitored throughout the trial.

RESULTS

For change from baseline in %-predicted FEV₁ at week 12, least-squares (LS) mean differences from placebo were 3.87 (P = 0.019), 6.29 (P < 0.001), and 5.34 (P = 0.001) percentage-points for MF-MDI 50, 100, and 200 mcg BID, respectively. The LS mean difference for MF-MDI 50 mcg BID versus MF-DPI 100 mcg QD PM was 1.39 (P = 0.368). AE incidences were similar among all treatment groups. There were no reports of oropharyngeal candidiasis or dysphonia, which were AEs pre-specified for analysis,.

CONCLUSIONS

In children ages 5-11 years with persistent asthma, all three doses of MF-MDI (50, 100, and 200 mcg BID) demonstrated significant improvement in FEV₁ after 12 weeks of treatment. MF was generally well tolerated with no new safety concerns identified in this trial. Pediatr Pulmonol. 2017;52:310-318. © 2016 Wiley Periodicals, Inc.

Can exhaled volatile organic compounds predict asthma exacerbations in children?

BACKGROUND

Asthma control does not yet meet the goals of asthma management guidelines. Non-invasive monitoring of airway inflammation may help to improve the level of asthma control in children.

OBJECTIVES

(1) To identify a set of exhaled volatile organic compounds (VOCs) that is most predictive for an asthma exacerbation in children. (2) To elucidate the chemical identity of predictive biomarkers.

METHODS

In a one-year prospective observational study, 96 asthmatic children participated . During clinical visits at 2 month intervals, asthma control, fractional exhaled nitric oxide, lung function (FEV₁, FEV₁/VC) and VOCs in exhaled breath were determined by means of gas chromatography time-of-flight mass spectrometry. Random Forrest classification modeling was used to select predictive VOCs, followed by plotting of receiver operating characteristic-curves (ROC-curves).

RESULTS

An inverse relationship was found between the predictive power of a set of VOCs and the time between sampling of exhaled breath and the onset of exacerbation. The sensitivity and specificity of the model predicting exacerbations 14 days after sampling were 88% and 75%, respectively. The area under the ROC-curve was 90%. The sensitivity for prediction of asthma exacerbations within 21 days after sampling was 63%. In total, 7 VOCs were selected for the classification model: 3 aldehydes, 1 hydrocarbon, 1 ketone, 1 aromatic compound, and 1 unidentified VOC.

CONCLUSION

VOCs in exhaled breath showed potential for predicting asthma exacerbations in children within 14 days after sampling. Before using this in clinical practice, the validity of predicting asthma exacerbations should be studied in a larger cohort.

A phase III randomized controlled trial of tiotropium add-on therapy in children with severe symptomatic asthma

BACKGROUND

Studies in adults and adolescents have demonstrated that tiotropium is efficacious as an add-on therapy to inhaled corticosteroids (ICSs) with or without other maintenance therapies in patients with moderate or severe symptomatic asthma.

OBJECTIVE

We sought to assess the efficacy and safety of once-daily tiotropium Respimat add-on therapy to high-dose ICS with 1 or more controller medications, or medium-dose ICS with 2 or more controller medications, in the first phase III trial of tiotropium in children with severe symptomatic asthma.

METHODS

In this 12-week, double-blind, placebo-controlled, parallel-group trial, 401 participants aged 6 to 11 years were randomized to receive once-daily tiotropium 5 μg (2 puffs of 2.5 μg) or 2.5 μg (2 puffs of 1.25 μg), or placebo (2 puffs), administered through the Respimat device as add-on to background therapy.

RESULTS

Compared with placebo, tiotropium 5 μg, but not 2.5 μg, add-on therapy improved the primary end point, peak FEV₁ within 3 hours after dosing (5 μg, 139 mL [95% CI, 75-203; P < .001]; 2.5 μg, 35 mL [95% CI, -28 to 99; P = .27]), and the key secondary end point, trough FEV₁ (5 μg, 87 mL [95% CI, 19-154; P = .01]; 2.5 μg, 18 mL [95% CI, -48 to 85; P = .59]). The safety and tolerability of tiotropium were comparable with those of placebo.

CONCLUSIONS

Once-daily tiotropium Respimat 5 μg improved lung function and was well tolerated as add-on therapy to ICS with other maintenance therapies in children with severe symptomatic asthma.

Nasal Airflow Measured by Rhinomanometry Correlates with FeNO in Children with Asthma

BACKGROUND

Rhinitis and asthma share similar immunopathological features. Rhinomanometry is an important test used to assess nasal function and spirometry is an important tool used in asthmatic children. The degree to which the readouts of these tests are correlated has yet to be established. We sought to clarify the relationship between rhinomanometry measurements, fractional exhaled nitric oxide (FeNO), and spirometric measurements in asthmatic children.

METHODS

Patients' inclusion criteria: age between 5 and 18 years, history of asthma with nasal symptoms, and no anatomical deformities. All participants underwent rhinomanometric evaluations and pulmonary function and FeNO tests.

RESULTS

Total 84 children were enrolled. By rhinomanometry, the degree of nasal obstruction was characterized as follows: (1) no obstruction in 33 children, (2) slight obstruction in 29 children, and (3) moderate obstruction in 22 children. FeNO was significantly lower in patients without obstruction than those with slight or moderate obstruction. Dividing patients according to ATS Clinical Practice Guidelines regarding FeNO, patients < 12 years with FeNO > 20 ppb had a lower total nasal airflow rate than those with FeNO < 20 ppb. Patients ≥ 12 years with FeNO > 25 ppb had a lower total nasal airflow rate than those with FeNO < 25 ppb.

CONCLUSIONS

Higher FeNO was associated with a lower nasal airflow and higher nasal resistance. This supports a relationship between upper and lower airway inflammation, as assessed by rhinomanometry and FeNO. The results suggest that rhinomanometry may be integrated as part of the functional assessment of asthma.

Parental Perceptions and Practices toward Childhood Asthma

Introduction. Parental perceptions and practices are important for improving the asthma outcomes in children; indeed, evidence shows that parents of asthmatic children harbor considerable misperceptions of the disease. Objective. To investigate the perceptions and practices of parents toward asthma and its management in Saudi children. Methods. Using a self-administered questionnaire, a two-stage cross-sectional survey of parents of children aged between 3 and 15 years, was conducted from schools located in Riyadh province in central Saudi Arabia. Results. During the study interval, 2000 parents were asked to participate in the study; 1450 parents responded, of whom 600 (41.4%) reported that their children had asthma, dyspnea, or chest allergy (recurrent wheezing or coughing), while 478 (32.9%) of the parents reported that their children were diagnosed earlier with asthma by a physician. Therefore, the final statistical analyses were performed with 600 participants. Furthermore, 321 (53.5%) respondents believed that asthma is solely a hereditary disease. Interestingly, 361 (60.3%) were concerned about side effects of inhaled corticosteroids and 192 (32%) about the development of dependency on asthma medications. Almost 76% of parents had previously visited a pediatric emergency department during an asthma attack. Conclusions. Parents had misperceptions regarding asthma and exhibited ineffective practices in its management. Therefore, improving asthma care and compliance requires added parental education.

Cost-effectiveness of FENO-based and web-based monitoring in paediatric asthma management: a randomised controlled trial

BACKGROUND

In children with asthma, web-based monitoring and inflammation-driven therapy may lead to improved asthma control and reduction in medications. However, the cost-effectiveness of these monitoring strategies is yet unknown.

OBJECTIVE

We assessed the cost-effectiveness of web-based monthly monitoring and of 4-monthly monitoring of FENO as compared with standard care.

METHODS

An economic evaluation was performed alongside a randomised controlled multicentre trial with a 1-year follow-up. Two hundred and seventy-two children with asthma, aged 4-18 years, were randomised to one of three strategies. In standard care, treatment was adapted according to Asthma Control Test (ACT) at 4-monthly visits, in the web-based strategy also according to web-ACT at 1 month intervals, and in the FENO-based strategy according to ACT and FENO at 4-monthly visits. Outcome measures were patient utilities, healthcare costs, societal costs and incremental cost per quality-adjusted life year (QALY) gained.

RESULTS

No statistically significant differences were found in QALYs and costs between the three strategies. The web-based strategy had 77% chance of being most cost-effective from a healthcare perspective at a willingness to pay a generally accepted €40 000/QALY. The FENO-based strategy had 83% chance of being most cost-effective at €40 000/QALY from a societal perspective.

CONCLUSIONS

Economically, web-based monitoring was preferred from a healthcare perspective, while the FENO-based strategy was preferred from a societal perspective, although in QALYs and costs no statistically significant changes were found as compared with standard care. As clinical outcomes also favoured the web-based and FENO-based strategies, these strategies may be useful additions to standard care.

TRIAL REGISTRATION NUMBER

Netherlands Trial Register (NTR1995).

Monitoring asthma in childhood

The goal of asthma treatment is to obtain clinical control and reduce future risks to the patient. However, to date there is limited evidence on how to monitor patients with asthma. Childhood asthma introduces specific challenges in terms of deciding what, when, how often, by whom and in whom different assessments of asthma should be performed. The age of the child, the fluctuating course of asthma severity, variability in clinical presentation, exacerbations, comorbidities, socioeconomic and psychosocial factors, and environmental exposures may all influence disease activity and, hence, monitoring strategies. These factors will be addressed in herein.

We identified large knowledge gaps in the effects of different monitoring strategies in children with asthma. Studies into monitoring strategies are urgently needed, preferably in collaborative paediatric studies across countries and healthcare systems.

Monitoring asthma in children is essential for disease control and should reflect age, triggers and disease activityhttp://ow.ly/J0k7f

Prescription patterns, adherence and characteristics of non-adherence in children with asthma in primary care

Adherence to treatment remains important for successful asthma management. Knowledge about asthma medication use and adherence in real-life offers opportunities to improve asthma treatment in children.

OBJECTIVE

To describe prescription patterns, adherence and factors of adherence to drugs in children with asthma.

METHODS

Population-based cohort study in a Dutch primary care database (IPCI), containing medical records of 176,516 children, aged 5-18 years, between 2000 and 2012. From asthma medication prescriptions, age, gender, seasonal and calendar year rates were calculated. Adherence was calculated using medication possession ratio (MPR) and ratio of controller to total asthma drug (CTT). Characteristics of children with high-vs.-low adherence were compared.

RESULTS

The total asthma cohort (n = 14,303; 35,181 person-years (PY) of follow-up) was mainly treated with short-acting β2-agonists (SABA; 40 users/100 PY) and inhaled corticosteroids (ICS; 32/100 PY). Median MPR for ICS was 56%. Children with good adherence (Q4 = MPR > 87%) were younger at start of ICS, more often visited specialists and had more exacerbations during follow-up compared to children with low adherence (Q1 = MPR < 37%).

CONCLUSION

In Dutch primary care children with asthma were mainly prescribed SABA, and ICS. Adherence to ICS was relatively low. Characteristics of children with good adherence were compatible with more severe asthma, suggesting that adherence is driven by treatment need or intensity of medical follow-up.

Monitoring strategies in children with asthma: a randomised controlled trial

BACKGROUND

Asthma guidelines recommend monitoring of asthma control. However, in a substantial proportion of children, asthma is poorly controlled and the best monitoring strategy is not known.

OBJECTIVES

We studied two monitoring strategies for their ability to improve asthma outcomes in comparison with standard care (SC): web-based monthly monitoring with the (Childhood) Asthma Control Test (ACT or C-ACT) and 4-monthly monitoring of FENO.

METHODS

In this randomised controlled, partly blinded, parallel group multicentre trial with a 1-year follow-up, children aged 4-18 with a doctor's diagnosis of asthma treated in seven hospitals were randomised to one of the three groups. In the web group, treatment was adapted according to ACT obtained via a website at 1-month intervals; in the FENO group according to ACT and FENO, and in the SC group according to the ACT at 4-monthly visits. The primary endpoint was the change from baseline in the proportion of symptom-free days (SFD).

RESULTS

Two-hundred and eighty children (mean age 10.4 years, 66% boys) were included; 268 completed the study. Mean changes from baseline in SFD were similar between the groups: -2.1% (web group, n=90), +8.9% (FENO group, n=91) versus 0.15% (SC, n=87), p=0.15 and p=0.78. Daily dose of inhaled corticosteroids (ICS) decreased more in the web-based group compared with both other groups (-200 μg/day, p<0.01), while ACT and SFD remained similar.

CONCLUSIONS

The change from baseline in SFD did not differ between monitoring strategies. With web-based ACT monitoring, ICS could be reduced substantially while control was maintained.

TRIAL REGISTRATION NUMBER

NTR 1995.

Prediction of asthma exacerbations in children by innovative exhaled inflammatory markers: results of a longitudinal study

BACKGROUND

In asthma management guidelines the primary goal of treatment is asthma control. To date, asthma control, guided by symptoms and lung function, is not optimal in many children and adults. Direct monitoring of airway inflammation in exhaled breath may improve asthma control and reduce the number of exacerbations.

AIM

1) To study the use of fractional exhaled nitric oxide (FeNO) and inflammatory markers in exhaled breath condensate (EBC), in the prediction of asthma exacerbations in a pediatric population. 2) To study the predictive power of these exhaled inflammatory markers combined with clinical parameters.

METHODS

96 asthmatic children were included in this one-year prospective observational study, with clinical visits every 2 months. Between visits, daily symptom scores and lung function were recorded using a home monitor. During clinical visits, asthma control and FeNO were assessed. Furthermore, lung function measurements were performed and EBC was collected. Statistical analysis was performed using a test dataset and validation dataset for 1) conditionally specified models, receiver operating characteristic-curves (ROC-curves); 2) k-nearest neighbors algorithm.

RESULTS

Three conditionally specified predictive models were constructed. Model 1 included inflammatory markers in EBC alone, model 2 included FeNO plus clinical characteristics and the ACQ score, and model 3 included all the predictors used in model 1 and 2. The area under the ROC-curves was estimated as 47%, 54% and 59% for models 1, 2 and 3 respectively. The k-nearest neighbors predictive algorithm, using the information of all the variables in model 3, produced correct predictions for 52% of the exacerbations in the validation dataset.

CONCLUSION

The predictive power of FeNO and inflammatory markers in EBC for prediction of an asthma exacerbation was low, even when combined with clinical characteristics and symptoms. Qualitative improvement of the chemical analysis of EBC may lead to a better non-invasive prediction of asthma exacerbations.

Monitoring asthma in children

The goal of asthma treatment is to obtain clinical control and reduce future risks to the patient. To reach this goal in children with asthma, ongoing monitoring is essential. While all components of asthma, such as symptoms, lung function, bronchial hyperresponsiveness and inflammation, may exist in various combinations in different individuals, to date there is limited evidence on how to integrate these for optimal monitoring of children with asthma. The aims of this ERS Task Force were to describe the current practise and give an overview of the best available evidence on how to monitor children with asthma. 22 clinical and research experts reviewed the literature. A modified Delphi method and four Task Force meetings were used to reach a consensus. This statement summarises the literature on monitoring children with asthma. Available tools for monitoring children with asthma, such as clinical tools, lung function, bronchial responsiveness and inflammatory markers, are described as are the ways in which they may be used in children with asthma. Management-related issues, comorbidities and environmental factors are summarised. Despite considerable interest in monitoring asthma in children, for many aspects of monitoring asthma in children there is a substantial lack of evidence.

Personalized medicine in children with asthma

Personalized medicine for children with asthma aims to provide a tailored management of asthma, which leads to faster and better asthma control, has less adverse events and may be cost saving. Several patient characteristics, lung function parameters and biomarkers have been shown useful in predicting treatment response or predicting successful reduction of asthma medication. As treatment response to the main asthma therapies is partly genetically determined, pharmacogenetics may open the way for personalized medicine in children with asthma. However, the number of genes identified for the various asthma drug response phenotypes remains small and randomized controlled trials are lacking. Biomarkers in exhaled breath or breath condensate remain promising but did not find their way from bench to bedside yet, except for the fraction of exhaled nitric oxide. E-health will most likely find its way to clinical practice and most interventions are at least non-inferior to usual care. More studies are needed on which interventions will benefit most individual children.

Asthma control questionnaires in the management of asthma in children: A review

Several self-administered questionnaires have been developed to assess childhood asthma control in a simple and standardized way. This review discusses the most commonly used questionnaires and explores their usefulness in asthma management in children. We conclude that the use of asthma control questionnaires in daily practice and in research contributes to the standardized evaluation of children with asthma and helps to track asthma symptoms, but validation studies in a wider range of settings are needed.

Electronic monitoring of symptoms and lung function to assess asthma control in children

BACKGROUND

Asthma remains poorly controlled in children. Home monitoring of asthma control may help to improve the level of asthma control.

OBJECTIVES

To compare 2 methods to assess asthma control: (1) prospective home monitoring, based on daily assessment of forced expiratory volume in 1 second (FEV1) and electronic symptom score, and (2) Asthma Control Questionnaire (ACQ) with retrospective assessment of symptoms and FEV1.

METHODS

Ninety-six children with asthma were prospectively followed up during 1 year. Asthma control was assessed by home monitoring, including an electronic symptom score based on Global Initiative for Asthma (GINA) criteria and FEV1 measurements. In the hospital, the ACQ was completed and FEV₁ was measured. Kappa analysis was performed to assess levels of agreement between the 2 methods.

RESULTS

Agreement between the 2 methods was low (κ coefficient of 0.393). In 29 children (37%), prospective home monitoring was less optimistic than the retrospective assessment of asthma control by the ACQ.

CONCLUSION

This study found low agreement between asthma control based on GINA criteria by means of prospective home monitoring and the hospital ACQ. The prospective home monitor detected more cases of less well-controlled asthma than the ACQ. However, optimization of adherence to home monitor use is necessary.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01239238.

Bronchodilation with mometasone furoate/formoterol fumarate administered by metered-dose inhaler with and without a spacer in children with persistent asthma

BACKGROUND

The bronchodilatory effect of mometasone furoate/formoterol fumarate (MF/F) administered by metered-dose inhaler (MDI) with or without a spacer has not been evaluated previously in children aged 5-11 years.

METHODS

This was a randomized, multicenter, placebo-controlled, single-dose, four-period crossover study. Children with persistent asthma aged 5-11 years participated in this study. Subjects used inhaled corticosteroids with/without long-acting beta-2 agonists for 12 weeks before enrollment and at screening had forced expiratory volume in 1 sec (FEV1 ) ≥70% predicted. Subjects received MF/F MDI 100/10 µg with/without spacer (AeroChamber Plus® with Flow-Vu® Anti-Static Valved Holding Chamber), F-Dry Powder Inhaler (F-DPI) 10 µg, and placebo MDI with/without spacer in separate treatment periods. The primary endpoint was FEV1 area under the curve from 0 to 12 hr (AUC0-12hr ) for the comparison of MF/F with spacer versus placebo. Secondary measurements included MF/F without spacer versus placebo, as well as MF/F with spacer versus MF/F without spacer, and F-DPI versus placebo. Analysis was performed with an analysis of covariance model for a crossover study.

RESULTS

Data from 87 subjects were analyzed. MF/F with spacer demonstrated a larger change in mean FEV1 AUC0-12hr versus placebo (115 vs. -9 mL), with a treatment difference of 124 mL (95% CI 94-154, P < 0.001). Similarly, MF/F without spacer versus placebo resulted in a 102 mL difference in mean-adjusted FEV1 AUC0-12hr (95% CI 73-131, P < 0.001), whereas the difference between MF/F with spacer versus MF/F without spacer was 22 mL (95% CI -8 to 52, P = 0.144). The difference between F-DPI versus placebo was 106 mL (95% CI 77-135, P < 0.001). No unexpected adverse events were observed.

CONCLUSIONS

In this trial, MF/F MDI 100/10 µg demonstrated significant bronchodilation in children aged 5-11 years regardless of the use of a spacer. No difference in bronchodilation was observed between MF/F MDI and F-DPI.

Determinants of asthma control among children in Saudi Arabia

OBJECTIVE

Asthma is the most common chronic disease among children. Uncontrolled asthma may considerably decrease the quality of life for patients and their families. Our objective was to identify possible risk factors for poor asthma control in children.

METHODS

A cross-sectional study was conducted among children with asthma aged 4-11 years who attended a pediatric clinic for follow-up visits at one of the major teaching hospitals in Riyadh, Saudi Arabia. Asthma control status was measured by the childhood asthma control test. Multiple logistic regression analysis was performed to explore the relationships between the outcome and exposure variables.

RESULTS

Uncontrolled asthma was present in 89 out of 158 children (59.3%). Asthma control improved with the number of siblings. Control improved by 69% with two or three siblings (OR = 0.31, 95% CI = 0.10-0.96) and by 87% with four or more siblings (OR = 0.13, 95% CI = 0.04-0.48). Similarly, asthma control improved with an increased asthma knowledge of the caregiver (OR = 0.87, 95% CI = 0.81-0.93). Household incomes less than SAR 15 000 and sharing a bedroom increased the odds of having uncontrolled asthma by 2.30 (95% CI = 1.02-5.21) and 3.33 (95% CI = 1.33-8.35), respectively.

CONCLUSIONS

In addition to knowledge, socioeconomic factors, such as family income, household crowding, and the number of siblings are associated with asthma control among children in Saudi Arabia. Further research is needed to investigate the role of these factors.

Will symptom-based therapy be effective for treating asthma in children?

Traditionally, symptoms are important patient-oriented outcomes in asthma treatment, and assessment of symptoms is an essential component of assessing asthma control. However, variable airways obstruction, airways hyperresponsiveness and chronic inflammation are key components of the asthma syndrome, and correlations among these hallmarks and symptoms are weak or even absent. Therefore, it might be questioned if symptom-based therapy is effective for treating asthma in (all) children. To date, there is no firm indication that monitoring asthma based on repetitive lung function measurement or markers of airway inflammation is superior to monitoring based on symptoms only. In the majority of patients, symptom-based asthma management may well be sufficient, and in preschool children, symptoms are presently the only feasible outcome. Nevertheless, there is some evidence that selected groups might benefit from an approach that takes into account individual phenotypic characteristics. In patients with poor perception, those with a discordant phenotype and those with persistent severe asthma, considering lung function, airways hyperresponsiveness and inflammatory markers in treatment decisions might improve outcomes.

How often do providers discuss asthma action plans with children? Analysis of transcripts of medical visits

OBJECTIVE

To examine how often providers discussed asthma action plans with children and their caregivers and child, clinical, and provider characteristics that were associated with those discussions.

METHOD

This was a cross-sectional analysis of audio-recorded visits between 35 general pediatric providers and 260 children (8-16 years old) with asthma and their caregivers. The visits were transcribed into text. The transcripts were coded for discussions about written asthma action plans.

RESULTS

Providers discussed written asthma action plans with 21.0% of children and caregivers. Providers were significantly more likely to discuss asthma action plans when the child was enrolled in Medicaid, the visit was asthma related, the visit was longer, the provider was not White, or more provider education.

CONCLUSION

In our sample, providers rarely discussed action plans with children and their caregivers. Providers should discuss asthma action plans with every child with persistent asthma and their caregivers and revise them regularly.

Limitations of asthma control questionnaires in the management and follow up of childhood asthma

It is important to achieve asthma control whenever possible in clinical practice. Asthma control questionnaires undoubtedly provide a useful measure of asthma control in research studies but their place in routine clinical practice has yet to be secured. There is considerable variation in the results yielded from different validated asthma control tools. It remains to be seen whether they improve the reliability of reporting of symptoms to health care professionals when compared to verbal reporting. In the presence of sensible care from compassionate and well informed doctors and nurses asthma control questionnaires will not improve outcomes for children. A patient-focused clinical encounter supplemented with lung function measurements and occasional eNO testing has more to offer families and children than control questionnaires and their routine use in the clinic cannot be recommended on the basis of current evidence.

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.

Association between allergic rhinitis and asthma control in Peruvian school children: a cross-sectional study

BACKGROUND

Asthma and allergic rhinitis are highly prevalent conditions that cause major illness worldwide. This study aimed to assess the association between allergic rhinitis and asthma control in Peruvian school children.

METHODS

A cross-sectional study was conducted among 256 children with asthma recruited in 5 schools from Lima and Callao cities. The outcome was asthma control assessed by the asthma control test. A score test for trend of odds was used to evaluate the association between allergic rhinitis severity and the prevalence of inadequate asthma control. A generalized linear regression model was used to estimate the adjusted prevalence ratios of inadequate asthma control.

RESULTS

Allergic rhinitis was present in 66.4% of the population with asthma. The trend analysis showed a positive association between allergic rhinitis and the probability of inadequate asthma control (P < 0.001). It was associated with an increased prevalence of inadequate asthma control, with adjusted prevalence ratios of 1.53 (95% confidence interval: 1.19-1.98).

CONCLUSION

This study indicates that allergic rhinitis is associated with an inadequate level of asthma control, giving support to the recommendation of evaluating rhinitis to improve asthma control in children.

Pediatric asthma control in Asia: phase 2 of the Asthma Insights and Reality in Asia-Pacific (AIRIAP 2) survey

BACKGROUND

We conducted Phase 2 of the Asthma Insights and Reality in the Asia-Pacific (AIRIAP 2) survey in 2006 to determine the level of asthma control in this region and the validity of the Asthma Control Test (ACT) and childhood ACT (C-ACT) in relation to asthma control.

METHODS

Pediatric participants (0 to <16 years; N = 988) with diagnosed asthma and current asthma symptoms or taking anti-asthma medications were recruited from 12 geographic areas in Asia. The survey consisted of the AIRIAP 2 questionnaire (asthma symptoms, use of urgent healthcare services and anti-asthma medication) and the ACT or C-ACT (English or Chinese translations only), both administered in the participant's preferred language. A symptom control index based on the Global Initiative for Asthma criteria (except lung function) was used to classify asthma control status.

RESULTS

Most participants had inadequately controlled asthma ('uncontrolled' = 53.4%, 528/988; 'partly controlled' = 44.0%, 435/988). Only 2.5% (25/988) had 'controlled' asthma. Demand for urgent healthcare services (51.7%, 511/988) and use of short-acting beta-agonists (55.2%, 545/988) was high. The optimal ACT and C-ACT cutoff score for detecting uncontrolled asthma (compared with controlled or partly controlled asthma) was determined to be ≤19 (receiver operating characteristic analysis) with good agreement between the ACT and C-ACT and the symptom control index.

CONCLUSIONS

Findings from this survey show that asthma control is suboptimal in many children in the Asia-Pacific region. Practical tools, such as the ACT or C-ACT, may help clinicians assess asthma control and facilitate adjustment of asthma medication.

Adherence to national guidelines for children with asthma at primary health centres in Sweden: potential for improvement

BACKGROUND

Although asthma is the most common chronic paediatric disease in Western Europe, the extent of adherence to guidelines for primary care management of paediatric asthma remains unclear.

AIMS

To evaluate adherence to national guidelines for primary care management of children with asthma.

METHODS

This survey involved 18 primary healthcare centres in Stockholm, Sweden. The medical records of 647 children aged 6 months to 16 years with a diagnosis of asthma, obstructive bronchitis, or cough were selected and scrutinised. 223 children with obstructive bronchitis or cough not fulfilling the evidence-based criteria for asthma were excluded, yielding a total of 424 subjects. Documentation of the most important indicators of quality as stipulated in national guidelines (i.e., tobacco smoke, spirometry, pharmacological treatment, patient education, and demonstration of inhalation technique) was examined.

RESULTS

Only 22% (n=49) of the children 6 years of age or older had ever undergone a spirometry test, but the frequency was greater when patients had access to an asthma nurse (p=0.003). Although 58% (n=246) of the total study population were treated with inhaled steroids, documented patient education and demonstration of inhalation technique was present in 14% (n=59). Exposure to tobacco smoke was documented in 14% (n=58).

CONCLUSIONS

This study reveals a substantial gap between the actual care provided for paediatric asthma and the recommendations formulated in national guidelines.

Internet-based self-management compared with usual care in adolescents with asthma: a randomized controlled trial

INTRODUCTION

Asthma control often is poor in adolescents and this causes considerable morbidity. Internet-based self-management (IBSM) improves asthma-related quality of life in adults. We hypothesized that IBSM improves asthma-related quality of life in adolescents.

METHODS

Adolescents (12-18 years) with persistent and not well-controlled asthma participated in a randomized controlled trial with 1 year follow-up and were allocated to IBSM (n = 46) or usual care (UC, n = 44). IBSM consisted of weekly asthma control monitoring with treatment advice by a web-based algorithm. Outcomes included asthma-related quality of life (Pediatric Asthma Quality of Life Questionnaire, PAQLQ) and asthma control (Asthma Control Questionnaire, ACQ) and were analyzed by a linear mixed-effects model.

RESULTS

At 3 months, PAQLQ improved with 0.40 points (95% CI: 0.17-0.62, P < 0.01), by IBSM compared to 0.0 points for UC (P = 0.02 for the difference). At 12 months the between-group difference was -0.05 (95% CI: -0.50 to 0.41, P = 0.85). At 3 months ACQ improved more in IBSM than in UC (difference: -0.32 points; 95% CI: -0.56 to -0.079, P < 0.01). At 12 months the difference was -0.05 (95% CI: -0.35 to 0.25, P = 0.75).

CONCLUSION

IBSM improved asthma-related quality of life and asthma control in adolescents with not well-controlled asthma after 3 months, but not after 12 months.

The Relationship between Asthma and Obesity in Urban Early Adolescents

Asthma and obesity, which have reached epidemic proportions, impact urban youth to a great extent. Findings are inconsistent regarding their relationship; no studies have considered asthma management. We explored the association of obesity and asthma-related morbidity, asthma-related health care utilization, and asthma management in urban adolescents with uncontrolled asthma. We classified 373 early adolescents (mean age=12.8 years; 82% Hispanic or Black) from New York City public middle schools into 4 weight categories: normal (body mass index [BMI]<85th percentile); overweight (85th percentile≤BMI<95th percentile); obese (95th percentile≤BMI<97th percentile); and very obese (BMI≥97th percentile). We compared sample obesity prevalence to national estimates, and tested whether weight categories predicted caregiver reported asthma outcomes, adjusting for age and race/ethnicity. Obesity prevalence was 37%, with 28% of the sample being very obese; both rates were significantly higher than national estimates. We found no significant differences in asthma-related health care utilization or asthma management between weight categories, and a few differences in asthma-related morbidity. Relative to normal weight and obese youth, overweight youth had higher odds of never having any days with asthma-related activity limitations. They also had higher odds of never having asthma-related school absences compared with obese youth. Overweight youth with asthma-related activity limitations had more days with limitations compared with normal weight youth. Overweight, but not obese youth, missed more school due to asthma than normal weight youth. Overweight and obesity prevalence was very high in urban, Hispanic, and Black adolescents with uncontrolled asthma, but not strongly associated with asthma-related morbidity, asthma-related health care utilization, or asthma management practices.

Prediction of asthma exacerbations in children: results of a one-year prospective study

BACKGROUND

Underdiagnosis and low levels of asthma control are frequent occurring problems in patients with asthma.

OBJECTIVE

The study aim was to evaluate the ability of non-invasive inflammatory markers in exhaled breath to predict exacerbations of childhood asthma, and to assess the time course of changes in these exhaled markers before, during and after exacerbations.

METHODS

The design was a prospective one-year longitudinal study. Regular two-month visits at the outpatient clinic were performed. Forty children with asthma (aged 6-16 years) participated. The primary outcome measure was the occurrence of an exacerbation. Assessment was made of the presence and severity of pulmonary symptoms, use of medication, and measurements of forced expiratory volume in 1 s using home monitor. The following independent parameters were assessed during outpatient visits: (1) exhaled nitric oxide, (2) inflammatory markers in exhaled breath condensate: acidity, nitrite, hydrogen peroxide, interleukin-1α, -5, -13, interferon-γ, (3) lung function, (4) asthma control score.

RESULTS

Thirty-eight of 40 children completed the study. Sixteen children developed exacerbations, of which ten were moderate and six severe. Univariate Cox regression analysis revealed that condensate acidity, interleukin-5 and asthma control score were significant predictors of an asthma exacerbation (P < 0.05). In the multivariate Cox regression analysis, exacerbations were best predicted by the asthma control score and by the level of interleukin-5 in exhaled breath condensate (Wald scores of 7.19 and 4.44, P = 0.007 and P = 0.035 respectively). The predicted survival curve of this multivariate model showed a two times reduced risk on exacerbations in the category of children with the 10% most optimal values of IL-5 and asthma control score.

CONCLUSIONS AND CLINICAL RELEVANCE

Both exhaled breath condensate interleukin-5 level and asthma control score were significant predictors of asthma exacerbations. These findings open up the possibility of assessing the potential of such parameters to titrate asthma treatment in future studies.