Educational and health outcomes of children treated for asthma: Scotland-wide record linkage study of 683 716 children

Sex differences in sociodemographic, clinical, and laboratory variables in childhood asthma: A birth cohort study

BACKGROUND

There are marked sex differences in the prevalence and severity of asthma, both during childhood and adulthood. There is a relative lack of comprehensive studies exploring sexdifferences in pediatric asthma cohorts.

OBJECTIVE

To identify the most relevant sex differences in sociodemographic, clinical, and laboratory variables in a well-characterized large pediatric asthma cohort.

METHODS

We performed a cross-sectional analysis of the Mayo Clinic Olmsted County Birth Cohort. In the full birth cohort, we used a natural language-processing algorithm based on the Predetermined Asthma Criteria for asthma ascertainment. In a stratified random sample of 300 children, we obtained additional pulmonary function tests and laboratory data. We identified the significant sex differences among available sociodemographic, clinical, and laboratory variables.

RESULTS

Boys were more frequently diagnosed with having asthma than girls and were younger at the time of asthma diagnosis. There were no sex differences in relation to socioeconomic status. We identified a male predominance in the presence of a tympanostomy tube and a female predominance in the history of pneumonia. A higher percentage of boys had a forced expiratory volume in 1 second/forced vital capacity ratio less than 0.85. Blood eosinophilia and atopic sensitization were also more common in boys. Finally, boys had higher levels of serum periostin than girls.

CONCLUSION

This study described significant sex differences in a large pediatric asthma cohort. Overall, boys had earlier and more severe asthma than girls. Differences in blood eosinophilia and serum periostin provide insights into possible mechanisms of the sex bias in childhood asthma.

An Updated Reappraisal of Dupilumab in Children and Adolescents with Severe Asthma

Severe asthma (SA) is still a demanding challenge in clinical practice. Type 2 inflammation is the most common phenotype in children and adolescents with SA. As a result, anti-inflammatory drugs, mainly corticosteroids (CSs), represent the first choice to reduce type 2 inflammation. However, SA patients may require high inhaled and oral CS doses to achieve and maintain asthma control. Some SA patients, despite the highest CS dosages, can even display uncontrolled asthma. Therefore, the biological era constituted a breakthrough in managing this condition. Dupilumab is a monoclonal antibody directed against the IL-4 receptor α-subunit (IL-4Rα), antagonizing against both IL-4 and IL-13, and has been approved for pediatric severe type 2 asthma. This review presents and discusses the most recent published studies on dupilumab in children and adolescents with SA. There is convincing evidence that dupilumab is a safe and effective option in managing SA as it can reduce asthma exacerbations, reduce CS use, and improve lung function, asthma control, and quality of life, also for caregivers. However, a thorough diagnostic pathway is mandatory, mainly concerning phenotyping. In fact, the ideal eligible candidate is a child or adolescent with a type 2 allergic phenotype.

Recommendations for asthma monitoring in children: A PeARL document endorsed by APAPARI, EAACI, INTERASMA, REG, and WAO

Monitoring is a major component of asthma management in children. Regular monitoring allows for diagnosis confirmation, treatment optimization, and natural history review. Numerous factors that may affect disease activity and patient well-being need to be monitored: response and adherence to treatment, disease control, disease progression, comorbidities, quality of life, medication side-effects, allergen and irritant exposures, diet and more. However, the prioritization of such factors and the selection of relevant assessment tools is an unmet need. Furthermore, rapidly developing technologies promise new opportunities for closer, or even "real-time," monitoring between visits. Following an approach that included needs assessment, evidence appraisal, and Delphi consensus, the PeARL Think Tank, in collaboration with major international professional and patient organizations, has developed a set of 24 recommendations on pediatric asthma monitoring, to support healthcare professionals in decision-making and care pathway design.

Preschool children from lower household incomes experience inequality in asthma treatment: findings from a Danish nationwide cohort study

BACKGROUND

The obligation to pay for asthma medication in a country with universal healthcare might lead to increased asthma exacerbations and inequitable healthcare access for children from low-income households. Thus, the aim of this study was to examine the association between household income and childhood/preschool asthma regarding hospitalization and medication receipt.

METHODS

In this nationwide register-based cohort study, we encompassed all 3-year-old children residing in Denmark, born between 2000 and 2014, along with their linked parents and followed them until their sixth birthday. Household income was divided into quartiles. Asthma was categorized in two mutually exclusive groups as either the redemption of two prescriptions for asthma medication or receiving a hospital diagnosis. We utilized Poisson regression to estimate the risk ratio (RR).

RESULTS

The analysis included 834 422 preschool children. The prevalence of asthma dependent on medication alone was 7.3%, while 1.8% of children necessitated asthma-related hospitalization. Income inequality was evident across all income quartiles. Notably, children from the lowest income quartile had a RR of 0.95 (95% CI: 0.92-0.98) of redeeming asthma medication and conversely a RR of 1.18 (95% CI: 1.14-1.23) of asthma-related hospitalization.

CONCLUSIONS

Despite universal healthcare, income inequality has a dual impact on children from low-income households. They face a diminished risk of redeeming asthma medication and a higher susceptibility to asthma-related hospitalizations indicating an unequal access to healthcare. Prioritizing efforts to reduce childhood health inequalities is crucial. However, further research, particularly qualitative studies, is needed to better comprehend the underlying mechanisms to address the complexities of income inequality.

The INSCHOOL project: Young people with long-term physical health conditions: An in-depth qualitative study of their needs at school

INTRODUCTION

The INSCHOOL project aimed to understand the school experiences and unmet needs of young people across a diversity of long-term physical health conditions.

METHODS

Young people aged 11-18 years, in mainstream secondary school in the United Kingdom, with one of 11 physical health conditions were invited to unique participant-driven interviews, focus groups, or written activities. Creative preparation activities were provided to give participants increased control over the data collection and prioritize their voices. A needs analysis, in combination with participatory analysis sessions with young people, identified the common needs of participants in relation to their school lives.

RESULTS

Eighty-nine young people participated from April 2022 to 2023. Analysis of their transcripts defined six common needs across all the health conditions: Need to safely manage my health at school; need for a flexible education pathway; need to be acknowledged and listened to in the right way; need to be included in and supported by the school community; need to build toward my future; need to develop attitudes and approaches to help me cope in school.

CONCLUSIONS

This study has generated new, actionable knowledge by identifying six major needs that young people have in relation to the intersection of their health condition and their school life. This paper shows that a commonalities approach to research and policy development is warranted given the similarities in experiences and needs. The common needs identified in the INSCHOOL project highlight six areas where future interventions could be targeted to begin making meaningful changes for all young people with long-term health conditions.

Does Asthma Increase the Odds of Suicidal Thoughts, Plans, and Attempts?

Background Asthma is a chronic inflammatory disease of the airways affecting more than 250 million people worldwide. In the past, a possible relationship between asthma and suicidality has been hypothesized. However, further research is required as this link has not been clearly established. Our objective was to use propensity score matching to answer the following research question: does having asthma increase one's odds of developing suicidality throughout their lifetime and, if so, how large is this increase? Methodology We utilized data from the 2018 National Survey on Drug Use and Health. We analyzed the relationship between currently having asthma and having had suicidal thoughts, suicide plans, and suicide attempts over the past 12 months. Chi-square analyses were performed both before and after completing propensity score matching. Results Before matching, it was found that, compared to individuals without asthma, asthmatic individuals had 31.2% higher odds of having suicidal thoughts (p = 0.010) and 97.4% higher odds of a suicide attempt (p = 0.012). After controlling for confounders by matching, there was no longer a relationship between having asthma and suicidal thoughts (p = 0.707), suicidal plans (p = 0.523), and suicidal attempts (p = 0.260). Conclusions These findings highlight that while asthma may appear to be associated with suicidality, this association does not persist after controlling for confounding factors. Hence, it is recommended that more research be conducted on this topic and that possible confounders be further researched. In particular, there is a need to better understand the role of social determinants and other contributors to health outcomes.

Efficacy and safety of fluticasone propionate/salmeterol and fluticasone propionate monotherapy in step-up treatment of childhood asthma: A systematic review and meta-analysis

BACKGROUND

Asthma is a chronic respiratory disease that affects millions of children worldwide and can impair their quality of life and development. Inhaled glucocorticoids are the mainstay of asthma treatment, but some children require step-up therapy with additional drugs to achieve symptom control. Fluticasone propionate and salmeterol (FSC) has been shown to reduce asthma exacerbations and improve lung function in adults. However, the evidence for its efficacy and safety in children is limited.

OBJECTIVE

This study aims to provide a comprehensive basis for treatment selection by summarizing existing clinical randomized controlled trials (RCTs) on the efficacy of FSC compared to fluticasone propionate (FP) monotherapy in children with asthma who require step-up treatment.

METHODS

Five online databases and three clinical trial registration platforms were systematically searched. The effect size and corresponding 95% confidence interval (CI) were calculated based on the heterogeneity among the included studies.

RESULTS

Twelve RCTs were identified and a total of 9, 859 patients were involved. The results of the meta-analysis revealed that the use of FSC was associated with a greater reduction in the incidence of asthma exacerbations than FP alone when the dose of FP was the same or when the duration of treatment exceeded 12 weeks. In addition, FSC resulted in a greater proportion of time with asthma-free and without the use of albuterol compared to FP alone when the duration of treatment exceeded 12 weeks. No significant differences were observed between FSC and FP alone in the incidence of drug-related adverse events and other adverse events.

CONCLUSION

Both FSC and FP alone are viable options for the initial selection of step-up treatment in asthmatic children. While, FSC treatment demonstrates a greater likelihood of reducing asthma exacerbations which is particularly important for reducing the personnel, social and economic burden in children requiring step-up asthma treatment.

Characteristics of Allergic, Eosinophilic, and Overlapping Asthma Phenotypes Among Pediatric Patients with Current Asthma: A Cross-Sectional Study from Saudi Arabia

Purpose

Asthma is one of the most common chronic diseases affecting 10%-30% of children in Saudi Arabia. Although data exist on adult asthma phenotyping and endotyping in Saudi Arabia, little is known about asthma phenotypes in Saudi children.

Patients and Methods

This cross-sectional study enrolled pediatric patients diagnosed with bronchial asthma and followed in the pediatric pulmonology clinic of the Abha Maternity and Children Hospital between August 2021 and May 2023.

Results

A total of 321 children (aged 5-14 years) were analyzed. The population was classified into allergic [169 (52.6%)], eosinophilic [144 (44.9%)], and overlapping allergic and eosinophilic asthma [97 (30.2%)] phenotypes. Regarding asthma severity, 35.5%, 50.2%, and 14.3% were classified as mild, moderate, and severe, respectively. Of the 321 patients in the study, 124 (38.6%) had at least one asthma exacerbation that required hospitalization. The number of reported missed school days in the previous year was 1571 days [190 (59.2%) patients reported at least one missed school day]. The factors associated with the likelihood of uncontrolled asthma for all study participants included: emergency room (ER) visit last year (OR = 3.7, 95% CI:0.6-15.9]), overlapping eosinophilic and allergic (OR = 3.2, 95% CI = 1.8-5.9), and allergic phenotype (OR = 2.7, 95% CI = 1.3-5.4). The level of asthma control differed significantly among the three asthma phenotypes (p = 0.037).

Conclusion

Allergic asthma is the most prevalent asthma phenotype in this study, followed by the eosinophilic phenotype. The research has also shown that several factors predict uncontrolled asthma, including a family history of asthma, previous admission to the PICU, and previous hospitalization ever. There is, therefore, a definite need for multicenter cohort studies to better understand the phenotypes and endotypes of childhood asthma, as it could offer therapeutic and prognostic relevance.

Severe Asthma and Biological Therapies: Now and the Future

Recognition of phenotypic variability in pediatric asthma allows for a more personalized therapeutic approach. Knowledge of the underlying pathophysiological and molecular mechanisms (endotypes) of corresponding biomarkers and new treatments enables this strategy to progress. Biologic therapies for children with severe asthma are becoming more relevant in this sense. The T2 phenotype is the most prevalent in childhood and adolescence, and non-T2 phenotypes are usually rare. This document aims to review the mechanism of action, efficacy, and potential predictive and monitoring biomarkers of biological drugs, focusing on the pediatric population. The drugs currently available are omalizumab, mepolizumab, benralizumab, dupilumab, and 1ezepelumab, with some differences in administrative approval prescription criteria between the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA). Previously, we described the characteristics of severe asthma in children and its diagnostic and therapeutic management.

Readmission Rates After Acute Respiratory Distress Syndrome in Children

Importance

An increasing number of children survive after acute respiratory distress syndrome (ARDS). The long-term morbidity affecting these survivors, including the burden of hospital readmission and key factors associated with readmission, is unknown.

Objective

To determine 1-year readmission rates among survivors of pediatric ARDS and to investigate the associations of 3 key index hospitalization factors (presence or development of a complex chronic condition, receipt of a tracheostomy, and hospital length of stay [LOS]) with readmission.

Design, Setting, and Participants

This retrospective cohort study used data from the commercial or Medicaid IBM MarketScan databases between 2013 and 2017, with follow-up data through 2018. Participants included hospitalized children (aged ≥28 days to <18 years) who received mechanical ventilation and had algorithm-identified ARDS. Data analysis was completed from March 2022 to March 2023.

Exposures

Complex chronic conditions (none, nonrespiratory, and respiratory), receipt of tracheostomy, and index hospital LOS.

Main Outcomes and Measures

The primary outcome was 1-year, all-cause hospital readmission. Univariable and multivariable Cox proportional hazard models were created to test the association of key hospitalization factors with readmission.

Results

One-year readmission occurred in 3748 of 13 505 children (median [IQR] age, 4 [0-14] years; 7869 boys [58.3%]) with mechanically ventilated ARDS who survived to hospital discharge. In survival analysis, the probability of 1-year readmission was 30.0% (95% CI, 29.0%-30.8%). One-half of readmissions occurred within 61 days of discharge (95% CI, 56-67 days). Both respiratory (adjusted hazard ratio [aHR], 2.69; 95% CI, 2.42-2.98) and nonrespiratory (aHR, 1.86; 95% CI, 1.71-2.03) complex chronic conditions were associated with 1-year readmission. Placement of a new tracheostomy (aHR, 1.98; 95% CI, 1.69-2.33) and LOS 14 days or longer (aHR, 1.87; 95% CI, 1.62-2.16) were associated with readmission. After exclusion of children with chronic conditions, LOS 14 days or longer continued to be associated with readmission (aHR, 1.92; 95% CI, 1.49-2.47).

Conclusions and Relevance

In this retrospective cohort study of children with ARDS who survived to discharge, important factors associated with readmission included the presence or development of chronic medical conditions during the index admission, tracheostomy placement during index admission, and index hospitalization of 14 days or longer. Future studies should evaluate whether postdischarge interventions (eg, telephonic contact, follow-up clinics, and home health care) may help reduce the readmission burden.

Educational achievement among children with a disability: do parental resources compensate for disadvantage?

We examined the impact of child disability on Grade Points Average (GPA) using all children aged 15-16 years who completed their lower secondary education and registered with a GPA score in the period from 2016 to 2020 in Norway (n = 247 120). We use registry data that contain information on the child's main diagnosis, such as physical-, neurological- and neurodevelopmental conditions, and the severity of the condition, additional to the child's family characteristics. First, we examined whether the impact of the child's disability on the GPA scores varied by diagnosis and the severity of the child's condition. Second, we examined whether higher parental socioeconomic status (SES) buffers against the negative impact of child disability on GPA scores. Using longitudinal register data with the school fixed-effect model, the results showed that children with neurological and neurodevelopmental disabilities obtained lower GPA scores than their typically developing peers without chronic conditions, however children with asthma and diabetes had comparable GPA scores. These associations were most evident for neurodevelopmental conditions, such as ADHD and autism but also notable for neurological conditions such as epilepsy. In general, a severe condition impacts GPA scores more negatively than a less severe condition. Moreover, our analysis revealed that children of highly educated parents obtained higher GPA scores than children who had parents with short education. This applied to both disabled and typically developing peers, except children with autism and epilepsy, among whom buffering due to the parent's education did not seem to apply.

Routine FEV1 measurement is essential in diagnosis and monitoring of childhood asthma: myth or maxim?

Childhood asthma is a common condition in children. This review describes the evidence from seven asthma guidelines for using spirometry in the diagnosis and monitoring of childhood asthma. All guidelines recommend spirometry as the primary test to be performed for diagnosing asthma in children aged >5 years. Spirometry is often normal in children with asthma. Guidelines are not consistent with respect to whether forced expiratory volume in 1 s (FEV1) or FEV1/forced vital capacity (FVC) should be measured, or their threshold for "abnormal" spirometry, and we describe the sensitivity and specificity for these different cut-offs. The role of spirometry in monitoring asthma is less clear in the guidelines, and some do not suggest spirometry should be done. There is no consensus on what spirometric measurement should be used, how often it should be measured and what is a minimum clinically important change in spirometry. The role of spirometry in diagnosing asthma is more clearly established when compared to its role in monitoring asthma. The potential of spirometry to aid decision making for asthma diagnosis and monitoring in children remains to be fully evaluated.

Educational aims

To provide knowledge of the commonly used guidelines for asthma diagnosis and management.To give insight into the opportunities and challenges in using spirometry to diagnose and monitor asthma in children.To provide an understanding of the precision of spirometry for diagnosing asthma.

School lives of adolescent school students living with chronic physical health conditions: a qualitative evidence synthesis

OBJECTIVE

Assess the existing evidence base in order to synthesise the current qualitative findings for the impact of chronic health conditions on the school lives of young people.

DESIGN

Qualitative evidence synthesis using thematic synthesis.

PATIENTS

Young people aged 11-18 years with a chronic health condition from one of the following groups: oncology, cystic fibrosis, diabetes, asthma, rheumatology, neuromuscular, colorectal, chronic pain, allergies and dermatology.

OUTCOME MEASURE

Qualitative findings and discussions present in included studies formed the data for the thematic synthesis.

RESULTS

From a search identifying 19 311 records, a sample of 35 papers were included. The included papers represented 15 countries and primarily employed interviews as part of data collection. Thematic synthesis resulted in six themes: 'keeping up/catching up/missing out/looking forward'; 'identity'; 'relationship with peers'; 'normality and difference'; 'autonomy'; 'relationships with staff'.

CONCLUSIONS

Thematic synthesis highlighted the commonalities, rather than divergence, of issues for young people across different chronic conditions. Policies need to be based on the experiences of the people they aim to provide for, and while attendance and attainment remain important, there is clearly more that needs to be considered when gathering data, designing interventions and developing policies to support this population. It may also be advisable for clinical professionals to include the broader psychosocial aspects of school life in discussions and plans to support young people with long-term conditions.

PROSPERO REGISTRATION NUMBER

CRD42021278153.

Integrative Review of Programs to Improve Outcomes for Children With Comorbid Asthma and Anxiety/Depressive Symptoms

Asthma is one of the most common pediatric chronic physical conditions. Youth with comorbid asthma and anxiety/depressive symptoms tend to have less controlled asthma and an increased use of health services in schools. The purpose of this integrative review was to examine the literature on educational and behavioral/ cognitive behavioral skills interventions for children with asthma and anxiety/depressive symptoms. Five electronic databases and forward/backward citations were searched. Eleven peer reviewed articles were retained for review. Main findings of the limited evidence suggest that educational and behavioral/cognitive behavioral skills programs may increase asthma knowledge and asthma-related self-efficacy while reducing anxiety/depressive symptoms. One study showed a decrease in use of quick relief inhalers and another had increased adherence to asthma controller medication. The literature indicates that educational and cognitive behavioral skills programs can have a positive impact on children with asthma and symptoms of anxiety/depression. School-based skills programs had better retention than outpatient programs.

Effect of asthma education on health outcomes in children: a systematic review

BACKGROUND

It remains unknown whether child-oriented asthma education is associated with better health outcomes. This meta-analysis investigated the effects of asthma education on hospitalisation and emergency department and clinic visits.

METHODS

We searched the Cochrane Library, PubMed and EMBASE for relevant studies from inception to 4 July 2021, and selected studies that reported hospitalisation or emergency department or clinic visits as outcomes. The participants were only children. Two authors independently selected the studies, assessed the quality of the included studies and retrieved the data. A third senior author was engaged to resolve disagreements. Fifteen longitudinal studies were included for the systematic review and meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 was used as the standard of reporting (PRISMA registration ID is 284509).

FINDINGS

Compared with the control group, the asthma education group had 54% lower hospitalisation risk (95% CI 0.32 to 0.66), and 31% lower emergency department visit risk (95% CI 0.59 to 0.81). Sensitivity analysis showed that the asthma education group had a reduced clinic visit risk (risk ratio (RR)=0.80, 95% CI 0.67 to 0.97). Subgroup analysis showed that asthma education involving both children and parents/guardians was associated with fewer hospitalisations (RR=0.38, 95% CI 0.24 to 0.59) and emergency department visits (RR=0.69, 95% CI 0.57 to 0.83). Asthma education in hospitals or non-hospitals can reduce the risk of hospitalisation and emergency department visits. However, only education in the hospitals was associated with the reduction of clinical visits (RR=0.45, 95% CI 0.22 to 0.92).

INTERPRETATION

Education is effective for controlling asthma, especially for reducing hospitalisation and emergency department and clinic visits. Education involving both children and parents/guardians is more effective than that involving only children. The setting of asthma education does not impact its effect to a large extent.

Identifying the important social outcomes for childhood cancer survivors: an e-Delphi study protocol

INTRODUCTION

Optimising the health of childhood cancer survivors is important given the high long-term survival rate coupled with a significant late effects burden. Included within the WHO's definition of 'Health' are social outcomes. These are of interest given their impact on adult functioning within society, complex interactions with physical and mental health outcomes and potential for cross generational effects. Categories included within the definition of social outcomes are ill defined leading to potential gaps in research and service provision which could affect the ability of survivors to achieve their maximal potential. An e-Delphi study will be used to achieve expert consensus on the most important social outcomes for childhood cancer survivors to inform future research and ultimately, service provision.

METHODS AND ANALYSIS

A heterogeneous sample of at least 48 panel members will be recruited across four groups chosen to provide different perspectives on the childhood cancer journey: childhood cancer survivors, health professionals, social workers and teachers. Purposive sampling from a UK, regional long-term follow-up clinic will be used to recruit a representative sample of survivors. Other panel members will be recruited through local channels and national professional working groups. Opinions regarding breakdown and relevance of categories of social outcome will be collected through 3-5 rounds of questionnaires using an e-Delphi technique. Open ended, 7-point Likert scale and ranking questions will be used. Each round will be analysed collectively and per group to assess inter-rater agreement. Agreement and strength of agreement will be indicated by a median score of 6 or 7 and mean absolute deviation from the median, respectively.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by Regional Ethics Committee 4, West of Scotland (ID 297344). Study findings will be disseminated to involved stakeholders, published in a peer-reviewed journal and presented at conferences.

BReATHE interventions (Beating Regional Asthma Through Health Education)-an innovative approach to children's asthma care in the North East and North Cumbria, UK: an interventional study

To objective of this project was to reduce unplanned hospital admission rates in children related to asthma to the Newcastle upon Tyne Hospitals National Health Service Trust (NUTH).Multiple educational interventions were introduced both locally and regionally including: a collection of educational materials aimed at young people and families, schools, primary care and secondary care on the website www.beatasthma.co.uk; regional training days; a nurse-led one-stop clinic; a new pathway following an acute attendance to hospital with an asthma attack; a local asthma service and cascade training for schools.The primary outcome measure was reduction in unplanned hospital admission rates in children due to asthma to the NUTH.Results showed that admission rates had been increasing at a sustained rate of approximately 30% each year in the 3 years prior to our intervention. After the Beating Regional Asthma Through Health Education interventions, unplanned admissions to NUTH reduced by 29% and this reduction has been sustained for the last 3 years. This compares with a regional increase of 10% over the same time period.In conclusion, simple but effective educational interventions resulted in a significant and sustained reduction in unplanned asthma admissions to NUTH. Further work is underway to extend the reach of these interventions into primary care and schools.

Diagnosis and management of asthma in children

Asthma is the the most common chronic respiratory condition of childhood worldwide, with around 14% of children and young people affected. Despite the high prevalence, paediatric asthma outcomes are inadequate, and there are several avoidable deaths each year. Characteristic asthma features include wheeze, shortness of breath and cough, which are typically triggered by a number of possible stimuli. There are several diagnostic challenges, and as a result, both overdiagnosis and underdiagnosis of paediatric asthma remain problematic.Effective asthma management involves a holistic approach addressing both pharmacological and non-pharmacological management, as well as education and self-management aspects. Working in partnership with children and families is key in promoting good outcomes. Education on how to take treatment effectively, trigger avoidance, modifiable risk factors and actions to take during acute attacks via personalised asthma action plans is essential.This review aimed to provide an overview of good clinical practice in the diagnosis and management of paediatric asthma. We discuss the current diagnostic challenges and predictors of life-threatening attacks. Additionally, we outline the similarities and differences in global paediatric asthma guidelines and highlight potential future developments in care. It is hoped that this review will be useful for healthcare providers working in a range of child health settings.

Issues affecting young people with asthma through the transition period to adult care

Asthma is among the most common medical conditions affecting children and young people, with adolescence a recognised period of increased risk, overrepresented in analyses examining recent increasing asthma mortality rates. Asthma may change significantly during this period and management also occurs in the context of patients seeking increased autonomy and self-governance whilst navigating increasing academic and social demands. A number of disease factors can destabilise asthma during adolescence including: increased rates of anaphylaxis, anxiety, depression, obesity, and, in females, an emerging resistance to corticosteroids and the pro-inflammatory effects of oestrogen. Patient factors such as smoking, vaping, poor symptom recognition, treatment non-adherence and variable engagement with health services contribute to difficult to treat asthma. Significant deficiencies in the current approach to transition have been identified by a recent EAACI task force, and subsequent asthma-specific recommendations, published in 2020 provide an important framework moving forward. As with other chronic conditions, effective transition programmes plan ahead, engage with adolescents and their families to identify the patients' management priorities and the current challenges they are experiencing with treatment. Transition needs may vary significantly across asthma patients and for more complex asthma may include dedicated transition clinics involving multidisciplinary care requiring input including, amongst others, allergy and immunology, psychological medicine, respiratory physicians and scientists and nurse specialists. Across different global regions, barriers to treatment may vary but need to be elicited and an individualised approach taken to optimising asthma care which is sustainable within the local adult healthcare system.

Educational and health outcomes of schoolchildren in local authority care in Scotland: A retrospective record linkage study

BACKGROUND

Looked after children are defined as children who are in the care of their local authority. Previous studies have reported that looked after children have poorer mental and physical health, increased behavioural problems, and increased self-harm and mortality compared to peers. They also experience poorer educational outcomes, yet population-wide research into the latter is lacking, particularly in the United Kingdom. Education and health share a bidirectional relationship; therefore, it is important to dually investigate both outcomes. Our study aimed to compare educational and health outcomes for looked after children with peers, adjusting for sociodemographic, maternity, and comorbidity confounders.

METHODS AND FINDINGS

Linkage of 9 Scotland-wide databases, covering dispensed prescriptions, hospital admissions, maternity records, death certificates, annual pupil census, examinations, school absences/exclusions, unemployment, and looked after children provided retrospective data on 715,111 children attending Scottish schools between 2009 and 2012 (13,898 [1.9%] looked after). Compared to peers, 13,898 (1.9%) looked after children were more likely to be absent (adjusted incidence rate ratio [AIRR] 1.27, 95% confidence interval [CI] 1.24 to 1.30) and excluded (AIRR 4.09, 95% CI 3.86 to 4.33) from school, have special educational need (SEN; adjusted odds ratio [AOR] 3.48, 95% CI 3.35 to 3.62) and neurodevelopmental multimorbidity (AOR 2.45, 95% CI 2.34 to 2.57), achieve the lowest level of academic attainment (AOR 5.92, 95% CI 5.17 to 6.78), and be unemployed after leaving school (AOR 2.12, 95% CI 1.96 to 2.29). They were more likely to require treatment for epilepsy (AOR 1.50, 95% CI 1.27 to 1.78), attention deficit hyperactivity disorder (ADHD; AOR 3.01, 95% CI 2.76 to 3.27), and depression (AOR 1.90, 95% CI 1.62 to 2.22), be hospitalised overall (adjusted hazard ratio [AHR] 1.23, 95% CI 1.19 to 1.28) for injury (AHR 1.80, 95% CI 1.69 to 1.91) and self-harm (AHR 5.19, 95% CI 4.66 to 5.78), and die prematurely (AHR 3.21, 95% CI 2.16 to 4.77). Compared to children looked after at home, children looked after away from home had less absenteeism (AIRR 0.35, 95% CI 0.33 to 0.36), less exclusion (AIRR 0.63, 95% CI 0.56 to 0.71), less unemployment (AOR 0.53, 95% CI 0.46 to 0.62), and better attainment (AIRR 0.31, 95% CI 0.23 to 0.40). Therefore, among those in care, being cared for away from home appeared to be a protective factor resulting in better educational outcomes. The main limitations of this study were lack of data on local authority care preschool or before 2009, total time spent in care, and age of first contact with social care.

CONCLUSIONS

Looked after children had poorer health and educational outcomes than peers independent of increased neurodevelopmental conditions and SEN. Further work is required to understand whether poorer outcomes relate to reasons for entering care, including maltreatment and adverse childhood events, neurodevelopmental vulnerabilities, or characteristics of the care system.

Educational associations with missed GP appointments for patients under 35 years old: administrative data linkage study

BACKGROUND

There is an evidence gap about whether levels of engagement with public services such as schools and health care affect people across the lifespan. Data on missed patient appointments from a nationally representative sample of Scottish general practices (GP) (2013-2016) were probabilistically linked to secondary school pupil data. We tested whether school attendance, exclusions (2007-2011) or lower educational attainment (2007-2016) was associated with an increased risk of missing general practice appointments.

METHODS

School attendance data were classified into quartiles of possible days attended for years we had data. School exclusions were derived as a categorical variable of 'ever excluded'. Attainment data were categorised via the Scottish Credit and Qualifications Framework (SCQF) level 3 or 6; a cumulative measure of attainment on leaving school. The associations between school attendance, exclusions and attainment and risk of missing medical appointments were investigated using negative binomial models, offset by number of GP appointments made and controlling for potential confounders.

RESULTS

112,534 patients (all aged under 35) had GP appointment and retrospective school attendance and exclusion data, and a subset of 66,967 also had attainment data available. Patients who had lower attendance, had been excluded from school or had lower educational attainment had an increased risk of missing GP appointments (all rate ratios > 1.40).

CONCLUSIONS

This study provides the first evidence from a population-representative sample in a high-income country that increased numbers of missed appointments in health care are associated with reduced school attendance, higher levels of school exclusion and lower educational attainment. Insights into the epidemiology of missingness across public services can support future research, policy and practice that aim to improve healthcare, health outcomes and engagement in services.

The impact of childhood asthma on academic performance: A matched population-based cohort study

BACKGROUND

There is inconclusive evidence of the effect of asthma on the academic performance of young people. This study aims to compare scholastic performance and high school completion of young people hospitalized with asthma compared to matched peers not hospitalized with asthma.

METHOD

A population-based matched case-comparison cohort study of young people aged ≤18 years hospitalized for asthma during 2005-2018 in New South Wales, Australia using linked birth, health, education and mortality records. The comparison cohort was matched on age, gender and residential postcode. Generalized linear mixed-modelling examined risk of school performance below the national minimum standard (NMS) and generalized linear regression examined risk of not completing high school for young people hospitalized with asthma compared to matched peers.

RESULTS

Young males hospitalized with asthma had a 13% and 15% higher risk of not achieving the NMS for numeracy (95%CI 1.04-1.22) and reading (95%CI 1.07-1.23), respectively, compared to peers. Young males hospitalized with asthma had a 51% (95%CI 1.22-1.86) higher risk of not completing year 10, and around a 20% higher risk of not completing year 11 (ARR: 1.25; 95%CI 1.15-1.36) or year 12 (ARR: 1.27; 95%CI 1.17-1.39) compared to peers. Young females hospitalized with asthma showed no difference in achieving numeracy or reading NMSs, but did have a 21% higher risk of not completing year 11 (95%CI 1.09-1.36) and a 33% higher risk of not completing year 12 (95%CI 1.19-1.49) compared to peers.

CONCLUSIONS

Educational attainment is worse for young people hospitalized with asthma compared to matched peers. Early intervention and strategies for better management of asthma symptoms may enhance academic performance for students.

Linking education and hospital data in England: linkage process and quality

INTRODUCTION

Linkage of administrative data for universal state education and National Health Service (NHS) hospital care would enable research into the inter-relationships between education and health for all children in England.

OBJECTIVES

We aim to describe the linkage process and evaluate the quality of linkage of four one-year birth cohorts within the National Pupil Database (NPD) and Hospital Episode Statistics (HES).

METHODS

We used multi-step deterministic linkage algorithms to link longitudinal records from state schools to the chronology of records in the NHS Personal Demographics Service (PDS; linkage stage 1), and HES (linkage stage 2). We calculated linkage rates and compared pupil characteristics in linked and unlinked samples for each stage of linkage and each cohort (1990/91, 1996/97, 1999/00, and 2004/05).

RESULTS

Of the 2,287,671 pupil records, 2,174,601 (95%) linked to HES. Linkage rates improved over time (92% in 1990/91 to 99% in 2004/05). Ethnic minority pupils and those living in more deprived areas were less likely to be matched to hospital records, but differences in pupil characteristics between linked and unlinked samples were moderate to small.

CONCLUSION

We linked nearly all pupils to at least one hospital record. The high coverage of the linkage represents a unique opportunity for wide-scale analyses across the domains of health and education. However, missed links disproportionately affected ethnic minorities or those living in the poorest neighbourhoods: selection bias could be mitigated by increasing the quality and completeness of identifiers recorded in administrative data or the application of statistical methods that account for missed links.

HIGHLIGHTS

Longitudinal administrative records for all children attending state school and acute hospital services in England have been used for research for more than two decades, but lack of a shared unique identifier has limited scope for linkage between these databases.We applied multi-step deterministic linkage algorithms to 4 one-year cohorts of children born 1 September-31 August in 1990/91, 1996/97, 1999/00 and 2004/05. In stage 1, full names, date of birth, and postcode histories from education data in the National Pupil Database were linked to the NHS Personal Demographic Service. In stage 2, NHS number, postcode, date of birth and sex were linked to hospital records in Hospital Episode Statistics.Between 92% and 99% of school pupils linked to at least one hospital record. Ethnic minority pupils and pupils who were living in the most deprived areas were least likely to link. Ethnic minority pupils were less likely than white children to link at the first step in both algorithms.Bias due to linkage errors could lead to an underestimate of the health needs in disadvantaged groups. Improved data quality, more sensitive linkage algorithms, and/or statistical methods that account for missed links in analyses, should be considered to reduce linkage bias.

Biologic Therapy and Severe Asthma in Children

Severe asthma is a heterogeneous, complex and chronic disease widespread in the pediatric population. According to the recent findings about the different endotypes of asthma in children, each one characterized by specific intracellular molecular pathways, several innovative biologic therapies have been developed. Due to their precise ability to target specific inflammatory type 2 mediators, biologics have revolutionized the care of chronic allergic diseases in the pediatric and adult population. In this review, we aim to provide the latest evidence about the use, indications, efficacy and safety of biologic therapies to treat severe asthma in children and adolescents.

Educational and health outcomes of children and adolescents receiving antidepressant medication: Scotland-wide retrospective record linkage cohort study of 766 237 schoolchildren

Background

Childhood depression is relatively common, under-researched and can impact social and cognitive function and self-esteem.

Methods

Record linkage of routinely collected Scotland-wide administrative databases covering prescriptions [prescribing information system (PIS)], hospitalizations (Scottish Morbidity Records 01 and 04), maternity records (Scottish Morbidity Records 02), deaths (National Records of Scotland), annual pupil census, school absences/exclusions, special educational needs (Scottish Exchange of Educational Data; ScotXed), examinations (Scottish Qualifications Authority) and (un)employment (ScotXed) provided data on 766 237 children attending Scottish schools between 2009 and 2013 inclusively. We compared educational and health outcomes of children receiving antidepressant medication with their peers, adjusting for confounders (socio-demographic, maternity and comorbidity) and explored effect modifiers and mediators.

Results

Compared with peers, children receiving antidepressants were more likely to be absent [adjusted incidence rate ratio (IRR) 1.90, 95% confidence interval (CI) 1.85–1.95] or excluded (adjusted IRR 1.48, 95% CI 1.29–1.69) from school, have special educational needs [adjusted odds ratio (OR) 1.77, 95% CI 1.65–1.90], have the lowest level of academic attainment (adjusted OR 3.00, 95% CI 2.51–3.58) and be unemployed after leaving school (adjusted OR 1.88, 95% CI 1.71–2.08). They had increased hospitalization [adjusted hazard ratio (HR) 2.07, 95% CI 1.98–2.18] and mortality (adjusted HR 2.73, 95% CI 1.73–4.29) over 5 years’ follow-up. Higher absenteeism partially explained poorer attainment and unemployment. Treatment with antidepressants was less common among boys than girls (0.5% vs 1.0%) but the associations with special educational need and unemployment were stronger in boys.

Conclusions

Children receiving antidepressants fare worse than their peers across a wide range of education and health outcomes. Interventions to reduce absenteeism or mitigate its effects should be investigated.

Health, educational and employment outcomes among children treated for a skin disorder: Scotland-wide retrospective record linkage cohort study of 766,244 children

BACKGROUND

To compare health, educational and employment outcomes of schoolchildren receiving medication for a skin disorder with peers.

METHODS

This retrospective population cohort study linked eight Scotland-wide databases, covering dispensed prescriptions, hospital admissions, maternity records, death certificates, annual pupil census, school examinations, school absences/exclusions and unemployment to investigate educational (absence, exclusion, special educational need, academic attainment), employment, and health (admissions and mortality) outcomes of 766,244 children attending local authority run primary, secondary and special schools in Scotland between 2009 and 2013.

RESULTS

After adjusting for sociodemographic and maternity confounders the 130,087 (17.0%) children treated for a skin disorder had increased hospitalisation, particularly within one year of commencing treatment (IRR 1.38, 95% CI 1.35-1.41, p<0.001) and mortality (HR 1.50, 95% CI 1.18-1.90, p<0.001). They had greater special educational need (OR 1.19, 95% CI 1.17-1.21, p<0.001) and more frequent absences from school (IRR 1.07, 95% CI 1.06-1.08, p<0.001) but did not exhibit poorer exam attainment or increased post-school unemployment. The associations remained after further adjustment for comorbid chronic conditions.

CONCLUSIONS

Despite increased hospitalisation, school absenteeism, and special educational need, children treated for a skin disorder did not have poorer exam attainment or employment outcomes. Whilst findings relating to educational and employment outcomes are reassuring, the association with increased risk of mortality is alarming and merits further investigation.

Asthma control affects school absence, achievement and quality of school life: a multicenter study

INTRODUCTION AND OBJECTIVES

Asthma may have a detrimental effect on school attendance and achievement. Friend relations, attendance to school activities, quality of life (QOL) of asthmatic children may be negatively affected. The aim of this study was to evaluate factors influencing school functioning for asthmatic school-age children.

MATERIALS AND METHODS

From January to May 2019, parents and school-age children who were followed by a diagnosis of asthma for more than one year, from seven pediatric allergy centers, were given a standard questionnaire including questions about child's disease, school performance, absenteeism, home-family-school conditions. A pediatric QOL questionnaire was filled out by children. For evaluating control in the previous year, children who had more than two exacerbations and/or had any exacerbations needing systemic corticosteroids in the previous year were defined as inadequate control. School absence over nine days was taken into account as this has been shown to bring a risk for successful school life.

RESULTS

507 patients were included. Asthma control status was found to be effective on school absence (p < 0.001), on school success (especially math scores) (p < 0.001), on friend relations (p = 0.033), QOL (p < 0.001), attendance to school activities (p < 0.001). Regular follow-up (p < 0.001), regular use of asthma medication (p = 0.014), tobacco smoke exposure (p < 0.001), heating with stove at home (p = 0.01) affected asthma control. School conditions such as crowdedness (p = 0.044), humidity of the class (p = 0.025), knowledge of teacher about child's asthma (p = 0.012) were effective on asthma control independent of home conditions and asthma treatment parameters.

CONCLUSION

School interventions are important to improve asthma management.

Neurodevelopmental multimorbidity and educational outcomes of Scottish schoolchildren: A population-based record linkage cohort study

BACKGROUND

Neurodevelopmental conditions commonly coexist in children, but compared to adults, childhood multimorbidity attracts less attention in research and clinical practice. We previously reported that children treated for attention deficit hyperactivity disorder (ADHD) and depression have more school absences and exclusions, additional support needs, poorer attainment, and increased unemployment. They are also more likely to have coexisting conditions, including autism and intellectual disability. We investigated prevalence of neurodevelopmental multimorbidity (≥2 conditions) among Scottish schoolchildren and their educational outcomes compared to peers.

METHODS AND FINDINGS

We retrospectively linked 6 Scotland-wide databases to analyse 766,244 children (390,290 [50.9%] boys; 375,954 [49.1%] girls) aged 4 to 19 years (mean = 10.9) attending Scottish schools between 2009 and 2013. Children were distributed across all deprivation quintiles (most to least deprived: 22.7%, 20.1%, 19.3%, 19.5%, 18.4%). The majority (96.2%) were white ethnicity. We ascertained autism spectrum disorder (ASD) and intellectual disabilities from records of additional support needs and ADHD and depression through relevant encashed prescriptions. We identified neurodevelopmental multimorbidity (≥2 of these conditions) in 4,789 (0.6%) children, with ASD and intellectual disability the most common combination. On adjusting for sociodemographic (sex, age, ethnicity, deprivation) and maternity (maternal age, maternal smoking, sex-gestation-specific birth weight centile, gestational age, 5-minute Apgar score, mode of delivery, parity) factors, multimorbidity was associated with increased school absenteeism and exclusion, unemployment, and poorer exam attainment. Significant dose relationships were evident between number of conditions (0, 1, ≥2) and the last 3 outcomes. Compared to children with no conditions, children with 1 condition, and children with 2 or more conditions, had more absenteeism (1 condition adjusted incidence rate ratio [IRR] 1.28, 95% CI 1.27-1.30, p < 0.001 and 2 or more conditions adjusted IRR 1.23, 95% CI 1.20-1.28, p < 0.001), greater exclusion (adjusted IRR 2.37, 95% CI 2.25-2.48, p < 0.001 and adjusted IRR 3.04, 95% CI 2.74-3.38, p < 0.001), poorer attainment (adjusted odds ratio [OR] 3.92, 95% CI 3.63-4.23, p < 0.001 and adjusted OR 12.07, 95% CI 9.15-15.94, p < 0.001), and increased unemployment (adjusted OR 1.57, 95% CI 1.49-1.66, p < 0.001 and adjusted OR 2.11, 95% CI 1.83-2.45, p < 0.001). Associations remained after further adjustment for comorbid physical conditions and additional support needs. Coexisting depression was the strongest driver of absenteeism and coexisting ADHD the strongest driver of exclusion. Absence of formal primary care diagnoses was a limitation since ascertaining depression and ADHD from prescriptions omitted affected children receiving alternative or no treatment and some antidepressants can be prescribed for other indications.

CONCLUSIONS

Structuring clinical practice and training around single conditions may disadvantage children with neurodevelopmental multimorbidity, who we observed had significantly poorer educational outcomes compared to children with 1 condition and no conditions.

Asthma and all-cause mortality in children and young adults: a population-based study

BACKGROUND

Studies suggest an increased all-cause mortality among adults with asthma. We aimed to study the relationship between asthma in children and young adults and all-cause mortality, and investigate differences in mortality rate by also having a life-limiting condition (LLC) or by parental socioeconomic status (SES).

METHODS

Included in this register-based study are 2 775 430 individuals born in Sweden between January 1986 and December 2012. We identified asthma cases using the National Patient Register (NPR) and the Prescribed Drug Register. Those with LLC were identified using the NPR. Parental SES at birth (income and education) was retrieved from Statistics Sweden. We estimated the association between asthma and all-cause mortality using a Cox proportional hazards regression model. Effect modification by LLC or parental SES was studied using interaction terms in the adjusted model.

RESULTS

The adjusted hazard rate (adjHR) for all-cause mortality in asthma cases versus non-asthma cases was 1.46 (95% CI 1.33 to 1.62). The highest increased rate appeared to be for those aged 5-15 years. In persons with asthma and without LLC, the adjHR remained increased at 1.33 (95% CI 1.18 to 1.50), but differed (p=0.002) from those with asthma and LLC, with an adjHR of 1.87 (95% CI 1.57 to 2.22). Parental SES did not alter the association (income, p=0.55; education, p=0.83).

CONCLUSION

This study shows that asthma is associated with an increased mortality in children and young adults regardless of LLC or parental SES. Further research is warranted to investigate the possible mechanisms for this association.

Advances in understanding and reducing the burden of severe asthma in children

Severe asthma in children is rare, accounting for only a small proportion of childhood asthma. After addressing modifiable factors such as adherence to treatment, comorbidities, and adverse exposures, children whose disease is not well controlled on high doses of medication form a heterogeneous group of severe asthma phenotypes. Over the past decade, considerable advances have been made in understanding the pathophysiology of severe therapy-resistant asthma in children. However, asthma attacks and hospital admissions are frequent and mortality is still unacceptably high. Strategies to modify the natural history of asthma, prevent severe exacerbations, and prevent lung function decline are needed. Mechanistic studies have led to the development of several biologics targeting type 2 inflammation. This growing pipeline has the potential to reduce the burden of severe asthma; however, detailed assessment and characterisation of each child with seemingly severe asthma is necessary so that the most effective and appropriate management strategy can be implemented. Risk stratification, remote monitoring, and the integration of multiple data sources could help to tailor management for the individual child with severe asthma.

Asthma and subsequent school performance at age 15-16 years: A Swedish population-based sibling control study

Asthma may negatively affect children’s school performance, such as grades and exam results. Results from previous studies have shown varying results and may have suffered from confounding and other biases. We used a Swedish population-based cohort of 570,595 children with data on asthma (including severity and control) in Grades 7–8 and 9, school performance from Grade 9 (grade point sum, non-eligibility for upper secondary school and national test results) and measured confounders from national registers. We used sibling comparisons to account for unmeasured familial factors. Children with asthma and severe asthma performed slightly better in school than children without asthma when adjusting for measured confounders, but the associations were attenuated in sibling comparisons. In contrast, children with uncontrolled asthma performed slightly worse (e.g. Grade 9: β_adj = −9.9; 95% CI −12.8 to −7.0; Cohen’s d = 0.16). This association remained for uncontrolled asthma in Grade 9 in sibling comparisons (Grade 9: β = −7.7 points; 95% CI −12.6 to −2.6; Cohen’s d = 0.12), but not for Grades 7–8. The attenuation of estimates when controlling for familial factors using sibling comparisons suggests that the differences were due to familial factors, rather than being causal. The remaining associations in sibling comparisons between uncontrolled asthma in Grade 9 and school performance are consistent with a causal association.

Heterogeneity of Mild to Moderate Persistent Asthma in Children: Confirmation by Latent Class Analysis and Association with 1-Year Outcomes

BACKGROUND

Compared with adults, phenotypic characterization of children with asthma is still limited and it remains difficult to predict which children with asthma are at highest risk for poor outcomes.

OBJECTIVE

To identify latent classes in a large population of treatment-adherent children with mild to moderate asthma enrolled in clinical trials and determine whether latent class assignment predicts future lung function abnormalities and exacerbation rate.

METHODS

Latent class analysis was performed on 2593 children with mild to moderate asthma aged 5 18 years, with 19 variables encompassing demographic characteristics, medical history, symptoms, lung function, allergic sensitization, and type 2 inflammation. Outcomes included lung function and the annualized exacerbation rate at 12 months of follow-up.

RESULTS

Five latent classes were identified with differing demographic features, asthma control, sensitization, type 2 inflammatory markers, and lung function. Exacerbation rates were 1.30 ± 0.12 for class 1 (multiple sensitization with partially reversible airflow limitation), 0.90 ± 0.05 for class 2 (multiple sensitization with reversible airflow limitation), 0.87 ± 0.08 for class 3 (lesser sensitization with reversible airflow limitation), 0.87 ± 0.05 for class 4 (multiple sensitization with normal lung function), and 0.71 ± 0.06 for class 5 (lesser sensitization with normal lung function). Lung function abnormalities persisted in class 1 at 12 months.

CONCLUSIONS

Children with mild to moderate asthma are a heterogeneous group. Allergic sensitization and lung function may be particularly useful in identifying children at the greatest risk for future exacerbation. Additional studies are needed to determine whether latent classes correspond to meaningful phenotypes for the purpose of personalized treatment.