Creation and implementation of SAMPRO™: A school-based asthma management program

How Schools Can Help Address Social Determinants of Health in Asthma Management

Schools are in a unique position to address social determinants of health (SDOHs) in pediatric asthma management because of their potential to provide resources and facilitate collaboration with health care providers and services for children at risk within their community. SDOHs include economic factors, educational attainment and health literacy, neighborhood factors and the built environment, social and community aspects including discrimination and racism, and health care access and quality. These factors have a significant impact on asthma health in children, and certain populations such as minoritzed populations and those living in high-poverty environments have been shown to be at greater risk for adverse effects of SDOHs on asthma outcomes. School-based asthma programs address several SDOHs including health literacy, the built environment, and health care quality and access and have been shown to improve asthma outcomes. Key components include connection between the school and the health care team, self-management education, and directly observed therapy. School nurses play a key role in directing and managing effective programs because they can evaluate and support a student's health while considering the effect of SDOHs at interpersonal, institutional, community, and policy levels.

Defining and Promoting Pediatric Pulmonary Health: Equitable Family and Community Partnerships

Optimizing pulmonary health across the lifespan begins from the earliest stages of childhood and requires a partnership between the family, pulmonologist, and pediatrician to achieve equitable outcomes. The Community Pediatrics session of the Defining and Promoting Pediatric Pulmonary Health workshop weaved together 4 community-based pillars with 4 research principles to set an agenda for future pediatric pulmonary research in optimizing lung and sleep health for children and adolescents. To address diversity, equity, and inclusion, both research proposals and workforce must purposefully include a diverse set of participants that reflects the community served, in addition to embracing nontraditional, community-based sites of care and social determinants of health. To foster inclusive, exploratory, and innovative research, studies must be centered on community priorities, with findings applied to all members of the community, particularly those in historically marginalized and minoritized groups. Research teams should also foster meaningful partnerships with community primary care and family members from study conceptualization. To achieve these goals, implementation and dissemination science should be expanded in pediatric pulmonary research, along with the development of rapid mechanisms to disseminate best practices to community-based clinicians. To build cross-disciplinary collaboration and training, community-academic partnerships, family research partnerships, and integrated research networks are necessary. With research supported by community pillars built on authentic partnerships and guided by inclusive principles, pediatric lung and sleep health can be optimized for all children and adolescents across the full lifespan in the community in which they live and thrive.

Children with uncontrolled asthma from economically disadvantaged neighborhoods: Needs assessment and the development of a school-based telehealth and electronic inhaler monitoring system

BACKGROUND

Children from economically disadvantaged communities often encounter healthcare access barriers, increasing risk for poorly controlled asthma and subsequent healthcare utilization. This highlights the need to identify novel intervention strategies for these families.

OBJECTIVE

To better understand the needs and treatment preferences for asthma management in children from economically disadvantaged communities and to develop a novel asthma management intervention based on an initial needs assessment and stakeholder feedback.

METHODS

Semistructured interviews and focus groups were conducted with 19 children (10-17 years old) with uncontrolled asthma and their caregivers, 14 school nurses, 8 primary care physicians, and three school resource coordinators from economically disadvantaged communities. Interviews and focus groups were audio-taped and transcribed verbatim and then analyzed thematically to inform intervention development. Using stakeholder input, an intervention was developed for children with uncontrolled asthma and presented to participants for feedback to fully develop a novel intervention.

RESULTS

The needs assessment resulted in five themes: (1) barriers to quality asthma care, (2) poor communication across care providers, (3) problems identifying and managing symptoms and triggers among families, (4) difficulties with adherence, and (5) stigma. A proposed video-based telehealth intervention was proposed to stakeholders who provided favorable and informative feedback for the final development of the intervention for children with uncontrolled asthma.

CONCLUSIONS

Stakeholder input and feedback provided information critical to the development of a multicomponent (medical and behavioral) intervention in a school setting that uses technology to facilitate care, collaboration, and communication among key stakeholders to improve asthma management for children from economically disadvantaged neighborhoods.

Ensuring equitable access to guideline-based asthma care across the lifespan: Tips and future directions to the successful implementation of the new NAEPP 2020 guidelines, a Work Group Report of the AAAAI Asthma, Cough, Diagnosis, and Treatment Committee

The most recent recommendations from the 2020 National Asthma Education and Prevention Program Update and Global Initiative for Asthma 2021 guide evidence-based clinical decision making. However, given the present state of health disparities by age, income, and race, the equitable implementation and dissemination of these guidelines will be unlikely without further guidance. This work group report reviews the current state of the new asthma guideline implementation; presents updated evidence-based therapeutic options with attention to specific patient populations; and addresses barriers to the implementation of these guidelines in minoritized, historically marginalized, and underresourced communities. Allergists and immunologists can use practical ways to accomplish the goals of improved asthma care access and advanced asthma care across the life span, with specific considerations to historically marginalized populations. Modifiable barriers to guideline implementation include financial barriers, environmental factors, and allergy subspecialty access and care coordination. Various programs to improve access to guideline-based asthma care include community programs, school-based asthma programs, and digital health solutions, with an emphasis on reducing disparities by race.

Improving Adherence in Urban Youth With Asthma: Role of Community Health Workers

BACKGROUND

The Asthma Action at Erie Trial is a comparative effectiveness trial comparing a community health worker (CHW) versus certified asthma educator (AE-C) intervention in low-income minority children.

OBJECTIVES

Determine whether asthma medication possession, adherence, technique, and triggers differ in children receiving an asthma CHW compared with an AE-C intervention.

METHODS

Children with uncontrolled asthma were randomized to receive 10 CHW home visits or 2 AE-C sessions in a clinic over 1 year. Asthma medication possession and inhaler technique were observed; adherence was measured using self-report, dose counters, and electronic monitors. Environmental triggers were captured by self-report, observation, and objective measurement. Mixed effects linear and logistic regression models were estimated for continuous and binary outcomes.

RESULTS

Children (n = 223) were mainly Hispanic (85%) and ages 5 to 16 years. Quick-relievers (82%), spacers (72%), and inhaled corticosteroid (ICS)-containing medications (44%) were tracked. Of those with uncontrolled asthma, 35% lacked an ICS prescription (n = 201). Children in the CHW arm were more likely to have an ICS prescription at 12 months (odds ratio 2.39; 95% CI 0.99-5.79). Inhaler technique improved 9.8% in the CHW arm at 6 months (95% CI 4.20-15.32). The ICS adherence improved in the CHW arm at 12 months, with a 16.0% (95% CI 2.3-29.7; P = .02) difference between arms. Differences in trigger exposure over time were not observed between arms.

CONCLUSIONS

The CHW services were associated with improved ICS adherence and inhaler technique, compared with AE-C services. More information is needed to determine the necessary dosage of intervention to sustain adherence.

A multilevel perspective on goals, barriers, and facilitators of school-based asthma management

BACKGROUND

School based asthma care is being increasingly used to combat uncontrolled pediatric asthma.

OBJECTIVE

The purpose of these secondary analyses was to explore multi-level perspectives regarding school-based asthma medical management for inner city, school-aged children with poor asthma control.

METHODS

Sixty-six participants from two large U.S. urban school districts and key stakeholders participated in 1:1 interviews and focus groups. Participants were selected from across the asthma care community (children/caregivers, school personnel, nurses, pharmacists, healthcare providers, and administrators/insurers). Qualitative and descriptive techniques were used to analyze data.

RESULTS

Goals: Children/caregivers prioritized living a normal active life with few asthma worries. Other stakeholders prioritized reducing student's asthma related emergency room visits and lost learning time. Facilitators: Continuity of care, strong relationships between care community members, and incentivizers were commonly suggested facilitators. School-based asthma management was viewed as a strong facilitator, particularly in the presence of a full-time school nurse. Barriers: Four themes were identified. (1) Greater systems and policy support for asthma management is needed in general, and at school in particular. (2) Overburdened families and systems often operate in crisis-mode, and asthma management is often not a priority until crisis is reached. (3) Discordance and distrust between members of the asthma care community can hinder shared asthma management. (4) Better communication is needed at all levels to improve care.

CONCLUSION

Moving away from a crisis-based approach to asthma management for high-risk children will require increased systemic support for proactive asthma care and optimized communication within the asthma care community.

Supplemental data for this article is available online at https://dx.doi.org/10.1080/02770903.2021.2018704.

Influenza vaccination coverage among an urban pediatric asthma population: Implications for population health

INTRODUCTION

Asthma is the most common chronic disease in children. Children with asthma are at high risk for complications from influenza; however annual influenza vaccination rates for this population are suboptimal. The overall aim of this study was to describe the characteristics of a high-risk population of children with asthma presenting to an urban pediatric emergency department according to influenza vaccination status.

METHODS

The study was a retrospective chart review of 4355 patients aged 2 to 18 years evaluated in a Michigan pediatric emergency department (PED) between November 1, 2017 and April 30, 2018 with an ICD-10-CM code for asthma (J45.x). Eligible patient PED records were matched with influenza vaccination records for the 2017-2018 influenza season from the Michigan Care Improvement Registry. Geospatial analysis was employed to examine the distribution of influenza vaccination status.

RESULTS

1049 patients (30.9%) with asthma seen in the PED had received an influenza vaccine. Influenza vaccination coverage varied by Census Tract, ranging from 10% to >99%. Most vaccines were administered in a primary care setting (84.3%) and were covered by public insurance (76.8%). The influenza vaccination rate was lowest for children aged 5-11 years (30.0%) and vaccination status was associated with race (p<0.001) and insurance type (p<0.001).

CONCLUSIONS

Identification of neighborhood Census Tract and demographic groups with suboptimal influenza vaccination could guide development of targeted public health interventions to improve vaccination rates in high-risk patients. Given the morbidity and mortality associated with pediatric asthma, a data-driven approach may improve outcomes and reduce healthcare-associated costs for this pediatric population.

Asthma medications in schools: a cross-sectional analysis of the Asthma Call-back Survey 2017-2018

CONTEXT

Asthma is the most common chronic disease affecting children in the United States. Goals for asthma management include symptom control, the ability to maintain a normal activity level, and minimizing adverse events.

OBJECTIVES

The objective of this study is to analyze the number of children with asthma that are permitted to carry medications at school and without an asthma action plan.

METHODS

In this study, we analyzed the Center for Disease Control and Prevention (CDC) Asthma Call-back Survey (ACBS) to assess the prevalence of children in school allowed to carry medication and with asthma action plans. Utilizing the sampling weights provided, we estimated population prevalence by age group and urbanicity.

RESULTS

Results showed that, overall, 34.8% of students reported they were not allowed to carry asthma medications in school. Specifically, nearly 51% of children ages 5 to 9 and 33% of children ages 10 to 14 were reported not to be allowed to carry medications at school. Further, 58.2% of children did not have a written asthma action plan. Reported urbanicity was not significantly associated with access to medication at school (p=0.46) or having an asthma action plan (p=0.57).

CONCLUSIONS

In our study, more than one-third of students were not permitted to carry asthma medications and nearly three-fifths did not have a written asthma action plan. Therefore, we recommend partnerships between schools, healthcare professionals, students, and osteopathic family physicians to increase access to asthma action plans and medication in schools.

Facilitating Health Information Exchange to Improve Health Outcomes for School-Aged Children: School Nurse Electronic Health Record Access

BACKGROUND AND OBJECTIVES

School-aged children with chronic conditions require care coordination for health needs at school. Access to the student's accurate, real-time medical information is essential for school nurses to maximize their care of students. We aim to analyze school nurse access to medical records in a hospital-based electronic health record (EHR) and the effect on patient outcomes. We hypothesized that EHR access would decrease emergency department (ED) visits and inpatient hospitalizations.

METHODS

This retrospective secondary data analysis was conducted using EHR data 6 months pre- and post-school nurse access to students' hospital-based EHR. The main outcome measures were the ED visits and inpatient hospitalizations.

RESULTS

For the sample of 336 students in the study, there was a 34% decrease in ED visits from 190 visits before access to 126 ED visits after access (p <0.01). Inpatient hospitalizations decreased by 44% from 176 before access to 99 after access (p <0.001). The incident rate of ED visits decreased (IRR: 0.66; 95% CI: 0.53-0.83; p = 0.00035), and hospitalizations decreased (IRR: 0.56; 95% CI: 0.44-0.72; p <0.0001) from pre to post access. These findings suggest school nurse access to medical records is a positive factor in improving school-aged patient outcomes.

CONCLUSION

School nurse access to medical records through the hospital-based EHR may be a factor to improve patient outcomes by utilizing health information technology for more efficient and effective communication and care coordination for school-aged children with chronic medical conditions.

Telehealth and Allergy Services in Rural and Regional Locations That Lack Specialty Services

Secondary to the coronavirus disease 2019 pandemic, telehealth quickly peaked as the dominant health care modality and its use still remains high. Although allergists and health care systems adapted quickly to adopt telehealth, its increased use has both highlighted its benefits for patients and allergists and demonstrated known concerns with delivering allergy specialty care to rural and regional patient populations. With increased concentration of both patients and allergists in urban areas, the ability to provide allergy specialty care to the rural and remote population continues to remain a challenge despite the advantages leveraged through telehealth. Herein, we review aspects specific to the rural patient population, tele-allergy outcomes with these patient cohorts, and efforts, both past and present, taken at different levels within the allergy community to promote our specialty through specific telehealth modalities to address and engage the rural and regional patient.

Social Determinants of Health in Asthma Through the Life Course

There is strong evidence supporting the influence of social determinants of health (SDOH) on the development and progression of asthma. SDOH are defined as conditions in which people are born, grow up, live, work, and age, which influence their opportunity to be healthy, risk of illness, and life expectancy. The goal of this article was to describe 2 case-based approaches (pediatric and adult) to assessing and addressing SDOH in asthma across the life course and in community settings. As asthma providers and specialists, the role of SDOH is complex in our clinical care; however, it is critical to address social needs identified through clinical care for our patients with asthma. Clinical-community partnerships, through grant and cost-sharing mechanisms with resource agencies, are necessary to ameliorate social needs for patients and their communities and have the potential to improve asthma outcomes. Although this is a unique and exciting time in health care to promote individual and population health, knowledge gaps remain, including best practices to integrate holistic SDOH care into the care of patients with asthma.

Association of +1923C > T, -1112C > T and +2044A > G Polymorphisms in IL-13 Gene with Susceptibility to Pediatric Asthma: A Systematic Review and Meta-Analysis

BackgroundPrevious studies have provided conflicting evidence implicating the IL-13 polymorphism and pediatric asthma. Thus, we performed a meta-analysis to combine and analyze the available studies to provide more accurate conclusions. Methods: A comprehensive retrieval in PubMed, EMBASE, Web of Science, and CNKI was performed up to February 05, 2020. Results: A total of 39 case-control studies including 15 studies with 4,968 cases and 7,091 controls were on +1923 C > T, ten studies with 3,175 cases and 2,983 controls on -1112 C > T, and 14 studies with 4,476 cases and 5,121 controls on +2044 A > G were selected. Pooled data showed that the IL-13 + 1923 C > T, -1112 C > T and +2044 A > G polymorphisms were significantly associated with risk of pediatric asthma. The IL-13 + 1923 C > T (Asians and Africans), -1112 C > T (Caucasians) and +2044 A > G (Asians) polymorphisms were more frequently associated in these ethnic groups. Conclusions: Our pooled data indicated that IL-13 + 1923 C > T, -1112 C > T and +2044 A > G polymorphisms were correlated with risk of pediatric asthma.

Stakeholders' views of supporting asthma management in schools with a school-based asthma programme for primary school children: a qualitative study in Malaysia

OBJECTIVE

The WHO Global School Health Initiative aimed to improve child and community health through health promotion programmes in schools, though most focus on preventing communicable disease. Despite WHO recommendations, no asthma programme is included in the Malaysian national school health service guideline. Therefore, we aimed to explore the views of school staff, healthcare professionals and policy-makers about the challenges of managing asthma in schools and the potential of a school asthma programme for primary school children.

DESIGN

A focus group and individual interview qualitative study using purposive sampling of participants to obtain diverse views. Data collection was guided by piloted semistructured topic guides. The focus groups and interviews were audiorecorded, transcribed verbatim and analysed using inductive thematic analysis. We completed data collection once data saturation was reached.

SETTING

Stakeholders in education and health sectors in Malaysia.

PARTICIPANTS

Fifty-two participants (40 school staff, 9 healthcare professionals and 3 policy-makers) contributed to nine focus groups and eleven individual interviews.

RESULTS

School staff had limited awareness of asthma and what to do in emergencies. There was no guidance on asthma management in government schools, and teachers were unclear about their role in school children's health. These uncertainties led to delays in the treatment of asthma symptoms/attacks, and suggestions that an asthma education programme and a school plan would improve asthma care. Perceived challenges in conducting school health programmes included a busy school schedule and poor parental participation. A tailored asthma programme in partnerships with schools could facilitate the programme's adoption and implementation.

CONCLUSIONS

Identifying and addressing issues and challenges specific to the school and wider community could facilitate the delivery of a school asthma programme in line with the WHO School Health Initiative. Clarity over national policy on the roles and responsibilities of school staff could support implementation and guide appropriate and prompt response to asthma emergencies in schools.

The COVID-19 pandemic: Adverse effects on the social determinants of health in children and families

OBJECTIVE

To describe the impact of social determinants on the experience of the coronavirus disease 2019 (COVID-19) pandemic within the pediatric population, how this impact may influence the long-term health and security of children, and what measures can be taken to ameliorate this impact moving forward.

DATA SOURCES

Nonsystematic review of relevant literature and news sources.

STUDY SELECTIONS

Relevant literature and news sources.

RESULTS

There have been increases in housing insecurity and food insecurity during the pandemic, including global increases in poverty. Public policies such as school closures have had a disproportionate impact on those facing adverse social determinants. There has been a dramatic increase in reports of abuse-related injuries and other injuries indicative of child abuse during the pandemic. In addition, there are disproportionate impacts of COVID-19 based on race and ethnicity within the United States. It is clear that children are facing more adverse determinants as a result of this pandemic and that there are both short-term and long-term implications associated. For those living in poverty or with other adverse social determinants of health, the pandemic has made a bad situation worse. Ongoing studies are required to measure the impact of COVID-19 on those with adverse social determinants, in particular among children.

CONCLUSION

Social determinants of health must be part of pandemic research priorities, public health and vaccination goals, and economic policy implementation. The impact of the COVID-19 pandemic has further served to shed a light on the broad disparities that exist within our society and their direct and indirect impacts on health outcomes.

The West Philadelphia asthma care implementation study (NHLBI#

Asthma is the most common chronic condition among children, with low-income families living in urban areas experiencing significantly higher rates. Evidence based interventions for asthma are routinely implemented in either the home, school, or primary care setting. However, even when caregivers of poor children are engaged in asthma interventions in one setting, they often have to navigate challenges in another setting, such as an under-resourced home, non-supportive school, or disengaged health care provider. The West Philadelphia Asthma Care Implementation Plan aims to compare the effectiveness of a primary care-based intervention, school-based intervention, and combined primary care and school intervention to usual care for improving asthma control in school-age children to explore if the synergistic effect of Community Health Worker (CHW) support in the home, school, and health care environments will result in improved asthma control. Children ages 5-13 with uncontrolled asthma from four West Philadelphia recruitment sites will be eligible for enrollment. The families of school age children interested in participating will be randomized to receive a primary care CHW or usual care. Those identified as attending a participating school will have a CHW-led school intervention or usual care in school. If proven effective, this care coordination program will assist caregivers in assessing resources, improving self-management skills, and ultimately reducing asthma-related ED visits and hospitalizations as well as provide additional information for healthcare systems and policy makers to inform their decisions about how and where to focus additional resources and investments in childhood asthma care to improve health outcomes.

Pediatric Inner-City Asthma

Inner-city children with asthma are known to have high disease mortality and morbidity. Frequently, asthma in this high-risk population is difficult to control and more severe in nature. Several factors, including socioeconomic hardship, ability to access to health care, adherence to medication, exposure to certain allergens, pollution, crowd environment, stress, and infections, play an important role in the pathophysiology of inner-city asthma. Comprehensive control of home allergens and exposure to tobacco smoke, the use of immune based therapies, and school-based asthma programs have shown promising results in asthma control in this population.

Engaging with the Richmond Community to Reduce Pediatric Asthma Disparities: Findings from a Community-engaged Needs Assessment

Childhood asthma disparities persist, with children living in low-income areas experiencing worse morbidity. We partnered with a community-academic research team and stakeholders to conduct a needs assessment to understand barriers and supports to asthma treatment. We convened a community advisory board, comprised of parents of children with asthma, youth with asthma, and members of key community organizations. Two focus groups with parents of children with asthma and four focus groups with youth with asthma were conducted, and a survey was administered to 100 parents. A visual mapping process was used to gather qualitative data about barriers, strategies, and outcomes, and allowed advisory board members to interpret focus group and survey data within the lived experiences of families. Focus group themes included parent stress/anxiety, concerns about school nurses, and lack of trust in providers. Findings from focus groups and surveys suggested that emergency department visits were not perceived negatively by families, although health providers and researchers generally view them as such. Public health implications include systemic changes that allow the healthcare system to address families' acute needs and worry. A community program focused on education and coordination among families, schools, and medical homes might improve asthma outcomes at the population level.

School-Based Telemedicine for Asthma Management

Asthma affects 10% of school-age children in the United States. These numbers nearly double in high-risk populations such as low-income and minority populations. Patients in these populations frequently live in communities that are medically underserved, with limited resources to implement comprehensive asthma interventions. It is important for researchers and clinicians to explore avenues to reduce the burden of illness in this population. Incorporating innovative strategies such as school-based telemedicine programs can potentially reduce morbidity, health care utilization, work absenteeism for caregivers, and school absenteeism for children with asthma. The aim of this review is to discuss the potential benefits of school-based asthma telemedicine programs, explore potential implementation models, and provide a comprehensive review of the literature including programs that use telemedicine in schools to assist with the management of asthma. Telemedicine is a feasible approach to increasing access to primary and specialty asthma care; however, there is a need for future randomized trials to establish best practices for implementation of telemedicine programs to aid in the care for children in school settings.

A community-based asthma program: Study design and methods of RVA Breathes

Disparities in pediatric asthma morbidity and healthcare utilization exist on the basis of race, ethnicity, environment, and income; interventions are needed to address these inequities. The following protocol describes an evidence-based intervention, RVA Breathes, designed to coordinate pediatric asthma care across family, home, community, and medical sectors. Community stakeholder feedback was utilized to refine the intervention specifically for the Richmond, Virginia community. The aims of this study are to assess the effect of RVA Breathes on asthma-related healthcare utilization, as well as secondary outcomes of asthma control, asthma symptoms, and quality of life. We will enroll 300 elementary school children from the Richmond City Public School system. Participants will be between the ages of 5-11, have a diagnosis of asthma, and have had an asthma exacerbation (as indicated by an asthma-related ED visit, hospitalization, unscheduled PCP visit, or use of systemic steroids) in the last two years. Participants will be randomized to one of three groups: asthma education + home environment remediation + school intervention, asthma education + home environment remediation, or a comparator condition. Data will be collected across one baseline research visit, four intervention sessions, and four follow-up research visits over the course of 18 months. A General Linear Mixed Model (GLMM) will be used to test primary aims. We expect the findings will provide support for coordination of asthma care across sectors. Further, we hope RVA Breathes will serve as a model of community-based pediatric asthma care.

Dissemination of Evidence-Based School Asthma Management Programs: Piloting Asthma 411 in an Urban Texas School District

BACKGROUND

The dissemination and implementation (D&I) of evidence-based initiative (EBIs) is critical to improved public health. The Asthma 411 EBI was piloted in Texas from 2013 to 2015. The pilot's evaluation assessed its effectiveness and identified approaches to support D&I of school-health EBIs.

METHODS

The pilot study was conducted in two schools; service categories included: a consulting physician, enhanced school asthma services, and support for links to community health resources. Data was collected on Emergency Medical Service (EMS) calls, aggregated nursing services, demographic characteristics, availability of medication provided through existing policies, and informal interviews.

RESULTS

During the pilot, school-day asthma-related Emergency Medical Service (EMS) calls were eliminated. Documented asthma self-management education, authorization for rescue medication, and efforts to communicate with parents and health providers increased. Between year-1 and year-2, the gap between unadjusted, weighted mean absences among students with and without asthma was reduced by 1.1 days. However, this difference was not seen in a fully adjusted negative, binomial regression model.

CONCLUSIONS

Evaluation of the Asthma 411 pilot suggests many EBI benefits were retained and identifies factors that may facilitate D&I of school health EBIs. Future research will clarify impacts on absenteeism and determine if observed benefits are sustained.

Food Allergy Management at School in the Era of Immunotherapy

PURPOSE OF REVIEW

Food allergy is increasing in prevalence, and management focuses on strict avoidance of known allergens and appropriately treating reactions. Any reaction has the potential to result in anaphylaxis, which can be fatal. Children spend a significant amount of time in the childcare or school setting, and interactions between families, school personnel, and clinicians are important to ensure the health and safety of children with allergies and asthma.

RECENT FINDINGS

This review examines current food allergy guidelines and legislation, an assessment of allergen-free schools, the importance of written anaphylaxis action plans, training and education of school personnel, emerging treatment options, and the social implications of having food allergies. As the clinical use and research into food allergen immunotherapy continues to expand, an additional level of education and management is required of school personnel and caregivers. Food allergy has both medical and social implications, which are magnified in the school setting.

Building Bridges for Asthma Care Program: A School-Centered Program Connecting Schools, Families, and Community Health-Care Providers

Asthma imposes tremendous burden on children, families, and society. Successful management requires coordinated care among children, families, health providers, and schools. Building Bridges for Asthma Care Program, a school-centered program to coordinate care for successful asthma management, was developed, implemented, and evaluated. The program consists of five steps: (1) identify students with asthma; (2) assess asthma risk/control; (3) engage the family and student at risk; (4) provide case management and care coordination, including engagement of health-care providers; and (5) prepare for next school year. Implementation occurred in 28 schools from two large urban school districts in Colorado and Connecticut. Significant improvements were noted in the proportions of students with completed School Asthma Care Plans, a quick-relief inhaler at school, Home Asthma Action/Treatment Plans and inhaler technique (p < .01 for all variables). Building Bridges for Asthma Care was successfully implemented extending asthma care to at-risk children with asthma through engagement of schools, health providers, and families.

A worldwide charter for all children with asthma

Childhood asthma is a huge global health burden. The spectrum of disease, diagnosis, and management vary depending on where children live in the world and how their community can care for them. Global improvement in diagnosis and management has been unsatisfactory, despite ever more evidence-based guidelines. Guidelines alone are insufficient and need supplementing by government support, changes in policy, access to diagnosis and effective therapy for all children, with research to improve implementation. We propose a worldwide charter for all children with asthma, a roadmap to better education and training which can be adapted for local use. It includes access to effective basic asthma medications. It is not about new expensive medications and biologics as much can be achieved without these. If implemented carefully, the overall cost of care is likely to fall and the global future health and life chance of children with asthma will greatly improve. The key to success will be community involvement together with the local and national development of asthma champions. We call on governments, institutions, and healthcare services to support its implementation.

The Impact of Social Determinants of Health on Children with Asthma

SzAsthma is the most common chronic disease of childhood. Disparities in asthma outcomes have led to international attention on the biologic, social, economic, and other factors that impact the health of children with asthma. Studies indicate that social determinants of health such as housing, neighborhood safety, and access to care significantly impact the health of children with asthma. However, screening for socioeconomic and environmental factors that impact asthma can be difficult to integrate into clinical practice. In addition, it is not yet clear which interventions to address these factors are most effective. This article will review recent studies of determinants and social determinants of health and propose a framework for identifying and addressing them in the care of children with asthma in a clinical setting.

Implementation Lessons From a Randomized Trial Integrating Community Asthma Education for Children

This study characterized and compared the implementation of clinically integrated community health workers (CHWs) to a certified asthma educator (AE-C) for low-income children with asthma. In the AE-C arm (N = 115), 51.3% completed at least one in-clinic education session. In the CHW arm (N = 108), 722 home visits were completed. The median number of visits was 7 (range, 0-17). Scheduled in-clinic asthma education may not be the optimal intervention for this patient population. CHW visit completion rates suggest that the schedule, location, and content of CHW asthma services better met patients' needs. Seven to 10 visits seemed to be the preferred CHW dose.

Asthma and Allergies in the School Environment

The school is a complex microenvironment of indoor allergens, pollutants, and other exposures. The school represents an occupational model for children and exposures in this environment have a significant health effect. Current research establishes an association between school exposure and asthma morbidity in children. This review will focus on common school environmental exposures (cockroach, rodents, cat, dog, classroom pets, dust mite, fungus, and pollution) and their impact on children with allergies and asthma. Understanding and evaluation of school-based environments is needed to help guide school-based interventions. School-based interventions have the potential for substantial benefit to the individual, school, community, and public health. However, there is a paucity data on school-based environmental interventions and health outcomes. The studies performed to date are small and cross-sectional with no control for home exposures. Randomized controlled school-based environmental intervention trials are needed to assess health outcomes and the cost-effectiveness of these interventions. The School Inner-City Asthma Intervention Study (SICAS 2), a NIH/NIAID randomized controlled clinical trial using environmental interventions modeled from successful home-based interventions, is currently underway with health outcome results pending. If efficacious, these interventions could potentially help further guide school-based interventions potentially with policy implications. In the meanwhile, the allergist/immunologist can continue to play a vital role in improving the quality of life in children with allergies and asthma at school through the use of the ADA policy and Section 504 of the Rehabilitation Act as well as encouraging adoption of toolkits to build successful school-based asthma programs and asthma-friendly schools.

Asthma in Schools: How School-Based Partnerships Improve Pediatric Asthma Care

Children with asthma experience frequent exacerbations that require careful care coordination among families, clinicians, and schools. Prior studies have shown that children with asthma miss more school each year compared with their healthy peers due to uncontrolled asthma symptoms. Successful school-based asthma programs have built strong partnerships among patients, their families, and clinicians to improve communication and the dissemination of asthma action plans and medications to schools. The widely endorsed School-based Asthma Management Program, consisting of 4 components, provides a comprehensive and expert-supported framework to coordinate care with schools.

New Directions in Pediatric Asthma

Childhood asthma affects many children placing them at significant risk for health care utilization and school absences. Several new developments relevant to the field of pediatric asthma have occurred over the last 5 years; yet, there is much more to learn. It is poorly understood how to prevent the disease, optimally address environmental challenges, or effectively manage poor adherence. Moreover, it is not clear how to customize therapy by asthma phenotype, age group, high risk groups, or severity of disease. Highlights of advances in pediatric asthma are reviewed and multiple essential areas for further exploration and research are discussed.

Applying a biopsychosocial model to inner city asthma: Recent approaches to address pediatric asthma health disparities

Pediatric asthma in inner cities is often severe and children living in these urban locations with socioeconomic disadvantage experience greater asthma morbidity. There are many interconnected risk factors that individually, and in combination, enhance asthma morbidity. These include biologic factors innate to the child, such as genetics and allergen susceptibility, as well as factors related to the family and neighborhood context. The biopsychosocial model can be used to frame these risk factors and develop interventions specific to the inner city. Successful inner city asthma interventions exist and key characteristics include multi-tiered components that operate within the community to coordinate disease management resources between patients, families and health care systems.

Pediatric Inner-City Asthma

Inner-city children with asthma are known to have high disease mortality and morbidity. Frequently, asthma in this high-risk population is difficult to control and more severe in nature. Several factors, including socioeconomic hardship, ability to access to health care, adherence to medication, exposure to certain allergens, pollution, crowd environment, stress, and infections, play an important role in the pathophysiology of inner-city asthma. Comprehensive control of home allergens and exposure to tobacco smoke, the use of immune based therapies, and school-based asthma programs have shown promising results in asthma control in this population.

Factors Associated With School Nurses' Self-Efficacy in Provision of Asthma Care and Performance of Asthma Management Behaviors

Asthma is a chronic disease affecting nearly 6 million children in the United States and accounts for nearly 14 million missed school days. School nurses' performance of asthma management behaviors (AMBs) may reduce exacerbations, thereby decreasing emergency visits and hospitalizations and increasing attendance at school. Self-efficacy can have a positive effect on AMBs. More research is needed on the interplay between environmental factors in school nurses' work setting, self-efficacy in providing asthma care (hereafter "self-efficacy in asthma care"), and performance of AMBs. This study used a descriptive cross-sectional online survey design with practicing registered school nurses in Pennsylvania (N = 231). Data analysis included descriptive statistics, correlation tests, and multiple regression. In separate models, self-efficacy in asthma care and student-nurse ratio were significantly associated with performance of AMBs. Schools and school nurses need stronger efforts to strengthen self-efficacy in asthma care, with the goal of increasing nurses' performance of AMBs.

Inner-City Asthma in Children

Asthma in inner-city children is often severe and difficult to control. Residence in poor and urban areas confers increased asthma morbidity even after adjusting for ethnicity, age, and gender. Higher exposure to household pests, such as cockroaches and mice, pollutants and tobacco smoke exposure, poverty, material hardship, poor-quality housing, differences in health care quality, medication compliance, and heath care access also contribute to increased asthma morbidity in this population. Since 1991, the National Institutes of Allergy and Infectious Diseases established research networks: the National Cooperative Inner-City Asthma Study (NCICAS), the Inner-City Asthma Study (ICAS), and the Inner-City Asthma Consortium (ICAC), to improve care for this at risk population. The most striking finding of the NCICAS is the link between asthma morbidity and the high incidence of allergen sensitization and exposure, particularly cockroach. The follow-up ICAS confirmed that reductions in household cockroach and dust mite were associated with reduction in the inner-city asthma morbidity. The ICAC studies have identified that omalizumab lowered fall inner-city asthma exacerbation rate; however, the relationship between inner-city asthma vs immune system dysfunction, respiratory tract infections, prenatal environment, and inner-city environment is still being investigated. Although challenging, certain interventions for inner-city asthma children have shown promising results. These interventions include family-based interventions such as partnering families with asthma-trained social workers, providing guidelines driven asthma care as well as assured access to controller medication, home-based interventions aim at elimination of indoor allergens and tobacco smoke exposure, school-based asthma programs, and computer/web-based asthma programs.

Creating a community-based comprehensive intervention to improve asthma control in a low-income, low-resourced community

Introduction: Asthma evidence-based interventions (EBI) are implemented in the home, school, community or primary care setting. Although families are engaged in one setting, they often have to navigate challenges in another setting.Objective: Our objective is to design and implement a comprehensive plan which integrates EBI's and connects the four sectors in underserved communities such as Philadelphia.Methods: September 2015-April 2016 we implemented a three-pronged strategy to understand needs and resources of the community including 1) focus groups and key informant interviews, 2) secondary data analysis and 3) pilot testing for implementation to determine gaps in care, and opportunities to overcome those gaps.Results: Analysis of the focus group and key informant responses showed themes: diagnosis fear, clinician time, home and school asthma trigger exposures, school personnel training and communication gaps across all four sectors. EBI's were evaluated and selected to address identified themes. Pilot testing of a community health worker (CHW) intervention to connect home, primary care and school resulted in an efficient transfer of asthma medications and medication administration forms to the school nurse office for students with uncontrolled asthma addressing a common delay leading to poor asthma management in school.Conclusion: Thus far there has been limited success in reducing asthma disparities for low-income minority children. This study offers hope that strategically positioning CHWs may work synergistically to close gaps in care and result in improved asthma control and reduced asthma disparities.

A Practical Approach to Severe Asthma in Children

Severe asthma accounts for only a small proportion of the children with asthma but a disproportionately high amount of resource utilization and morbidity. It is a heterogeneous entity and requires a step-wise, evidence-based approach to evaluation and management by pediatric subspecialists. The first step is to confirm the diagnosis by eliciting confirmatory history and objective evidence of asthma and excluding possible masquerading diagnoses. The next step is to differentiate difficult-to-treat asthma, asthma that can be controlled with appropriate management, from asthma that requires the highest level of therapy to maintain control or remains uncontrolled despite management optimization. Evaluation of difficult-to-treat asthma includes an assessment of medication delivery, the home environment, and, if possible, the school and other frequented locations, the psychosocial situation, and comorbid conditions. Once identified, aggressive management of issues related to poor adherence and drug delivery, remediation of environmental triggers, and treatment of comorbid conditions is necessary to characterize the degree of control that can be achieved with standard therapies. For the small proportion of patients whose disease remains poorly controlled with these interventions, the clinician may assess steroid responsiveness and determine the inflammatory pattern and eligibility for biologic therapies. Management of severe asthma refractory to traditional therapies involves considering the various biologic and other newly approved treatments as well as emerging therapies based on the individual patient characteristics.

Asthma in inner city children: recent insights: United States

PURPOSE OF REVIEW

Children living in US inner cities experience disparate burdens of asthma, especially in severity, impairment, exacerbations, and morbidity. Investigations seeking to better understand the factors and mechanisms underlying asthma prevalence, severity, and exacerbation in children living in these communities can lead to interventions that can narrow asthma disparities and potentially benefit all children with asthma. This update will focus on recent (i.e. late 2016-2017) advances in the understanding of asthma in US inner city children.

RECENT FINDINGS

Studies published in the past year expand understanding of asthma prevalence, severity, exacerbation, and the outcomes of guidelines-based management of these at-risk children, including: asthma phenotypes in US inner city children that are severe and difficult-to-control; key environmental determinants and mechanisms underlying asthma severity and exacerbations (e.g. allergy-mediated exacerbation susceptibility to rhinovirus); the importance of schools as a place for provocative exposures (e.g. mouse allergen, nitrogen dioxide) as well as a place where asthma care and outcomes can be improved; and the development and validation of clinically useful indices for gauging asthma severity and predicting exacerbations.

SUMMARY

These recent studies provide a trove of actionable findings that can improve asthma care and outcomes for these at-risk children.

Severe asthma in children: Evaluation and management

Severe asthma in children is associated with significant morbidity. Children with severe asthma are at increased risk for adverse outcomes including medication-related side effects, life-threatening exacerbations, and impaired quality of life. It is important to differentiate between severe therapy resistant asthma and difficult-to-treat asthma due to comorbidities. The most common problems that need to be excluded before a diagnosis of severe asthma can be made are poor medication adherence, poor medication technique or incorrect diagnosis of asthma. Difficult to treat asthma is a much more common reason for persistent symptoms and exacerbations and can be managed if comorbidities are clearly addressed. Children with persistent symptoms and exacerbations despite correct inhaler technique and good medical adherence to standard Step 4 asthma therapies according to the guidelines^1,2, should be referred to an asthma specialist with expertise in severe asthma.

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.

Asthma management in school: parents' and school personnel perspectives

Objective: Effective asthma management at school can help students with asthma stay healthy, learn better and participate fully during their school day. This study sought to understand school-based asthma care from the perspective of parents and school personnel to improve asthma care at school. Methods: A cross-sectional study was conducted in Hartford, CT. School personnel from 59 schools and 322 parents/guardians were invited to participate. Four cross-sectional surveys using Likert-type scales assessed parental and school personnel satisfaction, confidence in managing asthma, policy awareness, management of asthma during physical activity, and perceived gaps surrounding school-based asthma care. Results: 263/322 (82%) eligible parents of children with asthma (mean age 8.5 ± 4.3, 56% Hispanic, 30% African American) completed surveys. Thirty six school nurses (62%), 131 teachers (8%), 14 coaches (14%), and 17 school principals (29%) participated. 90% of parents were satisfied with asthma management in school. School nurses were more aware of asthma policies than teachers (74% vs. 24%, p < 0.001). 34% of school nurses, 30% of teachers and 36% of coaches were unaware of asthma-related absences. 14% of physical education teachers/coaches reported no asthma training. Conclusion: In this convenience sample of parents and school personnel, parents reported overall satisfaction regarding the asthma care their children receive at school, yet a number of gaps pertaining to school-based asthma care were identified. Increased asthma training and enhanced communication among school personnel is needed to address these gaps. National guidelines and resources are readily available to improve asthma care at school.

School and Community-based Nurse-led Asthma Interventions for School-aged Children and Their Parents: A Systematic Literature Review

PROBLEM

Asthma is one of the most prevalent chronic diseases in the world. Lack of asthma knowledge can lead to asthma exacerbations, more emergency room visits, school absences, and decreased quality of life. This systematic review examines the effectiveness of educational intervention programs on asthma management for school-aged children and their parents beyond inpatient clinic settings.

ELIGIBILITY CRITERIA

Educational asthma interventions for school-aged children and their parents with comparison with usual asthma care and the outcome related to asthma management. Studies included were peer-reviewed and published in English within the last five years.

SAMPLE

The eight study articles were identified in ProQuest, Medline, CINAHL, and PubMed databases.

RESULTS

The review demonstrated that educational asthma interventions for children and their parents significantly improved knowledge and skills related to asthma self-management.

CONCLUSIONS

School and community-based asthma educational intervention programs are key components for good management of asthma condition. Well-planned asthma education programs are valuable and should go beyond inpatient clinic settings for promoting and maintaining health for children with asthma and their parents.

IMPLICATIONS

School nurses are well-positioned to assume a more prominent role in asthma care to improve child health and academic outcomes. School nurses have an opportunity to establish a trusting relationship that is foundational for collaborating with parents and students for better asthma management.

Chicago Public School nurses examine barriers to school asthma care coordination

OBJECTIVE/DESIGN

Well documented asthma disparities in Chicago pose a continual challenge for the Chicago Public Schools (CPS). Coordinated Healthcare for Complex Kids (CHECK) is a health care demonstration project funded by a Centers for Medicare and Medicaid Services Health Care Innovation Award. A collaborative partnership was formed between CHECK and CPS. With CHECK support, CPS administered a survey to 160 nurses to understand the asthma problems nurses perceived and interest in intervention.

RESULTS

Seventy-five per cent (n = 120) completed the survey. While asthma was the top diagnosis managed by 95%, 72% reported gaps in asthma understanding. Appropriate communication between school nurses and providers occurred 33% of the time; 18% believed they received sufficient support to follow-up on deficient paperwork. The barriers mentioned were lack of medications (73%), time (67%), and communication with providers (61%). When asked their opinions on potential interventions, 78% of nurses supported web-based applications, 66% community health workers (CHW), and 66% stock albuterol in schools.

CONCLUSIONS

The greatest barriers for CPS nurses with asthma management are time and communication. Potential interventions such as web-based communication applications and CHW in schools were well received.

Building Bridges for Asthma Care: Reducing school absence for inner-city children with health disparities

BACKGROUND

Children with asthma are at increased risk for experiencing health and educational disparities because of increased school absence. School nurses are well positioned to support asthma management and improve school attendance.

OBJECTIVE

We sought to implement and assess the effect of the Building Bridges for Asthma Care Program on improving school attendance and measures of asthma control.

METHODS

Children with asthma (age, 5-14 years) in the Denver Public School System (n = 240) and the Hartford Public School System (n = 223) were enrolled in the Building Bridges Program during the 2013-2014 and 2014-2015 school years and followed until the end of the second school year. The primary outcome was school absence, with secondary outcomes, including asthma control, measured based on Childhood Asthma Control Test or the Asthma Control Test scores and rescue inhaler use.

RESULTS

Participants experienced a 22% absolute decrease in school absenteeism, the number of children with an Asthma Control Test/Childhood Asthma Control Test score of less than the control threshold of 20 decreased from 42.7% to 28.8%, and bronchodilator use greater than 2 times per week decreased from 35.8% to 22.9% (all changes were significant, P < .01).

CONCLUSIONS

Children enrolled in the Building Bridges for Asthma Care Program experienced reduced school absence and improved asthma control.

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.

Taming Asthma in School-Aged Children: A Comprehensive Review

Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity as measured by school absences, emergency department visits, and hospitalizations. Multiple factors play a role in the development, treatment and prevention of childhood asthma including racial/ethnic and socioeconomic disparities, both the home and school environments, and medication use. The goals of this review are to summarize these aspects of asthma in school-aged children and to present an updated review of medications as it relates to treatment strategies that will help in the care of these children. We conclude that phenotypic heterogeneity and appropriate environmental assessments and interventions are important considerations in the management of childhood asthma.

Asthma across the lifespan: Time for a paradigm shift

We have a unique opportunity to significantly reduce the worldwide burden of asthma in children and affect respiratory outcomes in adults. However, this will require a paradigm shift that is directed at altering the natural history of asthma, reducing asthma exacerbations, and preventing long-term adverse outcomes of childhood asthma. Attention should continue to be directed toward minimizing risk, as well as impairment, with a goal to achieve optimal control. Based on several National Institutes of Health studies conducted over the last 10 years, we now have the tools necessary to accomplish this goal. The tools include assessment of lung function over time or defining trajectories of lung growth, the Composite Asthma Severity Index score, a panel of useful biomarkers, the Seasonal Asthma Exacerbation Prediction Index score, and rapidly advancing technology that includes adherence monitoring. Future guideline revisions should consider incorporating recommendations to follow spirometry over time and defining trajectories of lung growth to assess risk for reduced lung growth and early decline, asthma burden by using biomarkers to select and monitor therapy, assessment of social determinants of health, evaluation of risk for seasonal exacerbations, and consideration of electronic adherence monitoring for difficult-to-manage asthma. Guidelines should continue to include a core dedicated to the diagnosis and treatment of intermittent and mild and moderate persistent asthma and include additional sections dedicated to the management of severe asthma.