How does asthma influence the daily life of children? Results of focus group interviews

The utility of the necessity-concerns framework (NCF) in explaining adherence and parental beliefs about controller medication in Saudi Arabian children with asthma

OBJECTIVE

This study aims to assess beliefs about asthma controller medications among parents of Saudi Arabian children with asthma and the association between these beliefs and medication adherence using the Necessity-Concerns Framework.

METHODS

A cross-sectional survey was provided to parents of children with asthma when they brought their children to routine appointments at local public clinics between May 16 and July 10, 2018. Participants electronically filled out validated Arabic versions of the Medication Adherence Reported Scale (MARS) and Beliefs About Medications Questionnaire (BMQ). Descriptive statistics were used to characterize the study participants, while hierarchical linear regression analysis assessed associations between parental beliefs about controller medications and medication adherence.

RESULTS

A total of 381 parents of children with asthma completed the study survey. The vast majority (89%) of study participants were non-adherent to their children's prescribed medications while only 11% were adherent. Additionally, our study revealed a significantly positive association between adherence and parents' beliefs in the necessity of the medication (p < .001), with concerns about the adverse effects of medication being negatively associated with parental adherence. A higher mean score for medication adherence was reported among the ambivalent groups compared to the accepting, indifferent, and skeptical groups.

CONCLUSIONS

Medication adherence among parents of children with asthma was relatively low. In addition, necessity beliefs were significantly associated with parental adherence to controller medications for their children with asthma. Further studies are warranted to investigate potential factors contributing to poor parental adherence and develop tailored interventions that support parental medication adherence for their asthmatic children.

Developments in the Management of Severe Asthma in Children and Adolescents: Focus on Dupilumab and Tezepelumab

Severe asthma in children and adolescents exerts a substantial health, financial, and societal burden. Severe asthma is a heterogeneous condition with multiple clinical phenotypes and underlying inflammatory patterns that might be different in individual patients. Various add-on treatments have been developed to treat severe asthma, including monoclonal antibodies (biologics) targeting inflammatory mediators. Biologics that are currently approved to treat children (≥ 6 years of age) or adolescents (≥ 12 years of age) with severe asthma include: anti-immunoglobulin E (omalizumab), anti-interleukin (IL)-5 (mepolizumab), anti-IL5 receptor (benralizumab), anti-IL4/IL13 receptor (dupilumab), and antithymic stromal lymphopoietin (TSLP) (tezepelumab). However, access to these targeted treatments varies across countries and relies on few and crude indicators. There is a need for better treatment stratification to guide which children might benefit from these treatments. In this narrative review we will assess the most recent developments in the treatment of severe pediatric asthma, as well as potential biomarkers to assess treatment efficacy for this patient population.

Dietary prevention strategies for childhood asthma

Asthma is the most common chronic disease in childhood and a rise in prevalence has been observed concomitantly with changing dietary habits in the Western world. This change has favored a more Westernized diet characterized by high intake of processed food and fat in contrast to a Mediterranean diet high in fruit, vegetable and fish intake. This has resulted in a decreased intake of several antioxidants and micronutrients including n-3 long-chained polyunsaturated fatty acids and vitamin D that are speculated to have anti-inflammatory effects and hold immunoregulatory properties. Several observational studies have investigated associations between dietary intake and wheeze and asthma but only few large well-conducted randomized controlled trials (RCTs) have been performed investigating the primary preventive effect of micronutrient supplementations. Currently, the recommendations from the Global Initiative for Asthma (GINA) for primary prevention of asthma in children do not include maternal dietary changes or supplementations during pregnancy, although the most recent report mentions both specific dietary patterns and micronutrients as potential protective supplementation regimes. This review will present the current literature and future research needs focusing on primary and secondary prevention of both early and late childhood asthma from dietary intake during pregnancy and early childhood to highlight potential preventive effects of specific dietary patterns and micronutrient supplements, which may facilitate the planning of future clinical trials in search of a preemptive strategy.

Associations between pediatric asthma and age at menarche: evidence from the Indonesian Family Life Survey

OBJECTIVE

To examine the association between pediatric asthma and age at menarche, and to assess whether early life factors modify the association.

METHODS

This is a retrospective cross-sectional study using the Indonesian Family Life Survey Fifth Wave which had a total of 11 822 females aged 15-57 years to evaluate whether those with pediatric asthma were associated with earlier menarche, compared to females without asthma. We performed a weighted linear regression model adjusting for age, urbanicity, parental smoking, infectious disease history during childhood, childhood socioeconomic status, and health status during childhood. We also performed analyses by age at asthma diagnosis, interval length between asthma diagnosis and menarche, urbanicity, parental smoking, and infectious disease history during childhood.

RESULTS

In the adjusted model, females with pediatric asthma had an earlier average age at menarche by 5.2 months and those diagnosed with asthma at 5-8 years of age had the fastest acceleration by 14.9 months. The significant association persisted among those with 0-5 years interval between asthma diagnosis and menarche, who resided in urban areas, and those without infectious disease history during childhood.

CONCLUSIONS

Our findings showed that females with pediatric asthma were associated with an earlier age at menarche, and some early life factors modified the association. Better asthma management with more targeted strategies at those at risk of earlier menarche may improve the reproductive and future health of children with asthma. Future studies to elucidate the mechanisms between pediatric asthma and age at menarche are warranted.

[Asthma and suicidal behavior in adolescents: a literature review]

INTRODUCTION

Adolescence is a difficult time in life and asthma has major psychological consequences for adolescents.

OBJECTIVES

This systematic literature review focused on the association between asthma and suicidal behaviors (suicidal ideations [SI], suicide plans [SP] and suicide attempts [SA]) among adolescents in the general population.

METHOD

Research on Medline for the 1980-2021 period. Objectives This systematic literature review focused on the association between asthma and suicidal behaviors (suicidal ideations [SI], suicide plans [SP] and suicide attempts [SA]) among adolescents in the general population.

RESULTS

An overwhelming majority of the studies taken into consideration demonstrated a significant positive association between asthma and suicidal behaviors. Among the 10 studies assessing SI (with or without SP), 9 of them found a significant positive association between asthma and SI. Eight studies assessed SA; five cross-sectional studies and one prospective study demonstrated a significant positive association between asthma and SA. Only one case-control study did not find a significant positive association between asthma and SA after hospitalization for asthma. The two cross-sectional studies assessing suicidal risk taken as a whole (SI, SP and SA) demonstrated a significant positive association between asthma and at least one suicidal behavior. (OR=1.71; P<0.001). However, several studies did not include depression as an adjustment factor.

CONCLUSION

It is important that healthcare professionals assess suicide risk in adolescent suffering from asthma, the objective being to avoid SA or death from SA.

Analysis of the Consumption of Drugs Prescribed for the Treatment of Asthma in Belgian Children

(1) Asthma is one of the most common chronic diseases in the world among children. The main purpose of this study was to analyze the consumption of asthma medications in order to investigate asthma in children (2-18 years) and the association with health care consumption; (2) a retrospective study using anonymized administrative data for 2013-2018 from the third largest Belgian health insurer was conducted; (3) in 2018, 12.9% of children received at least one asthma medication and 4.4% received at least two packages with a minimum of 30 days between purchases. Preschool children (2-6 years) were three times more likely to take asthma medication than older children (7-18 years). ICS, in combination or not with LABA, were the most dispensed drugs among children. Children with asthma medications were almost twice as likely to receive antibiotics, more likely to end up in the emergency room, and twice as likely to be hospitalized; (4) most children took ICS, according to the GINA guidelines. High rates of nebulization in young children were observed, despite the recommendation to use an inhaler with a spacing chamber as much as possible. Finally, children who took asthma medications were more likely to end up in the ER or be hospitalized.

Pediatric Obesity-Related Asthma: The Role of Nutrition and Nutrients in Prevention and Treatment

Childhood obesity rates have dramatically risen in numerous countries worldwide. Obesity is likely a factor in increased asthma risk, which is already one of the most widespread chronic respiratory pathologies. The pathogenic mechanism of asthma risk has still not yet been fully elucidated. Moreover, the role of obesity-related inflammation and pulmonary overreaction to environmental triggers, which ultimately result in asthma-like symptoms, and the importance of dietary characteristics is well recognized. Diet is an important adjustable element in the asthma development. Food-specific composition of the diet, in particular fat, sugar, and low-quality nutrients, is likely to promote the chronic inflammatory state seen in asthmatic patients with obesity. An unbalanced diet or supplementation as a way to control asthma more efficiently has been described. A personalized dietary intervention may improve respiratory symptoms and signs and therapeutic response. In this narrative review, we presented and discussed more recent literature on asthma associated with obesity among children, focusing on the risk of asthma among children with obesity, asthma as a result of obesity focusing on the role of adipose tissue as a mediator of systemic and local airway inflammation implicated in asthma regulation, and the impact of nutrition and nutrients in the development and treatment of asthma. Appropriate early nutritional intervention could possibly be critical in preventing and managing asthma associated with obesity among children.

Childhood patterns of overweight and wheeze and subsequent risk of current asthma and obesity in adolescence

BACKGROUND

Obesity and asthma in childhood often co-occur. Few studies have examined this relationship using repeated measures of body mass index (BMI) or asthma symptoms (such as wheeze).

OBJECTIVE

We compared two analytic approaches for repeated measures data to investigate this relationship.

METHODS

Our baseline sample consisted of 1277 children enrolled in a Boston-area cohort with BMI or wheeze at age 1 year and no missing covariates. We used latent class growth models (LCGM) and inverse probability weighting (IPW) of marginal structural models to examine the extent to which presence of overweight across childhood was associated with early adolescent current asthma, and conversely of repeated measures of wheeze across childhood with early adolescent obesity.

RESULTS

Using LCGM, a "persistent" childhood overweight class (vs "never") was associated with higher risk of asthma in early adolescence (RR 1.9; 95% CI 1.1, 3.0), while "persistent" childhood wheeze (vs "never") was associated with higher risk of obesity in early adolescence (RR 2.7; 95% CI 1.0, 6.4) after adjusting for baseline covariates. An IPW analysis treating childhood overweight and wheeze as time-varying exposures and adjusting for baseline and time-varying covariates resulted in weaker and less precise associations of "persistent" (vs "never") overweight with adolescent asthma (RR 1.3; 95% CI 0.3, 3.0), and of "persistent" (vs "never") wheeze with adolescent obesity (RR 2.3; 95% CI 0.4, 5.3).

CONCLUSION

Our point estimates from both approaches suggest an association between "persistent" childhood overweight and adolescent asthma, and between "persistent" childhood wheeze and adolescent obesity. LCGM results were stronger and more precise, whereas IPW results were less conclusive with wider 95% confidence intervals containing the null. The precision gained from LCGM may be at the expense of bias, and the use of both approaches helps to shed some light on this tradeoff.

Effect of high-intensity interval training in adolescents with asthma: The eXercise for Asthma with Commando Joe's® (X4ACJ) trial

BACKGROUND

Higher levels of cardiorespiratory fitness are associated with reduced asthma severity and increased quality of life in those with asthma. Therefore, the purpose of this study was to evaluate the effectiveness of a 6-month high-intensity interval training (HIIT) intervention in adolescents with and without asthma.

METHODS

A total of 616 adolescents (334 boys; 13.0 ± 1.1 years, 1.57 ± 0.10 m, 52.6 ± 12.9 kg, mean ± SD), including 155 with asthma (78 boys), were recruited as part of a randomized controlled trial from 5 schools (4 control and 1 intervention). The 221 intervention participants (116 boys; 47 asthma) completed 6 months of school-based HIIT (30 min, 3 times per week, 10-30 s bouts at >90% age-predicted maximum heart rate with equal rest). At baseline, mid-intervention, post-intervention, and 3-month follow-up, measurements for 20-m shuttle run, body mass index (BMI), lung function, Pediatric Quality of Life Inventory, Paediatric Asthma Quality of Life Questionnaire, and Asthma Control Questionnaire were collected. Additionally, 69 adolescents (39 boys (of the 36 with asthma there were 21 boys)) also completed an incremental ramp test. For analysis, each group's data (intervention and control) were divided into those with and without asthma.

RESULTS

Participants with asthma did not differ from their peers in any parameter of aerobic fitness, at any time-point, but were characterized by a greater BMI. The intervention elicited a significant improvement in maximal aerobic fitness but no change in sub-maximal parameters of aerobic fitness, lung function, or quality of life irrespective of asthma status. Those in the intervention group maintained their BMI, whereas BMI significantly increased in the control group throughout the 6-month period.

CONCLUSION

HIIT represents an effective tool for improving aerobic fitness and maintaining BMI in adolescents, irrespective of asthma status. HIIT was well-tolerated by those with asthma, who evidenced a similar aerobic fitness to their healthy peers and responded equally well to a HIIT program.

Focus on asthma 3: the psychosocial effects of asthma on the child and the family

This article is the third in a series on asthma. The first article explored global and UK trends in asthma and asthma care as they relate to children and young people, while the second article identified the adverse effects of air pollution on children, particularly those with asthma. This article explores the potentially significant psychosocial effects of asthma on the child and the family. A family-centred approach to care relies on healthcare professionals listening to and understanding families' health beliefs and narratives to target asthma education and aid self-efficacy, which can improve asthma control and quality of life.

Developing and testing a cognitive bolt-on for the EQ-5D-Y (Youth)

Purpose

The aim of this study was to develop and test a cognitive dimension as a bolt-on for the German version of the EQ-5D-Y (Youth).

Methods

A literature review and six focus groups with children and adolescents were used to develop the cognitive dimension for the EQ-5D-Y. In a two-phase pretest, the acceptability, feasibility and performance of this dimension were assessed (phase 1: qualitative face-to-face interviews, phase 2: standard pretest in a clinical setting). In total, 280 children and adolescents participated in this study.

Results

School performance, concentration, memory and learning ability represent the most important components of cognitive functioning in children and adolescents. Hence, those components were incorporated into the cognitive dimension of the EQ-5D-Y by adding four items. For children and adolescents living with a rheumatic disorder or type 1 diabetes mellitus, the EQ-5D-Y plus a cognitive bolt-on demonstrated good acceptability, feasibility and performance. The cognitive items improved the explanatory power for the EQ visual analogue scale (EQ-VAS). Factor analysis has shown that a reduction of the cognitive bolt-on into one or two item(s) is justifiable.

Conclusion

By enhancing the EQ-5D-Y with a cognitive bolt-on, we developed an instrument that incorporates current findings on Health-Related Quality of Life (HRQoL) and is suitable for the target population. Empirical results of this study show that cognitive functioning is an important part of HRQoL assessment in children and adolescents. The inclusion of a cognitive dimension in the EQ-5D-Y improves the HRQoL measurement.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-02899-x.

Cost-effectiveness analysis of double low-dose budesonide and low-dose budesonide plus montelukast among pediatric patients with persistent asthma receiving Step 3 treatment in China

AIMS

For children aged 1-5 years with persistent asthma, double low-dose inhaled corticosteroids (ICS) are recommended as the preferred Step 3 treatment and low-dose ICS plus leukotriene receptor antagonists (LTRA) as an alternative. Budesonide inhalation suspension (0.5 mg daily) and montelukast (4.0 mg daily) are commonly used low-dose ICS and LTRA, respectively, among children in China. This study compared the cost-effectiveness of double low-dose budesonide vs. low-dose budesonide plus montelukast from a Chinese healthcare payer's perspective.

METHODS

A Markov model was constructed with four health states (i.e. no exacerbation, mild exacerbation, moderate-to-severe exacerbation, and death). Transition probabilities were estimated based on exacerbation rates, case-fatality of hospitalized patients due to exacerbation, and natural mortality. Treatment adherence was considered and assumed to impact both drug costs and exacerbation rates. Costs (in 2019 Chinese Yuan [¥]) included drug costs and exacerbation management costs. Cost inputs and utilities for each health state were obtained from a public database and the literature. In-depth interviews were conducted with a health economics expert to validate the model, and a clinical expert to verify inputs and assumptions related to clinical practice. Costs and quality-adjusted life-years (QALYs) were estimated over a year. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Compared with low-dose budesonide plus montelukast, double low-dose budesonide was associated with lower costs (¥1,534 vs. ¥2,327), fewer exacerbation events (0.43 vs. 1.67) and slightly better QALYs (0.98 vs. 0.97). Sensitivity analyses supported the robustness of the results and the generalizability of findings across geographic regions in China.

CONCLUSION

The cost-effectiveness analysis suggests that double low-dose budesonide is a dominant Step 3 treatment strategy compared with low-dose budesonide plus montelukast for patients aged 1-5 years with persistent asthma in China.

The Dynamic Relationship Between Asthma and Obesity in Schoolchildren

Asthma and obesity are among the most prevalent chronic health conditions in children. Although there has been compelling evidence of co-occurrence of asthma and obesity, it is uncertain whether asthma contributes to the development of obesity or obesity contributes to the onset of asthma or both. In this study, we used a joint transition modeling approach with cross-lagged structure to understand how asthma and obesity influence each other dynamically over time. Subjects for this study included 5,193 kindergarten and first-grade students enrolled from 13 communities in 2002-2003 in the Southern California Children's Health Study, with up to 10 years of follow-up. We found that nonobese children with diagnosed asthma at a study visit were at 37% higher odds of becoming obese by the next annual visit compared with children without asthma (odds ratio = 1.38; 95% credible interval: 1.12, 1.71). However, the presence of obesity at the current visit was not statistically significantly associated with asthma onset in the next visit (odds ratio = 1.25; 95% credible interval: 0.94, 1.62). In conclusion, childhood asthma appears to drive an increase in the onset of obesity among schoolchildren, while the onset of obesity does not necessarily imply the future onset of asthma, at least in the short term.

The impact of chronic non-specific cough on children and their families: A narrative literature review

The aim of this article is to critically appraise and synthesize research that examines the impact chronic non-specific cough has on children and their families and to highlight gaps within the research. Chronic non-specific cough refers to a persistent cough without a specific diagnosis. While studies have begun to examine the impact on children and their families, this research has not been synthesized and appraised. A narrative literature review was undertaken. A comprehensive and systematic search was undertaken, using CINAHL, MEDLINE, British Nursing Index, PsycINFO, Cochrane Wiley Library and ASSIA databases. Studies were critically appraised for quality using the Hawker et al.'s appraisal tool. A narrative review of the findings was undertaken. Nine quantitative studies were included in the review. The article suggests that chronic non-specific cough affects the quality of life of both families and children, affecting quality of sleep, impacting upon participation in activities, causing emotional distress and creating substantial demand on the health service. Furthermore, the research highlighted the worries experienced by parents in relation to the cause of their child's cough. The review did not identify any qualitative research in this area and only one study collected data directly from children.

Sensitization to inhaled allergens in asthmatic children in southern Jordan: a cross-sectional study

BACKGROUND

Sensitization to inhaled allergens in children with bronchial asthma significantly affects asthma pathogenesis, severity and persistence into late childhood and adulthood. The present study determined the prevalence of sensitization to inhaled allergens in children with bronchial asthma and wheezing episodes in order to investigate the effect of positive sensitization on the severity and control of asthma symptoms and to screen for other associated allergic conditions.

METHODS

A cross-sectional study was conducted, including children between 6 months and 14 years of age attending the chest clinic of Al-Karak, south of Jordan, between November 2013 and February 2016. Skin prick tests (SPTs) using 11 standardized allergen extracts were conducted in 277 children. The severity of asthma was determined based on the Global Initiative for Asthma (GINA) assessment and the Childhood Asthma Control Test (C-ACT) in addition to the history of use of systemic steroids and hospital admissions within the past 12 months.

RESULTS

Sixty-seven percent of children with bronchial asthma reported sensitization to one or more of the inhaled allergens. The most common allergens were olive pollens (18%), cat fur (13.5%), and Dermatophagoides pteronyssinus (11.9%). There was a significant increase in allergen sensitization with age (p < 0.001). The most common concomitant allergic condition among children was allergic rhinitis (71.5%); however, allergic conjunctivitis was the only allergic condition that correlated with the skin test reactivity (p = 0.01). A family history of bronchial asthma was confirmed in 40.4% of children. Children with positive SPTs had lower ACT scores and reported more frequent use of systemic steroids and admissions to hospital within the past 12 months; however, this effect was not statistically significant (p > 0.05).

CONCLUSIONS

Sensitization to inhaled allergens is highly prevalent in children with asthma and wheezing episodes in southern Jordan and may be correlated with the severity of the disease. Therefore, appropriate measures to recognize and avoid these allergens are highly recommended. Most children in our study suffered from concomitant allergic rhinitis, indicating that an appropriate diagnosis and treatment of allergic rhinitis could significantly improve asthma control and thus the quality of life of these children.

TRIAL REGISTRATION

This study is not a clinical trial.

An Examination of Factors Affecting Quality of Life for Children With Asthma and Their Caregivers in Southeastern Georgia

INTRODUCTION

Despite effective treatments and interventions, asthma continues to affect children's health-related quality of life (QOL). This study explored factors affecting QOL of children with asthma and their caregivers.

METHODS

A mixed-model design was used. Children (7-17 years) completed the Paediatric Asthma Quality of Life Questionnaire, and parents/caregivers completed the Paediatric Asthma Caregiver's Quality of Life Questionnaire. These surveys focused on activity limitations, emotional function, and child symptoms.

RESULTS

The sample included 104 children and 104 caregivers. Analysis showed emergency department (ED) visits as a significant predictor of QOL for children in the domains of Physical Activity, Emotional, and Symptoms. Increased ED visits and reliever medication use predicted lower emotional QOL and physical QOL for parents, whereas increased use of controller medications predicated improved physical QOL.

DISCUSSION

Factors contributing to QOL, along with characteristics of those with the lowest QOL indicators, have been determined. Identification of interventions to reduce ED visits warrants further investigation.

Effect of disease management education on the quality of life and self-efficacy levels of children with asthma

PURPOSE

The aim of this study was to determine the effects of disease management education provided to children with asthma on their quality of life and self-efficacy levels.

METHODS AND DESIGN

The study design was a quasi-experimental design with The One Group Pretest-Posttest design. This study was conducted on 60 children with asthma between 10 and 18 years of age. Data were collected by "Information Form", "Pediatric Asthma Quality of Life Questionnaire", and "Self-Efficacy Scale for Children and Adolescents with Asthma". Children's quality of life and self-efficacy levels were assessed before receiving an individual asthma education intervention and then children were informed with an asthma management education book individually. Two months after the education intervention, the quality of life and self-efficacy levels of the children were re-evaluated.

RESULTS

The children's quality of life and self-efficacy levels increased significantly after education (p = 0.014). Maternal age, number of siblings, number of family members living in the same house, activity status, the frequency of experiencing symptoms, and the ability to use the inhalers on their own affected children quality of life. Child's age, knowledge about factors causing asthma, and ability to use medication on their own affected their self-efficacy ( p < 0.05).

PRACTICE IMPLICATIONS

According to these results, planned asthma education program and provided continuity of this education by nurses would be effective to improve the quality of life and levels of self-efficacy. Asthma management education for children with asthma by nurses after diagnosis is beneficial for improving the quality of life and levels of self-efficacy.

School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review

BACKGROUND

Asthma is a common respiratory condition in children that is characterised by symptoms including wheeze, shortness of breath, chest tightness, and cough. Children with asthma may be able to manage their condition more effectively by improving inhaler technique, and by recognising and responding to symptoms. Schools offer a potentially supportive environment for delivering interventions aimed at improving self-management skills among children. The educational ethos aligns with skill and knowledge acquisition and makes it easier to reach children with asthma who do not regularly engage with primary care. Given the multi-faceted nature of self-management interventions, there is a need to understand the combination of intervention features that are associated with successful delivery of asthma self-management programmes.

OBJECTIVES

This review has two primary objectives.• To identify the intervention features that are aligned with successful intervention implementation.• To assess effectiveness of school-based interventions provided to improve asthma self-management among children.We addressed the first objective by performing qualitative comparative analysis (QCA), a synthesis method described in depth later, of process evaluation studies to identify the combination of intervention components and processes that are aligned with successful intervention implementation.We pursued the second objective by undertaking meta-analyses of outcomes reported by outcome evaluation studies. We explored the link between how well an intervention is implemented and its effectiveness by using separate models, as well as by undertaking additional subgroup analyses.

SEARCH METHODS

We searched the Cochrane Airways Trials Register for randomised studies. To identify eligible process evaluation studies, we searched MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Database of Systematic Reviews (CDSR), Web of Knowledge, the Database of Promoting Health Effectiveness Reviews (DoPHER), the Database of Abstracts of Reviews of Effects (DARE), the International Biography of Social Science (IBSS), Bibliomap, Health Technology Assessment (HTA), Applied Social Sciences Index and Abstracts (ASSIA), and Sociological Abstracts (SocAbs). We conducted the latest search on 28 August 2017.

SELECTION CRITERIA

Participants were school-aged children with asthma who received the intervention in school. Interventions were eligible if their purpose was to help children improve management of their asthma by increasing knowledge, enhancing skills, or changing behaviour. Studies relevant to our first objective could be based on an experimental or quasi-experimental design and could use qualitative or quantitative methods of data collection. For the second objective we included randomised controlled trials (RCTs) where children were allocated individually or in clusters (e.g. classrooms or schools) to self-management interventions or no intervention control.

DATA COLLECTION AND ANALYSIS

We used qualitative comparative analysis (QCA) to identify intervention features that lead to successful implementation of asthma self-management interventions. We measured implementation success by reviewing reports of attrition, intervention dosage, and treatment adherence, irrespective of effects of the interventions.To measure the effects of interventions, we combined data from eligible studies for our primary outcomes: admission to hospital, emergency department (ED) visits, absence from school, and days of restricted activity due to asthma symptoms. Secondary outcomes included unplanned visits to healthcare providers, daytime and night-time symptoms, use of reliever therapies, and health-related quality of life as measured by the Asthma Quality of Life Questionnaire (AQLQ).

MAIN RESULTS

We included 55 studies in the review. Thirty-three studies in 14,174 children provided information for the QCA, and 33 RCTs in 12,623 children measured the effects of interventions. Eleven studies contributed to both the QCA and the analysis of effectiveness. Most studies were conducted in North America in socially disadvantaged populations. High school students were better represented among studies contributing to the QCA than in studies contributing to effectiveness evaluations, which more commonly included younger elementary and junior high school students. The interventions all attempted to improve knowledge of asthma, its triggers, and stressed the importance of regular practitioner review, although there was variation in how they were delivered.QCA results highlighted the importance of an intervention being theory driven, along with the importance of factors such as parent involvement, child satisfaction, and running the intervention outside the child's own time as drivers of successful implementation.Compared with no intervention, school-based self-management interventions probably reduce mean hospitalisations by an average of about 0.16 admissions per child over 12 months (SMD -0.19, 95% CI -0.35 to -0.04; 1873 participants; 6 studies, moderate certainty evidence). They may reduce the number of children who visit EDs from 7.5% to 5.4% over 12 months (OR 0.70, 95% CI 0.53 to 0.92; 3883 participants; 13 studies, low certainty evidence), and probably reduce unplanned visits to hospitals or primary care from 26% to 21% at 6 to 9 months (OR 0.74, 95% CI 0.60 to 0.90; 3490 participants; 5 studies, moderate certainty evidence). Self-management interventions probably reduce the number of days of restricted activity by just under half a day over a two-week period (MD 0.38 days 95% CI -0.41 to -0.18; 1852 participants; 3 studies, moderate certainty evidence). Effects of interventions on school absence are uncertain due to the variation between the results of the studies (MD 0.4 fewer school days missed per year with self-management (-1.25 to 0.45; 4609 participants; 10 studies, low certainty evidence). Evidence is insufficient to show whether the requirement for reliever medications is affected by these interventions (OR 0.52, 95% CI 0.15 to 1.81; 437 participants; 2 studies; very low-certainty evidence). Self-management interventions probably improve children's asthma-related quality of life by a small amount (MD 0.36 units higher on the Paediatric AQLQ(95% CI 0.06 to 0.64; 2587 participants; 7 studies, moderate certainty evidence).

AUTHORS' CONCLUSIONS

School-based asthma self-management interventions probably reduce hospital admission and may slightly reduce ED attendance, although their impact on school attendance could not be measured reliably. They may also reduce the number of days where children experience asthma symptoms, and probably lead to small improvements in asthma-related quality of life. Many of the studies tested the intervention in younger children from socially disadvantaged populations. Interventions that had a theoretical framework, engaged parents and were run outside of children's free time were associated with successful implementation.

Children with Obesity and Asthma: Which Are the Best Options for Their Management?

Obesity and asthma are complex disorders related to gene-environment interactions and various lifestyle factors. At present, they represent two of the most significant paediatric health problems worldwide, particularly in industrialized nations. The aim of this narrative review is to evaluate possible therapeutic strategies to manage asthma in children with overweight/obesity. PubMed was used to search for all of the studies published from January 2008 to June 2018 using the following key words: “asthma” and “overweight” or “obesity” or “obese” and “children” or “paediatric”. The literature review showed that growing evidence underlines the existence of an “obese asthma” phenotype characterised by difficult-to-control asthma with additional symptoms, worse control, more frequent and severe exacerbations, reduced response to inhaled corticosteroids, and lower quality of life than other phenotypes. Currently, therapeutic strategies centred on prevention are suggested and the development of resources to assist families with weight loss strategies seems useful for effective weight control and optimal asthma management. Studies on vitamin D supplementation and further knowledge are needed to better define the best therapeutic options to manage asthma in children with overweight/obesity and to reduce the onset and severity of this chronic respiratory disease through the design of a multifactorial intervention.

The Effects of Asthma and Bullying on Suicidal Behaviors Among US Adolescents

BACKGROUND

Positive associations between suicidal behaviors and asthma have been established in previous adolescent studies. Few studies consider social risk factors, such as bullying. This study involved an analysis of suicidal behaviors and asthma, but also includes an assessment of whether these relationships were modified by the co-occurrence of bullying.

METHODS

Data included 13,154 participants from the 2013 Youth Risk Behavior Survey (YRBS), collected by the US Centers for Disease Control and Prevention. Logistic regression models were constructed and summarized using odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

When comparing adolescents with asthma who were bullied at school to those who were not bullied at school, the odds of contemplating suicide were increased by nearly 2-fold (OR = 1.8, 95% CI = 1.5-2.3), and the odds of creating a suicide plan were 2.3 times higher (OR = 2.3, 95% CI = 1.7-3.1). The odds of a suicide attempt and incurring an injury from a suicide attempt were also substantially increased. Similarly, increased odds of suicidal behaviors were observed for adolescents with asthma who were bullied electronically.

CONCLUSION

Having asthma and being bullied are both associated with increased odds of suicidal behaviors.

"How Is My Child's Asthma?" Digital Phenotype and Actionable Insights for Pediatric Asthma

BACKGROUND

In the traditional asthma management protocol, a child meets with a clinician infrequently, once in 3 to 6 months, and is assessed using the Asthma Control Test questionnaire. This information is inadequate for timely determination of asthma control, compliance, precise diagnosis of the cause, and assessing the effectiveness of the treatment plan. The continuous monitoring and improved tracking of the child's symptoms, activities, sleep, and treatment adherence can allow precise determination of asthma triggers and a reliable assessment of medication compliance and effectiveness. Digital phenotyping refers to moment-by-moment quantification of the individual-level human phenotype in situ using data from personal digital devices, in particular, mobile phones. The kHealth kit consists of a mobile app, provided on an Android tablet, that asks timely and contextually relevant questions related to asthma symptoms, medication intake, reduced activity because of symptoms, and nighttime awakenings; a Fitbit to monitor activity and sleep; a Microlife Peak Flow Meter to monitor the peak expiratory flow and forced exhaled volume in 1 second; and a Foobot to monitor indoor air quality. The kHealth cloud stores personal health data and environmental data collected using Web services. The kHealth Dashboard interactively visualizes the collected data.

OBJECTIVE

The objective of this study was to discuss the usability and feasibility of collecting clinically relevant data to help clinicians diagnose or intervene in a child's care plan by using the kHealth system for continuous and comprehensive monitoring of child's symptoms, activity, sleep pattern, environmental triggers, and compliance. The kHealth system helps in deriving actionable insights to help manage asthma at both the personal and cohort levels. The Digital Phenotype Score and Controller Compliance Score introduced in the study are the basis of ongoing work on addressing personalized asthma care and answer questions such as, "How can I help my child better adhere to care instructions and reduce future exacerbation?"

METHODS

The Digital Phenotype Score and Controller Compliance Score summarize the child's condition from the data collected using the kHealth kit to provide actionable insights. The Digital Phenotype Score formalizes the asthma control level using data about symptoms, rescue medication usage, activity level, and sleep pattern. The Compliance Score captures how well the child is complying with the treatment protocol. We monitored and analyzed data for 95 children, each recruited for a 1- or 3-month-long study. The Asthma Control Test scores obtained from the medical records of 57 children were used to validate the asthma control levels calculated using the Digital Phenotype Scores.

RESULTS

At the cohort level, we found asthma was very poorly controlled in 37% (30/82) of the children, not well controlled in 26% (21/82), and well controlled in 38% (31/82). Among the very poorly controlled children (n=30), we found 30% (9/30) were highly compliant toward their controller medication intake-suggesting a re-evaluation for change in medication or dosage-whereas 50% (15/30) were poorly compliant and candidates for a more timely intervention to improve compliance to mitigate their situation. We observed a negative Kendall Tau correlation between Asthma Control Test scores and Digital Phenotype Score as -0.509 (P<.01).

CONCLUSIONS

kHealth kit is suitable for the collection of clinically relevant information from pediatric patients. Furthermore, Digital Phenotype Score and Controller Compliance Score, computed based on the continuous digital monitoring, provide the clinician with timely and detailed evidence of a child's asthma-related condition when compared with the Asthma Control Test scores taken infrequently during clinic visits.

The effect of balance training intervention on postural stability in children with asthma

OBJECTIVE

Pulmonary rehabilitation is mainly focused on exercise training and breathing retraining in children with asthma. Conversely, balance training is not usually recommended for the treatment, although postural deficits were found in these patients. Therefore, this study assessed the effect of balance training intervention on postural stability in children with asthma.

METHODS

Nineteen children with mild intermittent asthma (age 11.1 ± 2.1 years, height 147.6 ± 13.9 cm, weight 41.8 ± 13.3 kg) were randomly assigned to an experimental group or a control group and completed a four-week physiotherapy program including breathing exercises and aerobic physical training (six times/week, 45 minutes). Both groups performed the same training, but only the experimental group underwent exercises on balance devices. The center of pressure (CoP) velocity in the anteroposterior (V_y) and mediolateral (V_x) directions, and total CoP velocity (V_tot) were recorded before and after training in the preferred and the adjusted stances under eyes open (EO) and eyes closed (EC) conditions.

RESULTS

The addition of balance intervention led to significant improvements of V_tot (p = 0.02, p = 0.04) in both types of stance, V_x in the preferred stance (p = 0.03) and V_y in the adjusted stance (p = 0.01) under EO conditions. Significant improvements were also found in V_y in the adjusted stance (p = 0.01) under EC conditions.

CONCLUSIONS

Results of this study support the effectiveness of balance training as a part of physiotherapy treatment for improving balance performance, predominantly under EO conditions, in children with mild asthma.

The school as a health promoter for children with asthma: The purpose of an education programme

BACKGROUND

Not only is asthma one of the leading causes of hospitalisation in children under 15 years and one of the main reasons for primary care outpatient visits, it also accounts for 13 million lost days of school annually, which can affect children's learning, integration at school and overall academic achievements.

MATERIAL AND METHODS

This review article highlights the important role of the school in helping children and adolescents to control and manage their asthma through integrated and coordinated actions of health professionals, school staff, family, and the community.

RESULTS

We recommended key elements for a multidisciplinary team asthma school programme that can be replicated and implemented especially in developing countries where children and adolescents are in a more disadvantaged environment.

CONCLUSION

This multidisciplinary asthma school intervention when demonstrated with efficacy can be applied in the context of the real world, where many children and families who need care the most currently do not receive it.

PELICAN: Content evaluation of patient-centered care for children with asthma based on an online tool

BACKGROUND

We assessed the content of an intervention which integrates individual goals in outpatient clinic asthma management (based on self management principles) of children 6-12 years of age.

METHODS

This is a content evaluation study and was part of a randomized controlled multicenter trial with 9 months follow-up in five Dutch outpatient asthma clinics among children with asthma aged 6-12 years. Information on children's individual problems and their level of impairment (as indicated by the Pelican instrument), asthma management goals, and actions (as indicated by written action plans) was collected. Satisfaction of parents, children, and nurses were assessed with questionnaires and analyzed with descriptive statistics.

RESULTS

Most frequently identified problems by children (n = 42) were "cough," "cigarette smoke," and "shortness of breath." Eighty-two percent of items that were selected by children showed room for improvement. About 2-7 actions were formulated and children had an active role in more than 76% of the actions. "Using rescue medication prior to activities/triggers," and "talk to others about your asthma" were most frequently recommended. Children thought the Pelican instrument was easy (95%) and fun (65%) and both parents and nurses were positive about the incorporation of the program in asthma management. Following barriers were found: (1) only 25% of goals was formulated according to SMART principles; (2) traditional management aspects (such as medication use) are often treated instead of individual problems of children.

CONCLUSION

Implementation of patient-centered care based on the Pelican instrument is recommended in specialized care, although more extensive training of nurses in PCC will improve the successful execution of the evaluated treatment. Pediatr Pulmonol. 2016;51:993-1003. © 2016 Wiley Periodicals, Inc.

Assessing Asthma Symptoms in Adolescents and Adults: Qualitative Research Supporting Development of the Asthma Daily Symptom Diary

BACKGROUND

Despite the widespread availability of patient-reported asthma questionnaires, instruments developed in accordance with present regulatory expectations are lacking. To address this gap, the Patient-Reported Outcome (PRO) Consortium's Asthma Working Group has developed a patient-reported asthma daily symptom diary (ADSD) for use in clinical research to assess outcomes and support medical product labeling claims in adults and adolescents with asthma.

OBJECTIVES

To summarize the qualitative research conducted to inform the initial development of the ADSD and to provide evidence for content validity of the instrument in accordance with the Food and Drug Administration's PRO Guidance.

METHODS

Research informing the initial development and confirming the content validity of the ADSD is summarized. This comprised a review of published qualitative research, semi-structured concept elicitation interviews (n = 55), and cognitive interviews (n = 65) with a diverse and representative sample of adults and adolescents with a clinician-confirmed diagnosis of asthma in the United States to understand the asthma symptom experience and to assess the relevance and understanding of the newly developed ADSD.

RESULTS

From the qualitative literature review and concept elicitation interviews, eight core asthma symptoms emerged. These were broadly categorized as breathing symptoms (difficulty breathing, shortness of breath, and wheezing), chest symptoms (chest tightness, chest pain, and pressure/weight on chest), and cough symptoms (cough and the presence of mucus/phlegm). Conceptual saturation was achieved and differences in the experience of participants according to socio-demographic or clinical characteristics were not observed. Subsequent testing of the ADSD confirmed participant relevance and understanding.

CONCLUSIONS

The ADSD is a new patient-reported asthma symptom diary developed in accordance with the Food and Drug Administration's PRO Guidance. Evidence to date supports the content validity of the instrument. Item performance, reliability, and construct validity will be assessed in future quantitative research.

Are children with asthma overconfident that they are using their inhalers correctly?

OBJECTIVE

The objectives of this study were to quantify the extent to which children with asthma are overconfident that they are using their inhalers correctly and determine whether demographic and clinical characteristics are associated with children being overconfident.

METHODS

Children (n = 91) ages 7-17 with persistent asthma were recruited at two pediatric practices in North Carolina and demonstrated their inhaler technique for metered dose inhalers during an office visit. Children were dichotomized into two groups based on how confident they were that they were using their inhalers correctly: "completely confident" or "not completely confident". The mean number of inhaler steps (out of 8) children performed incorrectly was examined. We applied linear regression models for children in the "completely confident" group to determine whether demographic and clinical factors predicted their overconfidence, defined as the number of inhaler steps performed incorrectly.

RESULTS

Children were primarily male (56%) and non-Hispanic White (60%). Sixty-eight (75%) children were "completely confident" that they were using their inhalers correctly. The "completely confident" group missed an average of 1.5 steps. In the "completely confident" group, males (p < 0.04) missed significantly more steps than females. The two most common errors were forgetting to shake the inhaler and holding their breath for 10 s.

CONCLUSION

Regardless of their confidence level, children in our sample missed an average of 1-2 steps on an inhaler technique assessment. Findings from this study provide new evidence that it is insufficient to ask children if they are using their inhalers correctly. Therefore, it is vital that providers ask children to demonstrate their inhaler technique during health encounters.

Child Allergic Symptoms and Well-Being at School: Findings from ALSPAC, a UK Cohort Study

Background

Eczema and asthma are common conditions in childhood that can influence children’s mental health. Despite this, little is known about how these conditions affect the well-being of children in school. This study examines whether symptoms of eczema or asthma are associated with poorer social and mental well-being in school as reported by children and their teachers at age 8 years.

Methods

Participants were from the Avon Longitudinal Study of Parents and Children. Measures of child well-being in school were child-reported (n = 6626) and teacher reported (n = 4366): children reported on their enjoyment of school and relationships with peers via a self-complete questionnaire; teachers reported child mental well-being using the Strengths and Difficulties Questionnaire [binary outcomes were high ‘internalizing’ (anxious/depressive) and ‘externalizing’ (oppositional/hyperactive) problems (high was >90th percentile)]. Child rash and wheeze status were maternally reported and symptoms categorised as: ‘none’; ‘early onset transient’ (infancy/preschool only); ‘persistent’ (infancy/preschool and at school age); and ‘late onset’ (school age only).

Results

Children with persistent (OR 1.29, 95% CI 1.02 to 1.63) and late onset (OR 1.48, 95% CI 1.02 to 2.14) rash were more likely to report being bullied, and children with persistent wheeze to feel left out (OR 1.42, 95% CI 1.10 to 1.84). Late onset rash was associated with high teacher-reported internalising behaviours (OR 1.61, 95% CI 1.02 to 2.54), and persistent rash with high externalising behaviours (OR 1.37, 95% CI 1.02 to 1.84). Child sleep and maternal mental health explained some of the associations with teacher-reported mental well-being.

Conclusion

Symptoms of eczema or asthma can adversely affect a child’s social and mental well-being at primary school. This suggests interventions, such as additional support or education of peers, should begin at early stages in schooling.

Validation of the malaysian versions of parents and children health survey for asthma by using rasch-model

CONTEXT

In recent years, health-related quality of life (HRQOL) has become an important outcome measure in epidemiologic studies and clinical trials. For patients with asthma there are many instruments but most of them have been developed in English. With the increase in research project, researchers working in other languages have two options; either to develop a new measure or to translate an already developed measure. Children Health Survey for Asthma is developed by American Academy of Paediatrics which has two versions one for the parents (CHSA) and the other for the child (CHSA-C). However, there is no Malay version of the CHSA or the CHSA-C.

AIM

The aim of this study was to translate and determine the validity and reliability of the Malaysian versions of Parent and Children Health Survey for Asthma.

MATERIALS AND METHODS

Questionnaires were translated to Bahasa Malayu using previously established guidelines, data from 180 respondents (asthmatic children and their parent) were analysed using Rasch-Model; as, it is an approach that has been increasingly used in health field and also it explores the performance of each item rather than total set score.

RESULTS

The internal consistency was high for the parent questionnaire (CHSA) (reliability score for persons = 0.88 and for items was 0.97), and good for child questionnaire (CHSA-C) (reliability score for persons = 0.83 and for items was 0.94). Also, this study shows that all items measure for both questionnaires (CHSA and CHSA-C) are fitted to Rasch-Model.

CONCLUSION

This study produced questionnaires that are conceptually equivalent to the original, easy to understand for the children and their parents, and good in terms of internal consistency. Because of the questionnaire has two versions one for the child and the other for the parents, they could be used in clinical practice to measure the effect of asthma on the child and their families. This current research had translated two instruments to other language (BahasaMalayu) and evaluated their reliability and validity hence will help researchers from the same country to use these translated instruments in their studies.

Overweight children report qualitatively distinct asthma symptoms: analysis of validated symptom measures

BACKGROUND

Past studies of asthma in overweight/obese children have been inconsistent. The reason overweight/obese children commonly report worse asthma control remains unclear.

OBJECTIVE

To determine qualitative differences in symptoms between lean and overweight/obese children with early-onset, atopic asthma.

METHODS

We conducted a cross-sectional analytic study of lean (20% to 65% body mass index) and overweight/obese (≥85% body mass index) 10- to 17-year-old children with persistent, early-onset asthma. Participants completed 2 to 3 visits to provide a complete history, qualitative and quantitative asthma symptom characterization, and lung function testing. We determined associations between weight status and symptoms using multivariable linear and logistic regression methods.

RESULTS

Overweight/obese and lean asthmatic children displayed similar lung function. Despite lower fraction of exhaled nitric oxide (30.0 vs 62.6 ppb; P = .037) and reduced methacholine responsiveness (PC20FEV1 1.87 vs 0.45 mg/mL; P < .012), overweight/obese children reported more than thrice frequent rescue treatments (3.7 vs 1.1 treatments/wk; P = .0002) than did lean children. Weight status affected the child's primary symptom reported with loss of asthma control (Fisher exact test; P = .003); overweight/obese children more often reported shortness of breath (odds ratio = 11.8; 95% CI, 1.41-98.7) and less often reported cough (odds ratio = 0.26; 95% CI, 0.08-0.82). Gastroesophageal reflux scores were higher in overweight/obese children (9.6 vs 23.2; P = .003) and appear to mediate overweight/obesity-related asthma symptoms.

CONCLUSIONS

Overweight/obese children with early-onset asthma display poorer asthma control and a distinct pattern of symptoms. Greater shortness of breath and β-agonist use appears to be partially mediated via esophageal reflux symptoms. Overweight children with asthma may falsely attribute exertional dyspnea and esophageal reflux to asthma, leading to excess rescue medication use.

PELICAN: a cluster-randomized controlled trial in Dutch general practices to assess a self-management support intervention based on individual goals for children with asthma

OBJECTIVE

Insufficient asthma management leads to impaired health-related quality of life (HRQL). The aim of this study is to assess whether individualized self-management (ISM) support will improve HRQL in children with asthma compared to enhanced usual care (EUC) in Dutch general practices.

METHODS

A cluster-randomized controlled trial with 9-month follow-up. ISM is a nurse-led intervention that is optimized to the needs of children, leading to a written action plan. Power calculation demanded inclusion of 170 children (aged 6-11 years) diagnosed with asthma and active medication use.

RESULTS

Outcomes were HRQL of the child (Paediatric Asthma Quality of Life Questionnaire, PAQLQ-s) and several secondary outcomes. Data of 29 children (mean age 8.6 years, SD 1.7) were analyzed; ISM (n = 15) or EUC (n = 14). Logistic regression analysis (minimal clinical important difference; MCID ≥ 0.5) and descriptive analyses were performed. Despite high PAQLQ-s score at baseline (median ISM 6.35, EUC 6.02), a substantial number of subjects from both groups showed MCID of HRQL (ISM 33%, EUC 57%). Treatment differences on HRQL were not significant (OR 0.38, 95% CI 0.08, 1.69). Secondary outcomes did not show significant differences either, with exception of PAQLQ-s symptoms domain score in favor of EUC.

CONCLUSION

Due to recruitment problems and underpowered analyses, no firm conclusions on the effectiveness of ISM support for childhood asthma in primary care could be drawn. Still, this study can be considered a valuable pilot study and in the future, there might be better capacity in general practices to commit to such treatment.

Effects of exercise training on airway hyperreactivity in asthma: a systematic review and meta-analysis

BACKGROUND

Although physical exercise is recommended for asthmatics, evidence on the effects of exercise on clinical key factors is still missing.

OBJECTIVES

We performed a systematic review and meta-analysis to determine the effect of exercise training (EXT) on quality of life (QoL), bronchial hyperresponsiveness (BHR), exercise-induced bronchoconstriction (EIB), lung function and exercise capacity, plus the factors affecting changes in QoL and exercise capacity in asthmatics after a period of EXT.

DATA SOURCES

A computerized search was conducted in MEDLINE, EMBASE, and CINAHL (last search on 15 November 2012), without language restriction, and references of original studies and reviews were searched for further relevant studies.

STUDY SELECTION

Two independent investigators screened full-text studies with asthmatic subjects undertaking EXT (defined as training for ≥7 days, ≥2 times per week, ≥5 training sessions in total) that assessed at least one of the following outcomes: QoL, airway hyperreactivity, forced expiratory volume in one second (FEV₁), peak expiratory flow (PEF), inflammatory parameters, exercise capacity, or exercise endurance. Potentially relevant studies were excluded if only respiratory muscle training, breathing exercises or yoga was performed, if asthmatic subjects with co-morbidities were investigated, if only data of mixed patient groups without separate results for asthmatics were presented, if training regimens were not sufficiently specified, if no numerical outcome data were presented, and if new long-term medication was introduced in addition to physical training. Of 500 potentially relevant articles, 13.4 % (67 studies including 2,059 subjects) met the eligibility criteria and were included for further analyses.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data extraction and risk of bias assessment was performed according to the Cochrane Handbook for Systematic Reviews of Interventions. A meta-analysis of all randomized controlled trials (RCTs) was performed to determine the effect of EXT on asthma symptoms, BHR, EIB, FEV₁, exercise capacity and exercise endurance compared with control training. In addition, relative pre/post changes were analysed in all RCTs and controlled trials. Finally, multiple linear regression models were used to identify effects of relative changes in airway hyperreactivity (BHR or EIB), lung function (FEV₁ or PEF) and training hours on QoL and exercise performance.

RESULTS

In a total of 17 studies including 599 subjects, meta-analyses showed a significant improvement in days without asthma symptoms, FEV1 and exercise capacity while BHR only tended to improve. The analysis of relative within-group changes after EXT showed, however, significant improvements in QoL (17 %), BHR (53 %), EIB (9 %), and FEV1 (3 %) compared with control conditions. Multiple linear regression models revealed that changes in airway hyperreactivity and lung function significantly contributed to the change in QoL, while mainly the changes in airway hyperreactivity contributed to the change in exercise capacity.

CONCLUSION

EXT was shown to improve asthma symptoms, QoL, exercise capacity, BHR, EIB, and FEV1 in asthmatics and improvements in BHR explained part of the improvement in QoL and exercise capacity. Thus, physical activity should be recommended as a supplementary therapy to medication. However, more well controlled studies should be performed assessing the relationship of physical activity, QoL, airway hyperreactivity, lung function and especially airway inflammation as well as medication intake.

Validity, reliability and discriminative capacity of an electronic quality of life instrument (Pelican) for childhood asthma in the Netherlands

PURPOSE

To assess psychometric properties of the Pelican instrument, an online Dutch self-administered Quality of Life instrument for childhood asthma for scientific and clinical use.

METHODS

A cohort study was done in two asthma populations and healthy children. One asthma population had assessment at start, 4 and 8 weeks. The other asthma population and healthy children had one assessment. All children were aged 6-12 years. Children completed the Pelican instrument, Paediatric Asthma Quality of Life Questionnaire, feeling thermometer and Childhood Asthma Control Test. Lung function and fraction exhaled nitric oxide were measured. Parents completed Functional Status II, Asthma Control Questionnaire, Childhood Asthma Control Test questionnaires and symptom diaries. We assessed interpretability, structural validity, internal consistency, reliability, construct and discriminative validity of the Pelican instrument.

RESULTS

Eighty-five asthmatic (mean age 8.5 years) and 49 healthy children (mean age 8.4 years) participated. The Pelican instrument has 5 domains with 21 items after factor analysis. Internal consistency was 0.89 (CI 0.85-0.92), domain reliability showed Cronbach's α's from 0.64 to 0.76 and item-to-scale correlations from 0.61 to 0.81. Test-retest reliability was confirmed ICC = 0.88 (CI 0.79-0.93). Construct validity was demonstrated by significant moderate correlations with other relevant asthma outcomes like PAQLQ (r = -0.59, p < 0.01). Discriminative capacity between controlled or uncontrolled asthma (t = 3.20, p < 0.01, Δ = 0.64) and asthma versus healthy subjects (t = 6.31, p < 0.01, Δ = 0.94) was found.

CONCLUSIONS

The psychometric properties of the Pelican instrument were acceptable in Dutch paediatric asthma patients between 6 and 12 years old.

Medication use in Australian children with asthma: user's perspective

BACKGROUND AND OBJECTIVES

Medication use-related issues remain problematic in childhood asthma despite effective treatment strategies and public investment into improved asthma management strategies in industrialized countries. This study aimed to carry out an in-depth exploration of the views of parents/carers and children with asthma on medication use.

METHODS

Semi-structured qualitative interviews were conducted with a purposive convenience sample of children with asthma and their parents recruited from general practices in Sydney. Interviews were tape-recorded, transcribed verbatim, and thematically analyzed.

RESULTS

A total of 52 interviews (26 parents/carers and 26 children with asthma) were conducted. Major themes which emerged from the children's interviews included issues such as self-image, resistance to medication use, and lack of responsibility in medication taking. Parental or carer issues included lack of clear understanding of how medications worked, as well as administration difficulties, cost constraints, and beliefs about medications contrary to quality use.

DISCUSSION

This is one of the few research studies exploring the viewpoint of children with asthma about their medications in Australia. Despite investment in dissemination of professional, targeted evidence-based asthma management strategies in healthcare, there seems to be a lack of depth in terms of what parents understand about their child's asthma. Effective communication about medication usage, especially the inclusion of the child in the consultation to empower them to be involved in their own asthma care, may be the answer.

PELICAN: A quality of life instrument for childhood asthma: study protocol of two randomized controlled trials in primary and specialized care in the Netherlands

Background

Asthma is one of the major chronic health problems in children in the Netherlands. The Pelican is a paediatric asthma-related quality of life instrument for children with asthma from 6–11 years old, which is suitable for clinical practice in primary and specialized care. Based on this instrument, we developed a self-management treatment to improve asthma-related quality of life. The Pelican intervention will be investigated in different health care settings. Results of intervention studies are often extrapolated to other health care settings than originally investigated. Because of differences in organization, disease severity, patient characteristics and care provision between health care settings, extrapolating research results could lead to unnecessary health costs without the desired health care achievements. Therefore, interventions have to be investigated in different health care settings when possible. This study is an example of an intervention study in different health care settings. In this article, we will present the study protocol of the Pelican study in primary and specialized care.

Method/design

This study consists of two randomized controlled trials to assess the effectiveness of the Pelican intervention in primary and specialized care. The trial in primary care is a multilevel design with 170 children with asthma in 16 general practices. All children in one general practices are allocated to the same treatment group. The trial in specialized care is a multicentre trial with 100 children with asthma. Children in one outpatient clinic are randomly allocated to the intervention or usual care group. In both trials, children will visit the care provider four times during a follow-up of nine months. This study is registered and ethically approved.

Discussion

This article describes the study protocol of the Pelican study in different health care settings. If the Pelican intervention proves to be effective and efficient, implementation in primary and specialized care for paediatric asthma in the Netherlands will be recommended.

Trial registration

This study is registered by clinicaltrial.gov (NCT01109745)

Development of a core outcome set for clinical trials in childhood asthma: a survey of clinicians, parents, and young people

BACKGROUND

In clinical trials in childhood asthma, outcomes reflecting short-term disease activity are frequently measured, whilst functional status, quality of life (QoL), and long-term treatment effects are rarely assessed. There is also non-uniformity across studies in the selection and measurement of outcomes within these domains. The development of a core outcome set has the potential to reduce heterogeneity between trials, lead to research that is more likely to have measured relevant outcomes, and enhance the value of evidence synthesis by reducing the risk of outcome reporting bias and ensuring that all trials contribute usable information.

METHODS

Paediatricians and specialist nurses, identified through the British Paediatric Respiratory Society, completed a two-round Delphi survey. Separate cohorts of parents of children younger than 18 years, recruited in clinics, participated in each round. Young people with asthma, aged at least 13 years, participated in the first round. Outcomes were identified separately for preschool and school-aged children.We identified outcomes considered important in routine clinical assessment by clinicians and parents/young people. In round 1, 46 clinicians suggested outcomes they considered important when deciding whether to adjust a child's asthma therapy regime, and 49 parents/young people were asked, using open questions, how they judged whether their child's (for young people, their own) asthma therapy was appropriate. Two researchers independently classified responses into appropriate, corresponding outcomes.In round 2, 43 clinicians and 50 parents scored, from 0-4, the importance of each outcome suggested by at least 10 % of round 1 responders and selected the three most important.

RESULTS

The most important outcomes, when making shared decisions about regular therapies for school-aged and preschool children with asthma, were daytime and nocturnal symptoms, exacerbations, QoL, and mortality. Results from parents and clinicians were generally concordant, but parents placed more emphasis on long-term treatment effects.

CONCLUSIONS

We have developed a methodology to identify outcomes of most relevance to clinicians, parents, and young people when evaluating regularly administered therapies for asthma. Daytime and nocturnal symptoms, exacerbations, QoL, and mortality are particularly important outcomes that should be measured and reported in all clinical trials of regular therapies for children with asthma.

[Knowledge, attitudes and asthma quality of life of adolescents in schools. The need to educate our teaching centres]

INTRODUCTION

Knowledge and attitudes toward asthma can condition the integration of adolescents with asthma in school and affect their quality of life. Our objective was to determine the state of knowledge, attitudes on asthma in secondary schools, and its relationship to quality of life of pupils with asthma, as an early step to an educational intervention.

METHODS

Descriptive and cross-sectional study of pupils aged 13 and 14 years old and their teachers in 26 schools of Seville and province. We used, as study tools, the Newcastle Asthma Knowledge Questionnaire, the Gibson attitudes towards asthma, and the Paediatric Asthma Quality of Life Questionnaire. To assess the normality of variables, the Kolmogorov-Smirnov test was used, and for non-parametric variables the U Mann-Whitney and W Wilcoxon tests were used. For the association between variables, we use the regression coefficients and rho Spearman.

RESULTS

We studied 3827 pupils (279 with asthma) and 548 teachers. All had little knowledge about asthma. The quality of life in asthma was mild to moderately affected, and lower in girls, 5.38±1.08 (95% CI=5.20 to 5.55) than in boys 5.77 (± 1.18) (95% CI=5.56 to 5.97), P=.0000. We found no relationship between knowledge, attitudes and quality of life in asthma.

CONCLUSIONS

We found a low level of knowledge about asthma in pupils and teacher. Asthma sufferers have a mild to moderate asthma quality of life, which is worse for girls. Knowledge has no relationship with attitudes to asthma in all groups, or with the quality of life of asthma sufferers.

Medication use in children with asthma: not a child size problem

OBJECTIVE

The global burden of pediatric asthma is high. Governments and health-care systems are affected by the increasing costs of childhood asthma--in terms of direct health-care costs and indirect costs due to loss of parental productivity, missed school days, and hospitalizations. Despite the availability of effective treatment, the current use of medications in children with asthma is suboptimal. The purpose of this review is to scope the empirical literature to identify the problems associated with the use of pediatric asthma medications. The findings will help to design interventions aiming to improve the use of asthma medications among children.

METHODS

A literature search using electronic search engines (i.e., Medline, International Pharmaceutical Abstracts (IPA), PubMed, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) and the search terms "asthma," "children," and "medicines" (and derivatives of these keywords) was conducted.

RESULTS

The search terms were expanded to include emergent themes arising out of search findings. Content themes relating to parents, children themselves, health-care professionals, organizational systems, and specific medications and devices were found. Within these themes, key issues included a lack of parental knowledge about asthma and asthma medications, lack of information provided to parents, parental beliefs and fears, parental behavioral problems, the high costs of medications and devices, the child's self-image, the need for more child responsibility, physician nonadherence to prescribing guidelines, "off-label" prescribing, poor understanding of teachers, lack of access to educational resources, and specific medications.

CONCLUSION

These key issues should be taken into account when modifying the development of educational tools. These tools should focus on targeting the children themselves, the parent/carers, the health-care professionals, and various organizational systems.

Adapting the Asthma Life Impact Scale (ALIS) for use in Southern European (Italian) and Eastern European (Russian) cultures

BACKGROUND

The Asthma Life Impact Scale (ALIS) is a disease-specific measure used to assess the quality-of-life of people with asthma. It was developed in the UK and US and has proven to be acceptable to patients, to have good psychometric properties, and to be unidimensional.

OBJECTIVE

This paper reports on the adaptation and validation of the ALIS for use in representative Southern European (Italian) and Eastern European (Russian) languages.

METHODS

The ALIS was translated for both cultures using the dual-panel process. The newly translated versions were then tested with asthma patients to ensure face and content validity. Psychometric properties of the new language versions were assessed via a test?re-test postal survey conducted in both countries.

LIMITATIONS

It is possible that some cultural or language differences still exist between the different language versions. Further research should be undertaken to determine responsiveness. Further studies designed to determine the clinical validity of the Italian ALIS would be valuable.

RESULTS

Linguistic nuances were easily resolved during the translation process for both language adaptations. Cognitive debriefing interviews (Russia n=9, male=11.1%, age mean (SD)=55.4 (13.2); Italy n=15, male=66.7%, age mean (SD)=63.5 (11.2)) indicated that the ALIS was easy to read and acceptable to patients. Psychometric testing was conducted on the data (Russia n=61, age mean (SD)=40.7 (15.4); Italy n=71, male=42.6%, age mean (SD)=49.5 (14.1)). The results showed that the new versions of the ALIS were consistent (Russian and Italian Cronbach's alpha=0.92) and reproducible (Russian test-re-test=0.86; Italian test-re-test=0.94). The Italian adaptation showed the expected correlations with the NHP and the Russian adaptation showed strong correlations with the CASIS and CAFS and weak-to-moderate correlations with %FEV1 and %PEF. In both adaptations the ALIS was able to distinguish between participants based on self-reported general health, self-reported severity, and whether or not they were hospitalized in the previous week.

An asthma-related quality of life instrument is unable to identify asthmatic children with major psychosocial problems

Evidence shows that psychosocial problems among children and adolescents with asthma interfere with adherence to treatment and therefore need attention in asthma care. It is unknown whether the already frequently implemented asthma-related quality of life (QoL) instruments reflect psychosocial problems in children with asthma. The aim of this study was to assess the relationship between asthma-related QoL and psychosocial problems and to determine whether an asthma-related QoL instrument is able to identify those children and adolescents with asthma with major psychosocial problems. In a multicenter study psychosocial problems (Strengths and Difficulties Questionnaire) and asthma-related QoL (Pediatric Asthma (Caregivers) Quality of Life Questionnaire) were obtained in children and adolescents with asthma aged 6-16 years and their caregivers. A total of 339 children and adolescents (response rate 95%) from four pediatric outpatient clinics in the Netherlands with doctor-diagnosed asthma participated. Of the caregivers, 43% reported major or minor psychosocial problems of their child or adolescent which is two times more than in the reference group, whereas the percentage of adolescents reporting psychosocial problems was comparable to a reference population. Adolescents and caregivers reported few impairments in asthma-related QoL (median score between 6.2 and 7.0). However, an optimal asthma-related QoL did not rule out major psychosocial problems: 10% of the adolescents with an optimal asthma-related QoL score reported major psychosocial problems. And in one out of seven children with an optimal caregiver's asthma-related QoL score, major psychosocial problems were reported. The prevalence of psychosocial problems in children and adolescents with asthma is considerable. Assessment of asthma-related QoL alone is insufficient to identify those children with major psychosocial problems. We recommend the implementation of psychosocial screening, besides assessment of asthma-related QoL, in routine pediatric asthma care, to improve asthma management.