Involuntary smoking and asthma severity in children: data from the Third National Health and Nutrition Examination Survey

The influence of disparities on intensive care outcomes in children with respiratory diseases: A systematic review

CONTEXT

The negative effects of socioeconomic, environmental and ethnic inequalities on childhood respiratory diseases are known in the development of persistent asthma and can result in adverse outcomes. However, little is known about the effects of these disparities on pediatric intensive care unit (PICU) outcomes in respiratory diseases.

OBJECTIVE

The purpose of this systematic review is to evaluate the literature on disparities in socioeconomic, environmental and ethnic determinants and PICU outcomes. We hypothesize that these disparities negatively influence the outcomes of children's respiratory diseases at the PICU.

METHODS

A literature search (in PubMed, Embase.com and Web of Science Core Collection) was performed up to September 30, 2022. Two authors extracted the data and independently evaluated the risk of bias with appropriate assessment methods. Articles were included if the patients were below 18 years of age (excluding neonatal intensive care unit admissions), they concerned respiratory diseases and incorporated socioeconomic, ethnic or environmental disparities.

RESULTS

Eight thousand seven hundred fourty-six references were reviewed, and 15 articles were included; seven articles on the effect of socioeconomic status, five articles on ethnicity, one on the effect of sex and lastly two on environmental factors. All articles but one showed an unfavorable outcome at the PICU.

CONCLUSION

Disparities in socioeconomic (such as a low-income household, public health insurance), ethnic and environmental factors (such as exposure to tobacco smoke and diet) have been assessed as risk factors for the severity of children's respiratory diseases and can negatively influence the outcomes of these children admitted and treated at the PICU.

Serum cotinine cut-points for secondhand smoke exposure assessment in children under 5 years: A systemic review

Background

Serum cotinine has become the most widely used biomarker of secondhand smoke exposure (SHS) over time in all ages. The aim of this study was to review the serum cotinine cut-points used to classify children under 5 years as exposed to SHS.

Methods

A systematic review performed in the Pubmed (MEDLINE) and EMBASE databases up to April 2021 was conducted using as key words "serum cotinine", “tobacco smoke pollution” (MeSH), "secondhand smoke", "environmental tobacco smoke" and “tobacco smoke exposure”. Papers which assessed SHS exposure among children younger than 5 years old were included. The PRISMA 2020 guidelines were followed. Analysis was pre-registered in PROSPERO (registration number: CRD42021251263).

Results

247 articles were identified and 51 fulfilled inclusion criteria. The selected studies were published between 1985–2020. Most of them included adolescents and adults. Only three assessed postnatal exposure exclusively among children under 5 years. None of the selected studies proposed age-specific cut-points for children < 5 years old. Cut-point values to assess SHS exposure ranged from 0.015 to 100 ng/ml. The most commonly used cut-point was 0.05 ng/ml, derived from the assay limit of detection used by the National Health and Nutrition Examination Survey (NHANES).

Conclusions

No studies have calculated serum cotinine age-specific cut-points to ascertained SHS exposure among children under 5 years old. Children’s age-specific cut-points are warranted for health research and public health purposes aimed at accurately estimating the prevalence of SHS exposure and attributable burden of disease to such exposure, and at reinforcing 100% smoke-free policies worldwide, both in homes, private vehicles and public places.

Sex-Specific Association between Environmental Tobacco Smoke Exposure and Asthma Severity among Adults with Current Asthma

Background: Tobacco smoke has been associated with negative health outcomes, including those with chronic respiratory illnesses, such as asthma. This study aimed to assess the relationship between exposure to environmental tobacco smoke (ETS), as well as tobacco use (cigarette and electronic cigarettes), on asthma severity among adults with current asthma, with stratification by sex to understand potential biological sex differences. Methods: The study population consisted of Californian adults 18 years or older with self-reported physician/health care diagnosis of asthma and still having current asthma from 2020 California Health Interview Survey. All descriptive statistics and analyses were sex-stratified and survey-weighted. Crosstabulations were used to understand the association between asthma attack and ETS or firsthand smoke exposure, while binary logistic regression models were used to assess the effect of ETS exposure, current smoking status, and control variables on asthma attack in the past 12 months, with a sub-analysis among non-smoking adults with asthma. Results: Among the primary variable of interest, 35% of males and 30% of females reported ETS exposure in the past 12 months, while 13% of males and 6% of females reported being a current smoker. Past year asthma attack was reported among 43% and 55% of males and females, respectively. Among males, after adjusting for all control variables, asthma attack was significantly higher among those with ETS exposure (OR: 1.75, 95% CI: 1.01–3.02) and among current smokers (OR: 3.82, 95% CI: 1.49, 9.81). Male non-smokers with ETS exposure had a 109% higher odds of asthma attack, compared to non-exposure individuals. Conclusion: Using a population-based survey, our results highlight the ongoing burden of tobacco use and exposure particularly among males with current asthma, further corroborate the literature on the relationship between tobacco and asthma, and highlight putative sex-specific outcomes.

Effect of the School-Based Asthma Care for Teens (SB-ACT) program on asthma morbidity: a 3-arm randomized controlled trial

Urban adolescents with asthma often have inadequate preventive care. We tested the effectiveness of the School-Based Asthma Care for Teens (SB-ACT) program on asthma morbidity and preventive medication adherence.Methods:Subjects/Setting- 12-16yr olds with persistent asthma in Rochester, NY schools. Design- 3-group randomized trial (2014-2019). SB-ACT Intervention- Two core components: 1) Directly observed therapy (DOT) of preventive asthma medications, provided in school for at least 6-8 weeks for the teen to learn proper technique and experience the benefits of daily preventive therapy; 2) 4-6 weeks later, 3 sessions of motivational interviewing (MI) to discuss potential benefits from DOT and enhance motivation to take medication independently. We included 2 comparison groups: 1) DOT-only for 6-8wks, and 2) asthma education (AE) attention control. Masked follow-up assessments were conducted at 3, 5, and 7mos. Outcomes- Mean number of symptom-free days (SFDs)/2 weeks and medication adherence. Analyses- Modified intention-to-treat repeated measures analysis.Results: We enrolled 430 teens (56% Black, 32% Hispanic, 85% Medicaid). There were no group differences at baseline. We found no difference in SFDs at any follow-up timepoint. More teens in the SB-ACT and DOT-only groups reported having a preventive asthma medication at each follow-up (p<.001), and almost daily adherence at 3 and 5-months (p<.001, p=.003) compared to AE. By 7 months there were no significant differences between groups in adherence (p=.49).Conclusion: SB-ACT improved preventive medication availability and short-term adherence but did not impact asthma symptoms. Further work is needed to create developmentally appropriate and effective interventions for this group.

Spatial analysis of tobacco outlet density on secondhand smoke exposure and asthma health among children in Baltimore City

RATIONALE

Tobacco outlets are concentrated in low-income neighbourhoods; higher tobacco outlet density is associated with increased smoking prevalence. Secondhand smoke (SHS) exposure has significant detrimental effects on childhood asthma. We hypothesised there was an association between higher tobacco outlet density, indoor air pollution and worse childhood asthma.

METHODS

Baseline data from a home intervention study of 139 children (8-17 years) with asthma in Baltimore City included residential air nicotine monitoring, paired with serum cotinine and asthma control assessment. Participant addresses and tobacco outlets were geocoded and mapped. Multivariable regression modelling was used to describe the relationships between tobacco outlet density, SHS exposure and asthma control.

RESULTS

Within a 500 m radius of each participant home, there were on average six tobacco outlets. Each additional tobacco outlet in a 500 m radius was associated with a 12% increase in air nicotine (p<0.01) and an 8% increase in serum cotinine (p=0.01). For every 10-fold increase in air nicotine levels, there was a 0.25-point increase in Asthma Therapy Assessment Questionnaire (ATAQ) score (p=0.01), and for every 10-fold increase in serum cotinine levels, there was a 0.54-point increase in ATAQ score (p<0.05).

CONCLUSIONS

Increased tobacco outlet density is associated with higher levels of bedroom air nicotine and serum cotinine. Increasing levels of SHS exposure (air nicotine and serum cotinine) are associated with less controlled childhood asthma. In Baltimore City, the health of children with asthma is adversely impacted in neighbourhoods where tobacco outlets are concentrated. The implications of our findings can inform community-level interventions to address these health disparities.

Association of blood trihalomethane concentrations with asthma in U.S. adolescents: nationally representative cross-sectional study

Background

Population studies show that the use of swimming pools is associated with the risk of asthma and allergic diseases among children. Our objective was to explore the associations between blood trihalomethane (THM) concentrations and asthma among US adolescents, and assess to what extent the association is modified by active tobacco smoke exposure.

Methods

We included 2359 adolescents aged 12–19 years with measured blood concentrations of chloroform (trichloromethane (TCM)), bromodichloromethane (BDCM), dibromochloromethane (DBCM) and bromoform (tribromomethane (TBM)) from the National Health and Nutrition Examination Survey 2005–2012. Logistic regression models were fitted to assess the odds ratios for the association of blood THM concentrations (three or four categories) with the risk of self-reported current and ever (lifetime) asthma.

Results

Blood DBCM concentrations were associated with a higher risk of ever asthma among all adolescents (OR 1.54 (95% CI 1.07–2.21), comparing the extreme exposure categories). The relationship was stronger among adolescents exposed to tobacco smoke (OR 3.96 (95% CI 1.89–8.30), comparing the extreme exposure categories). We also found positive relationships between blood brominated THM concentrations (sum of BDCM, DBCM and TBM) and risk of ever asthma and between blood DBCM and brominated THM concentrations and risk of current asthma among adolescents with tobacco smoke exposure. The relative excess risk of ever asthma due to the interaction between high blood DBCM and brominated THM concentrations and tobacco smoke exposure was 1.87 (95% CI 0.30–3.43) and 0.78 (95% CI 0.07–1.49), respectively.

Conclusions

Exposure to THMs is associated with a higher risk of asthma in adolescents, particularly among those exposed to tobacco smoke.

Among a representative sample of 2359 US adolescents, we found that exposure to THMs was associated with a greater risk of asthma, particularly among those who were co-exposed to tobacco smokehttps://bit.ly/3mpHxgq

Oxidative Stress Promotes Corticosteroid Insensitivity in Asthma and COPD

Corticosteroid insensitivity is a key characteristic of patients with severe asthma and COPD. These individuals experience greater pulmonary oxidative stress and inflammation, which contribute to diminished lung function and frequent exacerbations despite the often and prolonged use of systemic, high dose corticosteroids. Reactive oxygen and nitrogen species (RONS) promote corticosteroid insensitivity by disrupting glucocorticoid receptor (GR) signaling, leading to the sustained activation of pro-inflammatory pathways in immune and airway structural cells. Studies in asthma and COPD models suggest that corticosteroids need a balanced redox environment to be effective and to reduce airway inflammation. In this review, we discuss how oxidative stress contributes to corticosteroid insensitivity and the importance of optimizing endogenous antioxidant responses to enhance corticosteroid sensitivity. Future studies should aim to identify how antioxidant-based therapies can complement corticosteroids to reduce the need for prolonged high dose regimens in patients with severe asthma and COPD.

Smoking cessation and counseling: A mixed methods study of pediatricians and parents

OBJECTIVE

Pediatric providers play an important role in parental and youth smoking cessation. The goal of this study was to understand smoking cessation attitudes of parents and the behaviors, confidence and self-efficacy of pediatricians related to providing smoking cessation counseling to parents and youth.

METHODS

A mixed methods study was conducted in a convenience sample of families (n = 1,549) and pediatric primary care clinicians (n = 95) in Connecticut using surveys and focus groups from April, 2016 to January, 2017.

RESULTS

The smoking rate (cigarettes or electronic cigarettes) among all households surveyed was 21%. Interest in quitting smoking was high (71%) and did not differ based on smoking amount, duration, type of community of residence (urban, rural, etc), or race/ethnicity. For example, compared to participants who smoked for <10 years, those who smoked ≥20 years had a similar interest in quitting (OR = 1.12; 95% CI: 0.85-1.48). Ninety percent of clinicians surveyed asked parents about their smoking behavior at least annually but 36% offered no smoking cessation counseling services or referral. Clinicians almost always reported counseling youth about the dangers of nicotine and tobacco use (99%), were more confident about counseling youth than parents (p<0.01) and reported low self-efficacy about smoking cessation and prevention counseling of parents and youth. Ninety-three percent of clinicians opined that electronic cigarettes were equally or more dangerous than cigarettes but 34% never counseled youth about the dangers of electronic cigarettes.

CONCLUSIONS

Clinicians frequently screen parents about their smoking behaviors, but rarely provide smoking cessation counseling and express low confidence in this activity. Clinicians are more confident counseling youth than parents. Clinicians also recognize the dangers of electronic cigarettes, yet they infrequently counsel youth about these dangers.

Child tobacco smoke exposure and healthcare resource utilization patterns

BACKGROUND

The objective was to examine the relationship between healthcare resource utilization patterns in tobacco smoke-exposed children (TSE group) compared with unexposed children (non-TSE group).

METHODS

We matched 380 children in the TSE group with 1140 children in the non-TSE group based on child age, sex, race, and ethnicity using propensity scores. Healthcare resource utilization variables included respiratory-related procedures, diagnostic testing, disposition, and medications. Logistic and linear regression models were built.

RESULTS

Child mean age was 4.9 (SD = 0.1) years, 50.5% were female, 55.5% black, and 73.2% had public insurance/self-pay. Compared to the non-TSE group, the TSE group was at increased odds to have the following performed/obtained: nasal bulb suctioning, infectious diagnostic tests, laboratory tests, and radiologic tests. The TSE group was more likely to be admitted to the hospital, and more likely to receive steroids and intravenous fluids during their visit. Among asthmatics, the TSE group was more likely to receive steroids, albuterol, or ipratropium alone, or a combination of all three medications during their visit, and be prescribed albuterol alone or steroids and albuterol.

CONCLUSION

Tobacco smoke-exposed children are more likely to have higher resource utilization patterns, highlighting the importance of screening and providing TSE prevention and remediation interventions.

IMPACT

Tobacco smoke exposure may affect the healthcare resource utilization patterns of children. Evidence is lacking concerning these associations among the highly vulnerable pediatric emergency department patient population. This study examined the association between tobacco smoke exposure and healthcare resource utilization patterns among pediatric emergency department patients. Tobacco smoke exposure increased the risk of pediatric patients having respiratory-related procedures, respiratory-related and non-respiratory-related testing, medications administered during the pediatric emergency department visit, and medications prescribed for home administration. Tobacco smoke-exposed patients were more likely to be admitted to the hospital compared to unexposed patients.

Asthma in urban Aboriginal children: A cross-sectional study of socio-demographic patterns and associations with pre-natal and current carer smoking

AIM

To describe socio-demographic patterns of asthma prevalence in urban Aboriginal children and quantify associations between asthma prevalence and pre-natal maternal and current carer smoking.

METHODS

Analyses used carer-reported survey data for 1290 urban Aboriginal children aged 2-17 years from the Study of Environment on Aboriginal Resilience and Child Health. Multilevel log-binomial regression was used to estimate asthma prevalence ratios (PRs) for child- and family-level socio-demographic factors, pre-natal maternal smoking and current carer smoking. Smoking-related PRs were compared with general-population estimates derived from meta-analyses of published cross-sectional data.

RESULTS

Overall, 33.9% of children had ever had asthma, and 12.9% had received treatment for asthma in the past month. Prevalence estimates declined with increasing household income and increasing household size (posterior probabilities of decreasing trend >0.98), while children exposed to pre-natal maternal smoking had a higher risk of asthma ever than unexposed children (PR 1.18 (95% credible interval 1.00-1.40)). Recently treated asthma prevalence was not significantly associated with pre-natal maternal (0.98 (0.71-1.41)) or current carer smoking (0.97 (0.68-1.37)); however, there was substantial uncertainty in our PR estimates, and 95% credible intervals contained general-population estimates derived from the meta-analyses (1.37 (1.17-1.65) for pre-natal smoking, 1.28 (1.15-1.44) for current parental or household smoking).

CONCLUSION

Among urban Aboriginal children in the Study of Environment on Aboriginal Resilience and Child Health cohort, asthma prevalence declines as household income and household size increase, while children exposed to pre-natal maternal smoking are at increased risk of ever having asthma. Our results emphasise the importance of reducing smoking in Aboriginal communities, particularly among pregnant women.

Medical Neglect as a Contributor to Poorly Controlled Asthma in Childhood

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

Secondhand Smoke Exposure and Subsequent Academic Performance Among U.S. Youth

INTRODUCTION

Previous research shows the associations between secondhand smoke exposure and health consequences among youth, but less is known about its effect on academic performance. This study examines a dose-response relationship between secondhand smoke exposure and subsequent academic performance among U.S. youth.

METHODS

Data were from a nationally representative sample of youth non-tobacco users (aged 12-16 years) in Wave 2 (2014-2015) who completed Wave 3 (2015-2016) of the Population Assessment of Tobacco and Health Study (n=9,020). Past-7-day number of hours exposed to secondhand smoke at Wave 2 and academic performance at Wave 3 (1=Mostly As to 9=Mostly Fs) were assessed. Weighted multivariable linear regression models were used to examine the association between hours of self-reported secondhand smoke exposure at Wave 2 and academic performance at Wave 3 (1=Mostly Fs, 9=Mostly As), adjusting for covariates including sociodemographics, prior academic performance, internalizing and externalizing problems, and substance use problems. Analyses were conducted in 2019.

RESULTS

More than 30% of U.S. youth non-tobacco users were exposed to secondhand smoke in the past 7 days. Compared with unexposed youth at Wave 2, those who were exposed for 1-9 hours had poorer academic performance at Wave 3 (adjusted regression coefficient= -0.11, 95% CI= -0.18, -0.04), and those who were exposed for ≥10 hours at Wave 2 had even poorer academic performance (adjusted regression coefficient = -0.31, 95% CI= -0.45, -0.18).

CONCLUSIONS

A dose-response relationship was observed between secondhand smoke exposure and academic performance among U.S. youth. Reducing youth secondhand smoke exposure may promote academic performance and subsequent educational attainment.

Tobacco Smoke Exposure, Respiratory Health, and Health-care Utilization Among US Adolescents

BACKGROUND

Tobacco smoke exposure adversely affects respiratory health. However, the effects of exposure on adolescents without asthma are not well known.

RESEARCH QUESTION

To what degree are biochemically measured and self-reported tobacco smoke exposure associated with pulmonary function and health-care utilization among US nonsmoking adolescents?

STUDY DESIGN AND METHODS

We analyzed 2007-2012 National Health and Nutrition Examination Survey data (N = 2,482). Tobacco smoke exposure was assessed with serum cotinine and self-reported home exposure. We built multiple regression, logistic regression, and Poisson regression models, depending on the outcome.

RESULTS

Approximately 3% of adolescents had high cotinine (3.00-15.00 ng/mL), 35.7% had low cotinine (0.05-2.99 ng/mL), and 10.9% had home exposure. Adolescents with high cotinine had significantly lower FEV₁% (mean, 97.4; SE, 2.09; β, -8.99; 95% CI, -15.64 to -2.33) and FVC% (mean, 97.4; SE, 2.06; β, -8.42; 95% CI, -14.74 to -2.11) than adolescents with no/minimal cotinine (< 0.05 ng/mL; mean, 101.0; SE, 0.45; mean, 99.9; SE, 0.46, respectively). Adolescents with high cotinine were less likely to have a past year health-care visit (adjusted OR [aOR], 0.57; 95% CI, 0.38 to 0.88), but more likely to have an overnight hospital stay (aOR, 4.82; 95% CI, 2.58 to 9.00), and at increased risk of having a higher number of overnight hospital stays (adjusted relative risk [aRR], 4.04; 95% CI, 2.27 to 7.21). Adolescents with low cotinine were less likely to have a health-care visit (aOR, 0.84; 95% CI, 0.71 to 0.99), but more likely to have an overnight hospital stay (aOR, 4.82; 95%CI, 2.58 to 9.00) than adolescents with no/minimal cotinine. Adolescents with low cotinine were at increased risk of having a higher number of health-care visits (aRR, 1.06; 95% CI, 1.02 to 1.11) and overnight hospital stays (aRR, 2.02; 95% CI, 1.46 to 2.81). Adolescents with home exposure had lower FEV₁% (mean, 99.9; SE, 1.17; β, -5.11; 95% CI, -9.26 to -0.96) and FVC% (mean, 100.0; SE, 1.16; β, -5.36; 95% CI, -9.30 to -1.42) than adolescents with no home exposure (mean, 101.0; SE, 0.38; mean, 100.2; SE, 0.39, respectively). Adolescents with home exposure were more likely to have an overnight hospital stay (aOR, 5.65; 95% CI, 3.66 to 8.73) and at increased risk of having a higher number of overnight hospital stays (aRR, 4.08; 95% CI, 2.76 to 6.03).

INTERPRETATION

Detectable serum cotinine levels and self-reported home exposure were distinctively associated with decreased pulmonary function and increased health-care utilization.

Parental Depression is Prospectively Associated With Lower Smoking Cessation Rates and Poor Child Asthma Outcomes

Background

Depressive symptoms are elevated in parents of asthmatic children compared with parents of healthy children. The role of depression in smoking cessation and pediatric asthma outcomes in this population is unclear.

Purpose

To prospectively examine the effect of parent depression on smoking cessation and child asthma outcomes.

Methods

Secondary analysis from a cessation induction trial involving Motivational Interviewing (MI) and biomarker feedback on secondhand smoke exposure (SHSe). Parents (n=341) had an asthmatic child (mean age=5.2 years) and did not have to want to quit smoking to enroll. Intervention included asthma education, MI, and SHSe feedback plus randomization to six counseling (MI; repeated feedback) or control calls (brief check on asthma) for 4 months. Depressive symptoms were defined as scoring ≥22 on the Center for Epidemiologic Study-Depression scale. Smoking outcomes were bioverified 7- and 30-day point-prevalence abstinence (ppa). Child asthma outcomes were past month functional limitation, health care utilization, and number of days with asthma symptoms. Data were obtained at baseline, 2, 4, and 6 months.

Results

Parental depression was associated with lower odds of abstinence (7-day ppa odds ratio [OR]=0.38, 95% confidence interval [CI]=0.23, 0.64; 30-day ppa OR=0.27, 95% CI=0.15, 0.47), greater odds of child health care utilization for asthma (OR=1.71, 95% CI=1.01, 2.92), and greater child asthma functional limitation (B=0.16, SE=0.06, p=.03) even after controlling for smoking status. Depression predicted a greater number of child asthma symptom days (B=1.08, SE=0.44, p=.01), but this became nonsignificant after controlling for smoking status.

Conclusions

Among parents who smoke, both depressive symptoms and smoking should be targeted for treatment aimed at improving pediatric asthma.

Viruses and non-allergen environmental triggers in asthma

Asthma is a complex inflammatory disease with many triggers. The best understood asthma inflammatory pathways involve signals characterized by peripheral eosinophilia and elevated immunoglobulin E levels (called T2-high or allergic asthma), though other asthma phenotypes exist (eg, T2-low or non-allergic asthma, eosinophilic or neutrophilic-predominant). Common triggers that lead to poor asthma control and exacerbations include respiratory viruses, aeroallergens, house dust, molds, and other organic and inorganic substances. Increasingly recognized non-allergen triggers include tobacco smoke, small particulate matter (eg, PM2.5), and volatile organic compounds. The interaction between respiratory viruses and non-allergen asthma triggers is not well understood, though it is likely a connection exists which may lead to asthma development and/or exacerbations. In this paper we describe common respiratory viruses and non-allergen triggers associated with asthma. In addition, we aim to show the possible interactions, and potential synergy, between viruses and non-allergen triggers. Finally, we introduce a new clinical approach that collects exhaled breath condensates to identify metabolomics associated with viruses and non-allergen triggers that may promote the early management of asthma symptoms.

Association of secondhand smoke exposure with asthma symptoms, medication use, and healthcare utilization among asthmatic adolescents

OBJECTIVE

To investigate the association between secondhand smoke exposure (SHSe) and asthma symptoms, medication use, and emergency department (ED)/urgent care (UC) utilization among adolescents.

METHODS

We performed a secondary cross-sectional analysis of Population Assessment of Tobacco and Health Study Wave 2 (2014-2015) including asthmatic adolescents (N = 2198). Logistic regression models and Poisson regression models were built.

RESULTS

Participants with SHSe ≥1 hour in the past 7 days were at increased risk of reporting shortness of breath and harder to exercise aOR, 1.22; 95% CI, 1.04-1.43), wheezing (aOR, 1.26; 95% CI, 1.01-1.56), wheezing disturbing sleep (aOR, 1.88; 95% CI, 1.35-2.63), wheezing during/after exercise (aOR, 1.41; 95% CI, 1.19-1.66), wheezing limiting speech (aOR, 2.11; 95% CI, 1.55-2.86), dry cough at night (aOR, 1.86; 95% CI, 1.54-2.24), and asthma symptoms disturbing sleep (aOR, 2.25; 95% CI, 1.81-2.79). Participants with SHSe ≥1 hour were more likely to take asthma medications (aOR, 1.25; 95% CI, 1.03-1.52), including steroids (aOR, 1.86; 95% CI, 1.19-2.91), oxygen therapy (aOR, 2.88; 95% CI, 1.82-4.54), and controlling medications (aOR, 1.50; 95% CI, 1.24-1.82). Symptoms and medications varied by living with a smoker and home SHSe. Participants with SHSe were at increased risk of having a higher number of asthma attacks that required steroid use. Participants who lived with a smoker and had home SHSe were at increased risk of having higher ED/UC visits for asthma.

CONCLUSIONS

SHSe reduction efforts are needed for asthmatic adolescents, and EDs/UCs are promising venues.

A randomized pilot trial of a school-based psychoeducational intervention for children with asthma

BACKGROUND

Asthma is a common childhood illness with high morbidity and mortality among minority and socio-economically disadvantaged children. Disparities are not fully accounted for by differences in asthma prevalence, highlighting a need for interventions targeting factors associated with poorer asthma control. One such factor is psychological stress.

OBJECTIVE

Here, we examine the feasibility and acceptability of "I Can Cope (ICC)," a school-based stress management and coping intervention for children with asthma.

METHODS

A parallel randomized pilot trial was conducted. One hundred and four low-income children (mean age 10 years; 54% male; 70% African American) with persistent asthma were recruited from 12 urban schools and randomized to the following: (a) ICC or one of two control conditions: (b) "Open Airways for Schools (OAS)"-an asthma education intervention or (c) no treatment.

RESULTS

Seventy one percentage of eligible children participated in the study, with a dropout rate of 12%. ICC was rated as highly acceptable by participating children and parents. Preliminary efficacy data suggest that when compared with no treatment, ICC resulted in decreased symptoms of depression, perceived stress and child-reported symptoms of asthma, and improvements in sleep quality and child-reported asthma control. There were no intervention-related changes in objective measures of asthma morbidity. The magnitude of intervention effects on psychological function did not differ between the ICC and OAS groups.

CONCLUSIONS

Results support the feasibility and acceptability of utilizing school-based interventions to access hard to reach children with asthma. Preliminary findings offer support for future, large-scale efficacy studies of school-based interventions designed to target multiple factors that contribute to asthma disparities.

Provider Counseling About Secondhand Smoke Exposure for Urban Children With Persistent or Poorly Controlled Asthma

Urban children continue to be exposed to secondhand smoke (SHS), and this is particularly concerning for children with asthma. The objective of this study is to describe SHS exposure among urban children with asthma and assess SHS counseling delivered at primary care visits. We interviewed caregivers of 318 children (2-12 years) with persistent asthma at the time of a health care visit and reviewed medical records. We found that one third (32%) of children lived with a caregiver who smoked and that 15% lived with other smokers. Children whose caregivers smoked had the lowest prevalence of home smoking bans compared with homes with other smokers and no smokers (65% vs. 72% vs. 95%, respectively). Overall, 67% of caregivers received some SHS counseling. Providers most often counseled caregiver smokers; counseling occurred less frequently for caregivers in homes with other or no smokers. Further efforts to improve provider SHS counseling for all children with asthma are needed.

The impact of conventional and nonconventional inhalants on children and adolescents

AIM

Inhalant abuse in the adolescent population is a growing concern for care givers, communities, physicians, and medical providers. The aim of this article is to provide a review of the literature about this new challenge. In addition, it raises awareness about recent health policy rulings.

METHODS

Review of the literature was done.

RESULTS

In this review article, the prevalence of different modes of inhalant use and abuse in children and young adults and their potential health implications will be examined: Cigarettes, ENDS (E Cigarettes), Hookah, Marijuana, and Huffing. Additionally, marketing and advertising tactics will be reviewed to understand how they target this population. A review of current health policy recommendations from the FDA, American Thoracic Society, and the American Academy of Pediatrics will also be discussed.

CONCLUSION

The rapid rise in e-cigarette and hookah use in school aged children should trigger a call to action in the medical and public health communities. Health policy recommendations need to be made to reduce the level of adolescent substance abuse.

Hair nicotine at 15 months old, tobacco exposure and wheeze or asthma from 15 months to 6 years old

OBJECTIVE

To investigate the relationship between hair nicotine levels at 15 months of age and prior parent-reported smoking exposure, and the risk of wheezing and current asthma from 15 months to 6 years of age.

STUDY DESIGN

We measured hair nicotine levels at 15 months of age in 376 of 535 infants enrolled in a prospective birth cohort in Christchurch, New Zealand. We obtained detailed information from parents about smoking exposure during pregnancy and in the home at 3 and 15 months of age. Data for demographics, wheezing, and asthma were obtained from yearly questionnaires up to age 6 years. We assessed hair nicotine levels in relation to reported smoke exposure in pregnancy and up to age 15 months, and the association between high levels of hair nicotine and annual reports of current wheeze and current asthma using multiple logistic regression.

RESULTS

Hair nicotine increased with numbers of smokers and daily cigarettes smoked at home, and was also strongly associated with smoking in pregnancy. High level of hair nicotine was associated with increased risk of wheeze (Odds ratio 2.30, P = 0.001) and, though not significant, of current asthma (Odds ratio 2.02, P = 0.056) at 15 months of age, after controlling for socio-economic status, ethnicity, body mass index, respiratory infections in the first 3 months of life, and duration of exclusive breastfeeding. At older ages the associations were non-significant.

CONCLUSION

In children aged 15 months hair nicotine level was related to smoking exposure, and was associated with increased risk of wheeze and asthma.

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

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

The Relationship Between Tobacco Smoke Exposure and Airflow Obstruction in US Children: Analysis of the National Health and Nutrition Examination Survey (2007-2012)

BACKGROUND

It has been difficult to determine the individual impact of prenatal and postnatal tobacco smoke exposure (TSE) on childhood lung function, as children are often exposed to both.

OBJECTIVE

The goal of this study was to determine the association between current TSE and airflow obstruction while adjusting for self-reported prenatal TSE.

METHODS

Children aged 6 to 11 years who participated in the National Health and Nutrition Examination Survey (2007-2012) who had serum cotinine levels measured and spirometry performed were included. Logistic regression was used to determine the association between log-transformed serum cotinine level and airflow obstruction while adjusting for confounders; the analysis was then stratified according to asthma status. The final model included both log-transformed serum cotinine level and prenatal exposure as covariates.

RESULTS

The sample consisted of 2,070 children; 9.6% had airflow obstruction. The association between cotinine levels and airflow obstruction was significant in an unadjusted analysis (OR, 1.12 [95% CI, 1.02-1.23]). In the multivariate analysis with both exposures included as covariates, serum cotinine level was not significantly associated with airflow obstruction (OR_adj, 1.07 [95% CI, 0.94-1.21]), and no association was seen in children with asthma and nonasthmatic children. Prenatal smoking was associated with airflow obstruction in children with asthma (OR_adj, 2.51 [95% CI, 1.08-5.79]) but not in nonasthmatic children (OR_adj, 1.08 [95% CI, 0.53-2.18]).

CONCLUSIONS

Current TSE was not independently associated with airflow obstruction in school-aged children. Prenatal TSE was associated with airflow obstruction in children with asthma. Repeated studies into potential mediators and confounders of this relationship are needed.

Secondhand smoke exposure, illness severity, and resource utilization in pediatric emergency department patients with respiratory illnesses

OBJECTIVE

Hospital-based data reveal that children who have secondhand smoke exposure (SHSe) experience severe respiratory illnesses and greater resource utilization. Our objective was to assess the relationship between SHSe and illness severity/resource utilization among children presenting to the pediatric emergency department (PED) with three common respiratory conditions-asthma, bronchiolitis, and pneumonia.

METHODS

A retrospective review of a yearlong consecutive sample of PED patients with SHSe status documentation and asthma, bronchiolitis, or pneumonia diagnoses was performed. PED illness severity/resource utilization variables included triage categorization, initial oxygen saturation, evaluation/testing (influenza A & B, respiratory syncytial virus, chest X-ray), procedures/interventions performed (supplemental oxygen, suctioning, intubation), medications administered, and disposition. Logistic and linear regression models were conducted to determine differences in each diagnosis group while controlling for sociodemographics, medical history, seasonality, and insurance type.

RESULTS

There were 3,229 children with documentation of SHSe status and an asthma (41%), bronchiolitis (36%), or pneumonia (23%) diagnosis. Across diagnosis groups, approximately 1/4 had positive documentation of SHSe. Asthmatic children with SHSe were more likely to receive corticosteroids (odds ratio (OR) = 1.71, 95% confidence interval (CI) = 1.19, 2.44) and/or magnesium sulfate (OR = 1.66, 95% CI = 1.14, 2.40). Children with SHSe and bronchiolitis were more likely to receive racemic epinephrine (OR = 2.48, 95% CI = 1.21, 5.08), have a chest X-ray (OR = 1.36, 95% CI = 1.00, 1.85), and/or be admitted (OR = 1.46, 95% CI = 1.09, 1.95). No differences in illness severity/resource utilization were identified for children with pneumonia.

CONCLUSIONS

SHS-exposed children with asthma or bronchiolitis have greater illness severity/resource utilization. Our findings highlight the importance of SHSe assessment, cessation, and research efforts in the PED setting.

Secondhand Smoke Exposure and Pediatric Healthcare Visits and Hospitalizations

INTRODUCTION

This study assessed the relationship between secondhand smoke exposure (SHSe) as measured by serum cotinine and healthcare utilization among children.

METHODS

In 2016, the 2009-2012 National Health and Nutrition Examination Survey data were analyzed including 4,985 children aged 3-19 years. Associations between SHSe and having a routine place for healthcare, type of place, and hospital utilization were examined using logistic regression models. Poisson regression analyses assessed the relationship between SHSe and number of hospital admissions. Relationships between SHSe and acute care visits and hospital utilization were examined among asthmatic children.

RESULTS

SHSe level did not differ by having a routine place for healthcare, although children with high SHSe indicative of active smoking (cotinine ≥3 ng/mL) were 3.49 times (95% CI=1.77, 6.89) more likely to use an emergency department. Children with high SHSe were 2.85 times (95% CI=1.87, 4.34) more likely to have had an overnight hospital stay. Children with high SHSe had 2.05 times (95% CI=1.46, 2.87) the risk of having a higher number of hospital admissions for overnight stays versus children with no SHSe (cotinine <0.05 ng/mL). Among asthmatic children, those with high SHSe and low SHSe (cotinine 0.05-2.99 ng/mL) were more likely to have an acute care visit, overnight hospital stay, and higher number of hospital admissions than asthmatic children with no SHSe.

CONCLUSIONS

High SHSe is associated with increased healthcare utilization. The emergency department and inpatient settings are important venues in which to routinely offer cessation and SHSe reduction interventions.

Coordinated Asthma Program Improves Asthma Outcomes in High-Risk Children

Innovative approaches within primary care are needed to reduce fragmented care, increase continuity of care, and improve asthma outcomes in children with asthma. Our objective was to assess the impact of coordinated team-based asthma care on unplanned asthma-related health care utilization. A multidisciplinary asthma team was developed to provide coordinated care to high-risk asthma patients. Patients received an in-depth diagnostic and family needs assessment, asthma education, and coordinated referral to social and community services. Over a 2-year period, 141 patients were followed. At both 1 and 2 years postintervention, there was a significant decrease from preintervention rates in urgent care visits (40%, P = .002; 50%, P < .0001), emergency department visits (63%, P < .0001; 70%, P < .0001), and inpatient hospitalization (69%, P = .002; 54%, P = .04). Our coordinated asthma care program was associated with a reduction in urgent care visits, emergency department visits, and inpatient hospitalizations among high-risk children with asthma.

Design of a pragmatic trial in minority children presenting to the emergency department with uncontrolled asthma: The CHICAGO Plan

Among children with asthma, black children are two to four times as likely to have an emergency department (ED) visit and die from asthma, respectively, compared to white children in the United States. Despite the availability of evidence-based asthma management guidelines, minority children are less likely than white children to receive or use effective options for asthma care. The CHICAGO Plan is a three-arm multi-center randomized pragmatic trial of children 5 to 11years old presenting to the ED with uncontrolled asthma that compares: [1] an ED-focused intervention to improve the quality of care on discharge to home, [2] the same ED-focused intervention together with a home-based community health worker (CHW)-led intervention, and [3] enhanced usual care. All children receive spacers for the metered dose inhaler and teaching about its use. The Patient-Reported Outcomes Measurement Information System (PROMIS) Asthma Impact Scale and Satisfaction with Participation in Social Roles at 6months are the primary outcomes in children and in caregivers, respectively. Other patient-reported outcomes and indicators of healthcare utilization are assessed as secondary outcomes. Innovative features of the CHICAGO Plan include early and continuous engagement of children, caregivers, the Chicago Department of Public Health, and other stakeholders to inform the design and implementation of the study and a shared research infrastructure to coordinate study activities. The objective of this report is to describe the development of the CHICAGO Plan, including the methods and rationale for engaging stakeholders, the shared research infrastructure, and other features of the pragmatic clinical trial design.

Exposure to secondhand smoke and asthma severity among children in Connecticut

OBJECTIVE

To determine whether secondhand smoke (SHS) exposure is associated with greater asthma severity in children with physician-diagnosed asthma living in CT, and to examine whether area of residence, race/ethnicity or poverty moderate the association.

METHODS

A large childhood asthma database in CT (Easy Breathing) was linked by participant zip code to census data to classify participants by area of residence. Multinomial logistic regression models, adjusted for enrollment date, sex, age, race/ethnicity, area of residence, insurance type, family history of asthma, eczema, and exposure to dogs, cats, gas stove, rodents and cockroaches were used to examine the association between self-reported exposure to SHS and clinician-determined asthma severity (mild, moderate, and severe persistent vs. intermittent asthma).

RESULTS

Of the 30,163 children with asthma enrolled in Easy Breathing, between 6 months and 18 years old, living in 161 different towns in CT, exposure to SHS was associated with greater asthma severity (adjusted relative risk ratio (aRRR): 1.07 [1.00, 1.15] and aRRR: 1.11 [1.02, 1.22] for mild and moderate persistent asthma, respectively). The odds of Black and Puerto Rican/Hispanic children with asthma being exposed to SHS were twice that of Caucasian children. Though the odds of SHS exposure for publicly insured children with asthma were three times greater than the odds for privately insured children (OR: 3.02 [2.84,3,21]), SHS exposure was associated with persistent asthma only among privately insured children (adjusted odds ratio (aOR): 1.23 [1.11,1.37]).

CONCLUSION

This is the first large-scale pragmatic study to demonstrate that children exposed to SHS in Connecticut have greater asthma severity, clinically determined using a systematic approach, and varies by insurance status.

Tobacco Smoke Exposure and Health-Care Utilization Among Children in the United States

PURPOSE

The purpose of this study was to assess patterns of health-care utilization among children who potentially had tobacco smoke exposure (TSE) compared to those who were not exposed.

DESIGN

A secondary data analysis of the 2011 to 2012 National Survey on Children's Health was performed.

SETTING

Households nationwide were selected.

PARTICIPANTS

A total of 95 677 children aged 0 to 17 years.

MEASURES

Sociodemographic characteristics, TSE status, and health-care visits were measured.

ANALYSIS

Multivariable logistic regression models were performed.

RESULTS

A total of 24.1% of children lived with smokers. Approximately 5% had home TSE. Participants who lived with a smoker were significantly more likely to have had a medical care visit (odds ratio [OR] = 1.22, confidence interval [CI] = 1.21-1.22) and were more likely to seek sick care or health advice at an emergency department (OR = 1.23, CI = 1.23-1.24) but were less likely to have had a dental care visit (OR = 0.82, CI = 0.82-0.83) than those who did not live with a smoker. Similar findings were found among participants who had home TSE.

CONCLUSION

TSE is a risk factor for increased use of pediatric medical care. Based on the high number of children who potentially had TSE and received sick care or health advice at an emergency emergency department, this setting may be a venue to deliver health messages to caregivers.

Difficult-to-control asthma: epidemiology and its link with environmental factors

PURPOSE OF REVIEW

The aim of the present review was to discuss the epidemiology of inadequate asthma control with an examination of contributing environmental factors.

RECENT FINDINGS

Despite advances in asthma therapies, a proportion of patients with asthma continue to have difficulty in gaining adequate asthma control. Asthma severity and control in childhood are of particular importance as they translate to asthma morbidity in adulthood. Children with comorbid severe allergic rhinitis were more likely to have uncontrolled asthma. Recent data suggest that mouse allergen, more so than cockroach allergen, may be the most relevant urban allergen exposure. Tobacco smoke exposure, even passive exposure, leads to increased asthma symptoms and decreased response to inhaled corticosteroids. Efforts to ban smoking in public places have resulted in promising asthma results for entire populations. Energy-saving efforts to tighten a home's air leaks can lead to increased indoor pollutant levels and, therefore, must be accompanied by efforts to reduce, filter, or exchange indoor pollutants. Obesity is independently associated with decreased asthma control. Furthermore, the detrimental effects of pollutant exposure are enhanced in an overweight individual with asthma.

SUMMARY

Lack of asthma control can be because of a complex web of factors including adherence, intrinsic factors, and environmental exposures. Further research into intervention strategies is needed to achieve improved rates of asthma control.

Differences in spirometry values between U.S. children 6-11 years and adolescents 12-19 years with current asthma, 2007-2010

BACKGROUND

National Asthma Education and Prevention Program (NAEPP) guidelines recommend that periodic spirometry be performed in youth with asthma. NAEPP uses different spirometry criteria to define uncontrolled asthma for children (6-11 years) and adolescents (12+ years).

OBJECTIVE

To describe differences in spirometry between U.S. children and adolescents with current asthma.

METHODS

We examined cross-sectional spirometry data from 453 U.S. youth with current asthma age 6-19 years from the 2007-2010 National Health and Nutrition Examination Surveys. The main outcomes were percentage predicted forced expiratory volume at 1 sec (FEV1%) ≤80 and the ratio of FEV1 to forced vital capacity (FEV1/FVC) ≤0.80. We also examined the prevalence of youth with spirometry values consistent with uncontrolled asthma, using NAEPP age-specific criteria, defined for children aged 6-11 years as FEV1% ≤80 or FEV1/FVC ≤0.80, and for adolescents aged 12-19 years as FEV1% ≤80.

RESULTS

Children 6-11 years and adolescents 12-19 years did not differ in prevalence of FEV1% ≤80 (10.1% vs. 9.0%) or FEV1/FVC ≤0.80 (30.6% vs. 29.8%). However, based on the NAEPP age-specific criteria, 33.0% of children 6-11 years and 9.0% of adolescents 12-19 years had spirometry values consistent with uncontrolled asthma (P < 0.001).

CONCLUSION

Children 6-11 years and adolescents 12-19 years with current asthma did not differ in the percentage with FEV1% ≤80 or FEV1/FVC ≤0.80. However, the percent of children and adolescents with spirometry values consistent with uncontrolled asthma did differ. The difference appears to stem mainly from the different spirometry criteria for the two age groups.

Prevalence of secondhand smoke exposure in asthmatic children at home and in the car: A cross-sectional study

OBJECTIVE

To compare secondhand smoke exposure (SHSe) prevalence at home and inside the car between asthmatic and non-asthmatic Portuguese children.

MATERIALS AND METHODS

This is a cross-sectional study that assessed children's SHSe in a representative sample of nine Portuguese cities. A validated self-reported questionnaire was administered to a random sample of 4th grade students during the school year of 2010/2011. The asthma prevalence was defined by the answers to three questions regarding asthma symptoms, medication and inhaler use. We performed chi-square tests and analysed frequencies, contingency tables, confidence intervals, and odd-ratios.

RESULTS

The self-reported questionnaire was administered to 3187 students. Asthma prevalence was 14.8% (472 students). Results showed that 32.3% of non-asthmatic children and 32.4% of asthmatic children were exposed to secondhand smoke as at least one of their household members smoked at home. The prevalence of parental smoking, smoking among fathers and smoking among mothers at home was also similar in both groups (asthmatic and non-asthmatic children). SHSe inside the car was 18.6% among non-asthmatic children and 17.9% among asthmatic children.

CONCLUSIONS

Asthmatic and non-asthmatic children were equally exposed to secondhand smoke, because no significant differences were found between the two groups concerning the prevalence of SHSe at home and inside the car. These findings highlight the need to include SHSe brief advice in paediatric asthma management.

Children with Chronic Lung Disease: Facilitating Smoking Cessation for their Caregivers

Through a QI project at a tertiary referral pediatric pulmonary center, our objective was to establish a methodical approach to identify and engage smoking parents of children with chronic lung disease in a smoking cessation program. We hypothesized that smoking caregivers of children with chronic lung disease would be more motivated to enroll in a smoking cessation program when referred from tertiary pediatric pulmonary center. We assessed smoking habits and interest in quitting of parents with surveys. Parents ready to quit within 30 days were referred to the Florida Quitline from clinic. Pulmonary function tests, exacerbations, hospitalizations and need for prednisone or antibiotics were obtained from the patient charts and surveys. Follow-up two to 6 months later assessed the quit rate and child's clinical well-being and lung function. A standard mechanism to identify caregivers who smoked was established by engaging our medical assistants through a prompt in our EMR system. Out of those caregivers who were identified as smokers and accompanied their children to clinic, 52% were interested in a referral to the Florida Quitline. Out of those, only 12% successfully completed the program and ceased to smoke. The Florida Quitline was unable to reach the majority of parents who were referred to them. The majority of those referred to the Ouitline were not successfully contacted or enrolled in the program. The current procedure for referring and enrolling individuals to the Quitline is not effective for our population, but compares to the national average.

Is secondhand smoke exposure associated with increased exacerbation severity among children hospitalized for asthma?

OBJECTIVE

To determine the association between secondhand smoke (SHS) exposure and length of stay (LOS) and other exacerbation severity indicators in children hospitalized for asthma.

METHODS

We conducted a retrospective chart review at 2 children's hospitals. Patients aged 2 to 18 hospitalized for asthma in 2012 were included. Outcome variables included LOS, PICU, magnesium, and intravenous (IV) steroids. Bivariate analysis determined differences between SHS-exposed and non-SHS-exposed groups. Geometric means were used for LOS to account for skewed distribution. Logistic and zero-truncated negative binomial regression models were used to determine the independent association between SHS exposure and hospitalization severity indicators.

RESULTS

A total of 623 patients were included; 41% reported SHS exposure. Mean LOS was 47.5 hours. In the SHS-exposed group, LOS was 50.0 (95% confidence interval [CI] 46.7-54.0) and in the nonexposed group it was 45.8 (95% CI 43.4-48.4) (P = .02). In regression analysis, institution modified the effect of SHS exposure on LOS. At Children's Hospital Colorado, SHS exposure was associated with a 20% increase in LOS (incidence rate ratio 1.2, 95% CI 1.1-1.3). At the Medical University of South Carolina, there was no significant association. SHS-exposed patients were more likely to receive IV steroids (odds ratio 1.6, 95% CI 1.1-2.3) CONCLUSIONS: Among children hospitalized for asthma, we identified a significant association at 1 institution between SHS exposure and LOS and found that IV steroid use was significantly associated with LOS at both institutions. Eliminating SHS exposure among children with asthma is important.

Risk and protective factors for the development of childhood asthma

Childhood asthma prevalence worldwide has been increasing markedly over several decades. Various theories have been proposed to account for this alarming trend. The disease has a broad spectrum of potential determinants ranging from genetics to lifestyle and environmental factors. Epidemiological observations have demonstrated that several important lifestyle and environmental factors including obesity, urban living, dietary patterns such as food low in antioxidants and fast food, non-breastfeeding, gut flora imbalance, cigarette smoking, air pollution, and viral infection are associated with asthma exacerbations in children. However, only environmental tobacco smoke has been associated with the development of asthma. Despite epidemiological studies indicating that many other factors are probably associated with the development of asthma, the relationships are not considered causal due to the inadequate evidence and inconsistent results from recent studies. This may highlight that sufficient data and exact mechanisms of causality are still in need of further study.

Exposure to cigarette smoke and Chlamydia pneumoniae infection in mice: Effect on infectious burden, systemic dissemination and cytokine responses: A pilot study

Cigarette smoke exposure has been considered a risk factor for infection with Chlamydia pneumoniae. C. pneumoniae infection is associated with respiratory tract infection and chronic respiratory disease, which is a serious public health concern. To determine whether prior exposure to cigarette smoke worsens C. pneumoniae infection (specifically, increases infectious burden and systemic dissemination) as well as alters cytokine responses in mice, adult female C57BL/6 mice were exposed to either filtered air (FA) or mainstream cigarette smoke (MCS) (15 mg/m(3), total suspended particulates) for 5 days/week for 2 weeks and then infected with C. pneumoniae (10(5) IFU) via intratracheal instillation. Mice were euthanized on Days 7, 14 or 26 post-infection (p.i.). Chlamydial burdens in the lungs and spleen were quantified by quantitative PCR (qPCR) and histologic analyses were performed; cytokine levels (TNFα, IL-4, IFNγ) in bronchoalveolar lavage fluid and serum were assayed by enzyme-linked immunosorbent assay (ELISA). The results indicated that: (1) mice exposed to either FA or MCS had similar chlamydial burdens in the lungs and spleen on Days 14 and 26 p.i.; (2) proximal and distal airway inflammation was observed on Day 14 p.i. in both FA and MCS mice, but persisted in MCS mice until Day 26 p.i.; FA exposed mice demonstrated resolution of distal airway inflammation; and (3) MCS mice displayed higher serum levels of IFNγ and IL-4 on Day 26 p.i. These findings indicate that exposure of mice to MCS (at a concentration equivalent to smoking < 1 pack cigarettes/day) led to greater C. pneumoniae-induced inflammation, as indicated by prolonged inflammatory changes.

Factors associated with asthma control in children: findings from a national Web-based survey

BACKGROUND

Although achieving and maintaining control of asthma is considered to be the goal of asthma treatment, determinants of asthma control are not fully understood. Our aim was to assess factors associated with asthma control among paediatric patients in the general population.

METHODS

In June 2012, a Web-based survey was conducted to identify Japanese children aged 6 to 11 yr who currently have asthma and evaluate control of their disease using the Childhood Asthma Control Test (C-ACT). Associations were evaluated among uncontrolled asthma (C-ACT score <20) between environmental factors, demographics and comorbid allergic diseases.

RESULTS

Among the 3066 children with current asthma, 447 (14.6%) had uncontrolled asthma. Multivariable analysis identified factors such as low birthweight (adjusted OR 1.65, 95% CI 1.25-2.18), obesity (adjusted OR 1.44, 95% CI 1.05-1.99) and pet ownership before birth (adjusted OR 1.68, 95% CI 1.24-2.29) to be associated with uncontrolled disease. Comorbid allergic diseases, especially rhinitis were a significant risk of uncontrolled asthma (adjusted OR for severe rhinitis: 3.88, 95% CI 2.50-6.00). The severity of rhinitis symptoms was inversely correlated with the C-ACT score (p < 0.001).

CONCLUSIONS

A population-based Web survey showed an association between several factors and the control of paediatric asthma. The assessment of these factors may help identify the children at risk with uncontrolled asthma.

Human airway musculature on a chip: an in vitro model of allergic asthmatic bronchoconstriction and bronchodilation

Many potential new asthma therapies that show promise in the pre-clinical stage of drug development do not demonstrate efficacy during clinical trials. One factor contributing to this problem is the lack of human-relevant models of the airway that recapitulate the tissue-level structural and functional phenotypes of asthma. Hence, we sought to build a model of a human airway musculature on a chip that simulates healthy and asthmatic bronchoconstriction and bronchodilation in vitro by engineering anisotropic, laminar bronchial smooth muscle tissue on elastomeric thin films. In response to a cholinergic agonist, the muscle layer contracts and induces thin film bending, which serves as an in vitro analogue for bronchoconstriction. To mimic asthmatic inflammation, we exposed the engineered tissues to interleukin-13, which resulted in hypercontractility and altered relaxation in response to cholinergic challenge, similar to responses observed clinically in asthmatic patients as well as in studies with animal tissue. Moreover, we reversed asthmatic hypercontraction using a muscarinic antagonist and a β-agonist which are used clinically to relax constricted airways. Importantly, we demonstrated that targeting RhoA-mediated contraction using HA1077 decreased basal tone, prevented hypercontraction, and improved relaxation of the engineered tissues exposed to IL-13. These data suggest that we can recapitulate the structural and functional hallmarks of human asthmatic musculature on a chip, including responses to drug treatments for evaluation of safety and efficacy of new drugs. Further, our airway musculature on a chip provides an important tool for enabling mechanism-based search for new therapeutic targets through the ability to evaluate engineered muscle at the levels of protein expression, tissue structure, and tissue function.

Improving preventive care in high risk children with asthma: lessons learned

OBJECTIVES

Rates of preventive asthma care after an asthma emergency department (ED) visit are low among inner-city children. The objective of this study was to test the efficacy of a clinician and caregiver feedback intervention (INT) on improving preventive asthma care following an asthma ED visit compared to an attention control group (CON).

METHODS

Children with persistent asthma and recent asthma ED visits (N = 300) were enrolled and randomized into a feedback intervention or an attention control group and followed for 12 months. All children received nurse visits. Data were obtained from interviews, child salivary cotinine levels and pharmacy records. Standard t-test, chi-square and multiple logistic regression tests were used to test for differences between the groups for reporting greater than or equal to two primary care provider (PCP) preventive care visits for asthma over 12 months.

RESULTS

Children were primarily male, young (3-5 years), African American and Medicaid insured. Mean ED visits over 12 months was high (2.29 visits). No difference by group was noted for attending two or more PCP visits/12 months or having an asthma action plan (AAP). Children having an AAP at baseline were almost twice as likely to attend two or more PCP visits over 12 months while controlling for asthma control, group status, child age and number of asthma ED visits.

CONCLUSIONS

A clinician and caregiver feedback intervention was unsuccessful in increasing asthma preventive care compared to an attention control group. Further research is needed to develop interventions to effectively prevent morbidity in high risk inner-city children with frequent ED utilization.

Low-level environmental tobacco smoke exposure and inflammatory biomarkers in children with asthma

OBJECTIVE

The effects of low-level environmental tobacco smoke (ETS) exposure, on asthma control, lung function and inflammatory biomarkers in children with asthma have not been well studied. The objective of the study was to assess ETS exposure in school-age children with asthma whose parents either deny smoking or only smoke outside the home, and to assess the impact of low-level ETS exposure on asthma control, spirometry and inflammatory biomarkers.

METHODS

Forty patients age 8-18 years with well-controlled, mild-to-moderate persistent asthma treated with either inhaled corticosteroids (ICS) or montelukast were enrolled. Subjects completed an age-appropriate Asthma Control Test and a smoke exposure questionnaire, and exhaled nitric oxide (FeNO), spirometry, urinary cotinine and leukotriene E(4) (LTE(4)) were measured. ETS-exposed and unexposed groups were compared.

RESULTS

Only one parent reported smoking in the home, yet 28 (70%) subjects had urinary cotinine levels ≥1 ng/ml, suggesting ETS exposure. Seven subjects (18%) had FeNO levels >25parts per billion, six of whom were in the ETS-exposed group. In the ICS-treated subjects, but not in the montelukast-treated subjects, ETS exposure was associated with higher urinary LTE(4), p = 0.04, but had no effect on asthma control, forced expiratory volume in 1 s or FeNO.

CONCLUSIONS

A majority of school-age children with persistent asthma may be exposed to ETS, as measured by urinary cotinine, even if their parents insist they don't smoke in the home. Urinary LTE(4) was higher in the ETS-exposed children treated with ICS, but not in children treated with montelukast.

The effects of low-level environmental tobacco smoke exposure on pulmonary function tests in preschool children with asthma

OBJECTIVES

Though parents of children with asthma smoke, they often avoid smoking in their homes or near their children, thus limiting exposure. It is not known if such low-level environmental tobacco smoke (ETS) results in measurable exposure or affects lung function. The objectives of this study were to measure urinary cotinine in preschool children with asthma, and to examine the relationship between low-level ETS exposure and pulmonary function tests (PFTs).

METHODS

Preschool children with asthma were enrolled. Parents completed questionnaires on ETS exposure and asthma control, urinary cotinine concentrations were measured and PFTs were compared between subjects with and without recent ETS exposure.

RESULTS

Forty one subjects were enrolled. All parents denied smoking in their home within the last 2 weeks, but 14 (34%) parents admitted to smoking outside their homes or away from their children. Fifteen (37%; 95%CI: 23-53) of the children had urinary cotinine levels ≥1 ng/ml, of which seven (17%; 95%CI: 8-32) had levels ≥5 ng/ml. FEV1 and FEV0.5 were lower in subjects with a urinary cotinine level ≥5 ng/ml as compared to those with levels <1 ng/ml or between 1 and 5 ng/ml; both at baseline and after inhalation of albuterol. Five of seven subjects with urinary cotinine levels ≥5 ng/ml had FEV0.5 less than 65% of predicted values. There were no significant differences in IOS measures.

CONCLUSIONS

Despite parental denial of smoking near their children, preschool children may be exposed to ETS. Such low-level ETS exposure may affect lung function, possibly in a dose-dependent manner.

Cotinine in children admitted for asthma and readmission

OBJECTIVE

To explore the relationship between tobacco smoke exposure (reported versus biomarker) and rates of readmission for children hospitalized for asthma.

METHODS

We enrolled a prospective cohort of 774 children aged 1 to 16 years admitted for asthma or bronchodilator-responsive wheezing. The primary outcome was at least 1 asthma- or wheeze-related readmission within 1 year. Caregivers reported any tobacco exposure at home, in a secondary residence, or in the car. We measured serum and saliva cotinine levels with mass spectrometry. We used logistic regression to evaluate associations between tobacco exposure and readmissions.

RESULTS

A total of 619 children had complete tobacco exposure data; 57% were African American and 76% had Medicaid. Seventeen percent of children were readmitted within 1 year. Tobacco exposure rates were 35.1%, 56.1%, and 79.6% by report, serum, and saliva measures, respectively. Caregiver report of any tobacco exposure was not associated with readmission (adjusted odds ratio: 1.18; 95% confidence interval: 0.79-1.89), but having detectable serum or salivary cotinine was associated with increased odds of readmission (adjusted odds ratio [95% confidence interval]: 1.59 [1.02-2.48] and 2.35 [1.22-4.55], respectively). Among children whose caregivers reported no tobacco exposure, 39.1% had detectable serum cotinine and 69.9% had detectable salivary cotinine. Of the children with reported exposure, 87.6% had detectable serum cotinine and 97.7% had detectable salivary cotinine.

CONCLUSIONS

Detectable serum and salivary cotinine levels were common among children admitted for asthma and were associated with readmission, whereas caregiver report of tobacco exposure was not.

Children with asthma versus healthy children: differences in secondhand smoke exposure and caregiver perceived risk

INTRODUCTION

Secondhand smoke (SHS) exposure remains a public health problem. Few, if any, studies include both children with and without asthma to assess differences in caregiver smoking behavior, risk perception, and SHS.

METHODS

Participants were 738 daily U.S. smokers (443 caregivers of children with asthma [CG-AC] and 295 caregivers of healthy children [CG-HC]; 50.9% White, 25% Black, 15% Latino). Data are cross-sectional; SHS was measured through self-report and passive dosimetry.

RESULTS

Compared with CG-HC, CG-AC had fewer risk factors for exposing children to SHS (lower nicotine dependence, higher motivation to quit, greater perceived benefits of cessation on child's health, and lower optimistic bias; all p values < .05). Specifically, 60.6% of CG-AC reported a household smoking ban versus 40.1% of CG-HC (p < .05), though >95% of both groups had detectable levels of SHS in their home. CG-AC self-reported lower SHS than CG-HC, but both groups had nearly equivalent SHS when measured objectively. CG-AC were almost twice as likely as CG-HC to report a home smoking ban when they had detectable levels of household SHS as measured by passive dosimetry (OR = 1.71; 95% CI = 1.2, 2.4; p = .003).

CONCLUSIONS

Caregivers of children with chronic health conditions, such as asthma, may be motivated to self-report lower levels of SHS. Child health status (e.g., asthma) may cue practitioners to inquire about SHS, but given the low proportion of household bans and high levels of actual exposure among both groups, SHS exposure assessment and reduction/elimination counseling should be prompted to occur for all children.

Triple tobacco screen: opportunity to help families become smokefree

BACKGROUND

American Academy of Pediatrics policy recommends that pediatricians document environmental tobacco smoke (ETS) exposure of a child at every visit. The extent to which pediatricians adhere to this policy, however, is unknown.

PURPOSE

The goal of the study was to examine the extent to which pediatricians screen parents for tobacco use and home- and car-related smoking rules. Further, the potential association between factors associated with pediatrician inquiry into parental tobacco use and rules is examined.

METHODS

Post-visit exit interviews were conducted in ten pediatric practices between June 2009 and March 2011 with parents whose children had been seen by a healthcare provider. Parents were considered to have been given the "triple tobacco screen" if they reported being asked by a pediatric healthcare provider about their smoking behavior, smokefree home rules, and smokefree car rules. Bivariate analysis and multivariable logistic regression was done to explore factors associated with parents being given any component of the triple tobacco screening. Data were analyzed between March 2012 and February 2013.

RESULTS

Of 9145 parents interviewed, 20% of the parents reported being asked at least one question from the triple tobacco screen, and only 9% reported being asked all three questions. Overall, 17% of parents reported being asked about their smoking status, 16% about smokefree home rules, and 11% about smokefree car rules. Few smoking parents (23%) and fewer nonsmoking parents (19%) were screened about their tobacco use and behavior.

CONCLUSIONS

Pediatricians infrequently addressed ETS exposure of children among parents who do and do not smoke. Substantial missed opportunities may exist to counsel smokers and reduce ETS exposure of children in the most common exposure locations-the home and car.

Impact of a multi-level intervention to prevent secondhand smoke exposure in schoolchildren: a randomized cluster community trial

OBJECTIVE

To assess the effectiveness of a multi-level (individual, family, and school) school-based intervention to prevent the exposure to secondhand smoke (SHS) in a population of schoolchildren (12-14 years old).

METHOD

This was a community trial with cluster randomization of schools to an intervention and comparison group (ClinicalTrials.Gov identifier NCT01881607). The intervention targeted schoolchildren in Terrassa (Catalonia, Spain). We assessed SHS exposure in different settings and tobacco consumption by means of a questionnaire before and one year after the intervention.

RESULTS

We analyzed data from 1734 students with both baseline and follow-up data. The crude analysis showed that SHS exposure among students in the intervention group significantly decreased at school (-14.0%), at home (-19.9%), and on transportation (-21.8%). In the comparison group, SHS exposure significantly decreased only at home (-16.9%). After adjustment for potential confounders, the good accomplishment of the activities showed a possible trend towards a non-significant reduction in exposure at home, transportation, and leisure time.

CONCLUSION

While this school-based multi-level intervention had no overall effect in SHS exposure, the improvement of the activities focused on preventing SHS would be needed in order to achieve a significant decrease in the proportion of children exposed to SHS.

Parent report and electronic medical record agreement on asthma education provided and children's tobacco smoke exposure

OBJECTIVE

To examine the concordance between parent report and electronic medical record documentation of asthma health education provided during a single clinic visit and second-hand tobacco smoke exposure among children with asthma.

METHODS

Parents of children with asthma were recruited from two types of clinics using different electronic medical record systems: asthma-specialty or general pediatric health department clinics. After their child's outpatient visit, parents were interviewed by trained study staff. Interview data were compared to electronic medical records for agreement in five categories of asthma health education and for the child's environmental tobacco smoke exposure. Kappa statistics were used to identify strength of agreement. Chi square and t-tests were used to examine differences between clinic types.

RESULTS

Of 255 parents participating in the study 90.6% were African American and 96.1% were female. Agreement was poor across all clinics but was higher within the asthma specialty clinics than the health department clinics for smoke exposure (κ = 0.410 versus 0.205), asthma diagnosis/disease process (κ = 0.213 versus -0.016) and devices reviewed (κ = 0.253 versus -0.089) with parents generally reporting more education provided. For the 203 children with complete medical records, 40.5% did not have any documentation regarding smoking exposure in the home and 85.2% did not have any documentation regarding exposure elsewhere.

CONCLUSIONS

We found low concordance between the parent's report and the electronic medical record for smoke exposure and asthma education provided. Un- or under-documented smoke exposure and health education have the potential to affect continuity of care for pediatric patients with asthma.

Tobacco or healthy children: the two cannot co-exist

Tobacco exposure increases mortality and morbidity of the fetus, the child, the adolescent, and their children in turn. Nearly half the children in the world are exposed. Smoking is not merely personal choice or personal responsibility; those subtle phrases undermine those who have no choice in the matter. Tobacco control must take a multi-pronged attack. Smoking cessation by adults in childbearing years must take center stage of these efforts, because it is the only way to ensure a smoke-free environment for children. Smoke-free parents provide a role model for smoke-free young people, and erode the image of smoking as a desirable adult behavior to emulate. Pediatricians and pediatric pulmonologists have a key role to play here. This goal will reduce morbidity and mortality among adults and children. Legislation regarding taxation, environments, tobacco constituents, product placement and display, packaging, and media education are all key to this core goal. Smoke-free policy must be protected from attack based on trade agreements. Research is needed into more effective ways to attract and help people give up smoking, and into educating and re-deploying tobacco industry workers in emerging and developed countries.

Smoke, smoking and cessation: the views of children with respiratory illness

OBJECTIVE

To explore the attitudes of Māori (indigenous New Zealanders) and Pacific children with respiratory illness towards smoking, secondhand smoke (SHS) and smoking cessation.

METHODS

Forty-one Māori and Pacific children (aged 6-11 years) in New Zealand (NZ) were interviewed about their attitudes towards smoking, how SHS affects them and their respiratory disease, ideas they have about how to reduce SHS exposure, their fears and concerns about smoking, and experience asking parents to quit smoking. The interviews were transcribed and deductively analysed.

RESULTS

The children said that SHS made them feel "bad," "angry," "uncomfortable" and "really sick," making them want to get away from the smoke. They were aware that smoking "is dangerous" and that "you could die from it." Many children had fears for smokers around them. The children reported on rules restricting smoking around children: "You're not allowed smoke in the car where babies are." A number of children reported that adults complied with those rules, but some reported that people still smoked around them. The children had experienced people around them quitting and had an awareness of how difficult it is to quit smoking. The most common reason perceived for quitting was concern for children. A lot of the children thought they could ask parents to quit and other suggestions included hiding people's tobacco, and use of smoke-free pamphlets, or signs.

CONCLUSIONS

Even young children from low socioeconomic minority groups are aware of the dangers of smoking and SHS, and hold negative views about smoking. Health promotion messages for parents could have more weight if they convey the concerns voiced by children.

Tobacco smoking, exposure to second-hand smoke, and asthma and wheezing in schoolchildren: a cross-sectional study

AIM

To analyse the association between tobacco smoking, exposure to second-hand smoke (SHS) and reports of wheezing and asthma in a sample of schoolchildren.

METHODS

A structured questionnaire was administered to 1766 students (7th grade, aged 12-13 years) at 25 schools in Terrassa, Spain (2006). We determined the prevalence of active smoking, exposure to SHS and reports of wheezing and asthma, and their association by means of prevalence odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

97.5% of children were nonsmokers, 1.5% were experimental smokers and 1% were regular smokers. 41.1% of children reported exposure to SHS at home, 40.0% at school, 53.9% in their leisure time and 33.2% while using private or public transportation. Wheezing was reported by 9.2% of children, and 9.2% reported asthma. A significant association was found between smoking tobacco and wheezing: OR in experimental smokers = 3.0 (95% CI 1.2-7.7), and OR in active smokers = 4.2 (95% CI 1.4-12.5). Exposure to SHS while using transportation was associated with wheezing (OR = 1.4; 95% CI 1.0-2.0). Tobacco smoking and exposure to SHS were not associated with asthma.

CONCLUSION

Active and experimental smokers, and those who reported exposure to SHS while using public or private transportation, had higher likelihood of reporting wheezing. No association between active or passive smoking and asthma was observed.