The impact of severe asthma on schoolchildren

Decreasing Goal Oxygen Saturations in Bronchiolitis Is Associated With Decreased Length of Stay

OBJECTIVES

For patients hospitalized with bronchiolitis, many hospitals have implemented clinical practice guidelines to decrease variability in care. Our hospital updated its bronchiolitis clinical pathway by lowering goal oxygen saturation from 90% to 88%. We compared clinical outcomes before and after this change within the context of the pathway update.

METHODS

This was a retrospective analysis of patients <24 months old admitted to a pediatric tertiary care center from 2019 to 2021 with bronchiolitis. Patients with congenital heart disease, asthma, home oxygen, or admitted to an ICU were excluded. The data were stratified for patients admitted before and after the clinical pathway update. Statistical methods consisted of 2 group comparisons using the χ-square test for categorical variables, the Wilcoxon rank-sum test for continuous variables, and multiple regression analysis.

RESULTS

A total of 1386 patients were included, 779 preupdate and 607 postupdate. There was no statistically significant difference in the admission rate of patients presenting to the emergency department with bronchiolitis between the 2 groups (P value .60). The median time to room air was 40.0 hours preupdate versus 30.0 hours postupdate (P value < .001). The median length of stay was 48.0 hours preupdate versus 41.0 hours postupdate (P value < .001). Readmission rate was 2.7% within 7 days of discharge preupdate, and 2.1% postupdate (P value .51).

CONCLUSIONS

Decreasing goal oxygen saturation to 88% was associated with a statistically significant decrease in time spent on oxygen and length of stay for patients admitted with bronchiolitis with no increase in readmissions.

Oxygen saturation targets in pediatric respiratory disease

BACKGROUND

The present study aimed to assess the appropriate oxygen saturation target in patients with pediatric respiratory diseases by lowering the oxygen saturation target from SpO₂ 94% to 90%. No previous study has explored appropriate oxygen saturation targets in respiratory diseases other than bronchiolitis.

METHODS

The present, prospective, single-arm intervention trial enrolled pediatric inpatients with bronchiolitis, bronchitis, pneumonia, and asthma. The oxygen saturation target was lowered from SpO₂ 94% to 90% after the patients' general condition improved. The patients continued to be observed for 12 h after achieving SpO₂ 94%. The duration from the first cut-off point (SpO₂ 90% for 12 h without oxygen) to the second cut-off point (SpO₂ 94% for 12 h) was then evaluated.

RESULTS

In total, 248 patients completed the study. Patients with bronchiolitis, bronchitis, pneumonia, and asthma had an interval between the two cut-off points of 23.9, 15.5, 19.1, and 13.8 h, respectively, (mean 17.2 h; 95% confidence interval 15.0-19.5).

CONCLUSIONS

In generally healthy children, setting the oxygen saturation target at SpO₂ 90% after confirming improvement in their general condition was safe. The time required for increasing SpO₂ from 90% to 94% was longest in the patients with bronchiolitis.

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.

Academic achievement of adolescents with asthma or atopic disease

Background

Over a fifth of children and adolescents suffer with asthma or atopic disease. It is unclear whether asthma impacts academic performance in children and adolescents, and little is known about the association of eczema, food allergy or hayfever and academic performance.

Objective

To examine whether asthma, eczema, food allergy or hayfever impacts on adolescent academic performance and to assess the role of unmeasured confounding.

Methods

This study used the Childhood and Adolescent Twin Study of Sweden cohort born 1992‐1998. At age 9‐12 years, parents reported on their child's ever or current asthma, eczema, food allergy and hayfever status (n = 10 963). At age 15, linked national patient and medication register information was used to create current and ever asthma definitions including severe and uncontrolled asthma for the same children. Academic outcomes in Grade 9 (age 15‐16 years) included: eligibility for high school (Grades 10‐12), and total mark of the best 16 subject units, retrieved from the Grade 9 academic register. Whole cohort analyses adjusted for known covariates were performed, and co‐twin control analyses to assess unmeasured confounders.

Results

There were no associations found for asthma or food allergy at 9‐12 years and academic outcomes in adolescence. In addition, at age 15, there were no statistically significant associations with current, ever, severe or uncontrolled asthma and academic outcomes. Eczema and hayfever at age 9‐12 years were found to be positively associated with academic outcomes; however, co‐twin control analyses did not support these findings, suggesting the main analyses may be subject to unmeasured confounding.

Conclusion and clinical relevance

Having asthma or an atopic disease during childhood or adolescence does not negatively impact on academic performance. This information can be used by clinicians when talking with children and parents about the implications of living with asthma or atopic disease.

Exploring the intersection of executive function and medication adherence in school-age children with asthma

Asthma is one of the most common chronic diseases of childhood. For children with persistent asthma, asthma control is largely related to controller medication adherence. With increasing calls for children to be involved in their own asthma management, there is a gap in our knowledge about the executive functioning of children with asthma.

OBJECTIVE

The purpose of this study was to explore the relationship between executive function, asthma, and medication adherence among school-age children with asthma.

METHODS

Thirty-one children ages 7 to 11 years (M = 8.9 ± 1.51) and one of their parents were enrolled in this study. Parents reported on asthma control while children reported on asthma control, medication beliefs, medication adherence, and completed an executive function battery that assessed inhibition, updating, shifting and planning.

RESULTS

Compared to the reference sample, children in this study had significantly lower composite scores in inhibition, t (31) = -3.84, p =. 001, and shifting, t (30) = -3.73, p =. 001. Controlling for age and asthma control, hierarchical regression analyses revealed that shifting accounted for 16% of the variance in child-reported medication adherence.

CONCLUSIONS

This study revealed lowered executive functioning scores among school-age children with persistent asthma. Furthermore, it appears executive functioning and controller medication adherence are intertwined and warrant future exploration.

Improving Evidence Based Bronchiolitis Care

Bronchiolitis is the number one cause of hospitalization in infants during the first year of life. Clinical guidelines recommend primarily supportive care and discourage use of pharmacotherapies and diagnostics. However, there continues to be widespread use of non-recommended therapies and variation in the use of therapeutic interventions among hospitals in the United States. Here we review evidence-based management of this common disease in order to optimize resource utilization, decrease healthcare costs, and decrease unnecessary hospitalization. Current evidence does not support the routine use of chest radiographs, viral testing or laboratory evaluation in children with bronchiolitis. In addition, routine administration of bronchodilators, including albuterol and nebulized epinephrine, corticosteroids and hypertonic saline are not recommended for infants and children with bronchiolitis. Intravenous or nasogastric hydration and nutritional support, supplemental oxygen, and respiratory support are recommended. Standardization of bronchiolitis care with evidence based institutional clinical pathways spanning ED to inpatient care can help optimize resource utilization while simultaneously improving care of bronchiolitis and reducing hospital length of stays and costs.

Update in Pediatric Hospital Medicine

Pediatric Hospital Medicine has significantly developed as a field over the past two decades. With the goal of improving care for hospitalized children, much of the research in this field has focused on reducing unnecessary interventions, optimizing necessary treatments, and reducing variability for common inpatient conditions. While this is far from an exhaustive chapter on the vast diversity and advances in this field, it focuses on the updates for some of the top diagnoses in hospital medicine and the major trends in the field. Updated management of acute viral bronchiolitis, urinary tract infections, neonatal infections, brief resolved unexplained events (formerly, apparent life-threatening events), and osteomyelitis are highlighted with emphasis on major management changes. In addition, and distinct to pediatric hospital medicine, the topics of overuse and high value care are discussed as they have gained momentum in influencing the way hospitalists think and practice.

Is asthma associated with cognitive impairments? A meta-analytic review

INTRODUCTION

Asthma is a chronic disease with significant health burden and socioeconomic and racial/ethnic disparities related to diagnosis and treatment. Asthma primarily affects the lungs, but can impact brain function through direct and indirect mechanisms. Some studies have suggested that asthma negatively impacts cognition, while others have failed to identify asthma-related cognitive compromise. We aimed to conduct a meta-analysis of cognition in individuals with asthma compared to that in healthy controls. We also examined the impact of some key potential moderators.

METHOD

Data on cognitive outcome measures and sociodemographic, illness-related, and study-related variables were extracted from studies reporting cognitive test performance in individuals with asthma compared to that in controls.

RESULTS

There was no evidence of publication bias. A random-effects model examining differences in task performance between 2017 individuals with asthma and 2131 healthy controls showed significant effects in the small to medium range. Cognitive deficits associated with asthma were global, with strongest effects on broader measures involving academic achievement and executive functioning, but with additional impact on processing speed, global intellect, attention, visuospatial functioning, language, learning, and memory. Severity of asthma was a key moderator, with greatest cognitive deficits associated with severe asthma. Cognitive burden was also greatest in asthma patients who were younger, males, from low socioeconomic backgrounds, and from racial/ethnic minorities. Effects were independent of type of population (child versus adult), type of study (norm-referenced versus control-referenced), or reported use of oral or inhaled corticosteroid medications.

CONCLUSIONS

There is cognitive burden associated with asthma, particularly among vulnerable groups with severe asthma. This could be due to increased risk of intermittent cerebral hypoxia in severe asthma. The clinical need to assess cognition in individuals with asthma is underscored.

Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis

This guideline is a revision of the clinical practice guideline, "Diagnosis and Management of Bronchiolitis," published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows:

Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value

BACKGROUND

Despite estimates that waste constitutes up to 20% of healthcare expenditures in the United States, overuse of tests and therapies is significantly under-recognized in medicine, particularly in pediatrics. The American Board of Internal Medicine Foundation developed the Choosing Wisely campaign, which challenged medical societies to develop a list of 5 things physicians and patients should question. The Society of Hospital Medicine (SHM) joined this effort in the spring of 2012. This report provides the pediatric work group's results.

METHODS

A work group of experienced and geographically dispersed pediatric hospitalists was convened by the Quality and Safety Committee of the SHM. This group developed an initial list of 20 recommendations, which was pared down through a modified Delphi process to the final 5 listed below.

RESULTS

The top 5 recommendations proposed for pediatric hospital medicine are: (1) Do not order chest radiographs in children with asthma or bronchiolitis. (2) Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. (3) Do not use bronchodilators in children with bronchiolitis. (4) Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. (5) Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.

CONCLUSION

We recommend that pediatric hospitalists use this list to prioritize quality improvement efforts and include issues of waste and overuse in their efforts to improve patient care.

Psychiatric Factors in Asthma

Emotional factors are an obstacle in the diagnosis and management of asthma. This review discusses three problem patterns: negative emotions in relatively normal patients with asthma; patients presenting possible functional symptoms and; patients presenting asthma in conjunction with psychiatric deviations. Negative emotions influence the symptoms and management of asthma, even in relatively normal patients. Psychogenic symptoms appear normal, but culminate in functional symptoms in a minority of patients. Diagnosing and treating asthma in patients with comorbid asthma and psychiatric symptoms is very difficult. On the one hand, treating asthma may often be just treating the emotions. On the other hand, negative emotions make the treatment of asthma guesswork. Physicians should estimate emotional influences in their patients' symptoms for an optimal evaluation of medication efficacy. Assessment and analysis of emotional factors surrounding exacerbations seems essential, e.g. emotional precipitants of asthma and asthma-evoked negative emotions. Moreover, patients should be informed about stress-induced breathlessness and the consequences of overuse of bronchodilators. When patients present with atypical symptoms, or do not properly respond to asthma medication, functional symptoms should be suspected. Psychiatric analysis may often lead to the conclusion that symptoms have a functional basis. In patients with comorbid asthma and anxiety disorders, asthma should be the focus for treatment since difficult-to-control asthma often causes anxiety problems in the first place. Moreover, panic-like symptoms in asthma are often related to sudden onset asthma exacerbations. However, in patients with comorbid asthma and depression, depression should become the focus of treatment. The reason is that optimal treatment of depressive asthmatics is probably impossible. Special issues include specific problems with children, compliance problems, and physicians' dilemmas regarding the simultaneous treatment of asthma and psychiatric symptoms.

Beginning school with asthma independently predicts low achievement in a prospective cohort of children

BACKGROUND

Concerns about the achievement of children with asthma and respiratory conditions are especially important in New Zealand, which has one of the world's highest rates of childhood asthma. The present study evaluated whether entering school with asthma was associated with low achievement after the first year.

METHODS

A child cohort was recruited to a prospective study at time of first enrollment into randomly selected schools in Christchurch. Parent interviews covered demographics and respiratory status. Physician reports were sought for children with asthma, and all respiratory information was clinically reviewed. The children's achievement in reading and math was individually assessed at school entry and reassessed after 12 months. Schools reported absences. Intelligence subtests were administered.

RESULTS

Two hundred ninety-eight children were recruited, including 55 (18.5%) with current asthma. At 1-year follow-up, retention was 93.7%. Children who entered school with asthma were more likely to be ≥ 6 months behind other participants in reading words (P = .023) and books (P = .026), but not in math (P = .167) at the end of the first year of school. Achievement was not related to asthma severity. Entering school with asthma reliably predicted low reading achievement independent of other known covariates of low achievement (high absenteeism, minority status, male gender, single-parent family, poor academic skills at school entry, and low socioeconomic status).

CONCLUSIONS

Entering school with asthma was a significant predictor of low achievement in reading at 12-month follow-up, independent of asthma severity, high absenteeism, or other covariates of low achievement.

The use of focus groups in the development of the PROMIS pediatrics item bank

PURPOSE

To understand differences in perceptions of patient-reported outcome domains between children with asthma and children from the general population. We used this information in the development of patient-reported outcome items for the Patient-Reported Outcomes Measurement Information System Pediatrics project.

METHODS

We conducted focus groups composed of ethnically, racially, and geographically diverse youth (8-12, 13-17 years) from the general population and youth with asthma. We performed content analysis to identify important themes.

RESULTS

We identified five unique and different challenges that may confront youth with asthma as compared to general population youth: (1) They experience more difficulties when participating in physical activities; (2) They may experience anxiety about having an asthma attack at anytime and anywhere; (3) They may experience sleep disturbances and fatigue secondary to their asthma symptoms; (4) Their health condition has a greater effect on their emotional well-being and interpersonal relationships; and (5) Youth with asthma report that asthma often leaves them with insufficient energy to complete their school activities, especially physical activities.

CONCLUSIONS

The results confirm unique experiences for children with asthma across a broad range of health domains and enhance the breadth of all domains when creating an item bank.

Long-term occupational consequences of asthma in a large French cohort of male workers followed up for 5 years

OBJECTIVES

The aim of this study was to describe the long-term occupational consequences of asthma in males of the ESTEV study, a French longitudinal cohort of working subjects aged 37-52 at inclusion.

METHODS

Medical data, self-perceived health status, sick leave, occupational social class and employment characteristics were recorded twice by occupational physicians in 1990 (12,233 subjects) and 1995 (10,608 subjects). Asthma was characterized as to its onset (childhood, i.e., before age 20 vs. adult) and to its past versus current status by the physician.

RESULTS

Of the 398 asthmatics, the onset was before age 20 for 226 and the asthma status was classified as current for 159 subjects. Unemployment was not higher before baseline or during follow-up, in asthmatics as compared to non-asthmatics, despite a significantly higher prevalence of sick leave in the previous year among current asthmatics (38.4% vs. 27.0%, P = 0.005). Being a blue collar worker in 1990 is negatively related to childhood asthma but not to the current asthma status. In 1995, current adult-onset asthmatics had stopped working due to disability more frequently than never-asthmatics.

CONCLUSION

Our findings suggest that the major consequence of asthma on employment status is a selective exclusion, observed in childhood asthmatics at the beginning of their working life and in current adult-onset asthmatics at the end of their working life. Past unemployment was shown not to be higher in working asthmatics.

Nasal symptoms are associated with school performance in adolescents

Children with asthma and allergy have higher school absence rates than others, but little is known about their school performance. In a study of 9538 adolescents, nasal symptoms severe enough to affect daily activity were associated with low-grade sum, particularly in adolescents using anti-allergy medication.

The relationship between specific anxiety syndromes and somatic symptoms in adolescents with asthma and other chronic diseases

BACKGROUND

The impact of a chronic disease on the emotional well-being of children and adolescents is controversial in the literature. This study tested the hypotheses that 1) a specific approach is required to assess emotional deviations in adolescents with chronic diseases and 2) specific anxiety symptoms are predictive of excessive somatic symptoms.

METHODS

Emotional and somatic symptoms were measured in four groups, selected from a community sample of 897 adolescents: 32 with asthma, 20 with other severe chronic diseases, 30 with median scores (the true comparison group), and 29 with minimal scores on common measures of trait anxiety and depression.

RESULTS

The asthma and chronic disease groups scored not significantly higher than the true comparison group on trait anxiety, depression, negative affectivity, five anxiety syndromes, anxiety-related physical, and miscellaneous somatic symptoms. The asthma and chronic disease groups scored only higher than the true comparison group on panic attacks and respiration symptoms. Regression analyses showed that severity of asthma was no significant factor, and the minimal group scored consistently lower than the other groups, except on physical injury fears. There were no group differences in positive affect. Girls scored higher than boys on specific anxiety syndromes (except on obsessive-compulsive disorder) and also on respiration symptoms.

CONCLUSION

Adolescents with severe chronic diseases deviated from a true comparison control group on panic attacks, but not on other negative and positive emotions.

Do indoor pollutants and thermal conditions in schools influence student performance? A critical review of the literature

To assess whether school environments can adversely affect academic performance, we review scientific evidence relating indoor pollutants and thermal conditions, in schools or other indoor environments, to human performance or attendance. We critically review evidence for direct associations between these aspects of indoor environmental quality (IEQ) and performance or attendance. Secondarily, we summarize, without critique, evidence on indirect connections potentially linking IEQ to performance or attendance. Regarding direct associations, little strongly designed research was available. Persuasive evidence links higher indoor concentrations of NO(2) to reduced school attendance, and suggestive evidence links low ventilation rates to reduced performance. Regarding indirect associations, many studies link indoor dampness and microbiologic pollutants (primarily in homes) to asthma exacerbations and respiratory infections, which in turn have been related to reduced performance and attendance. Also, much evidence links poor IEQ (e.g. low ventilation rate, excess moisture, or formaldehyde) with adverse health effects in children and adults and documents dampness problems and inadequate ventilation as common in schools. Overall, evidence suggests that poor IEQ in schools is common and adversely influences the performance and attendance of students, primarily through health effects from indoor pollutants. Evidence is available to justify (i) immediate actions to assess and improve IEQ in schools and (ii) focused research to guide IEQ improvements in schools.

PRACTICAL IMPLICATIONS

There is more justification now for improving IEQ in schools to reduce health risks to students than to reduce performance or attendance risks. However, as IEQ-performance links are likely to operate largely through effects of IEQ on health, IEQ improvements that benefit the health of students are likely to have performance and attendance benefits as well. Immediate actions are warranted in schools to prevent dampness problems, inadequate ventilation, and excess indoor exposures to substances such as NO(2) and formaldehyde. Also, siting of new schools in areas with lower outdoor pollutant levels is preferable.

Poor adherence to self-medication instructions in children with asthma and their parents

This study describes a self-treatment program for parents of children with asthma. The aim was to prevent asthma exacerbations by learning to recognise prodromal signs and acting upon them by increasing inhaled corticosteroids (ICS). The study questions were: (1) can we teach parents and children to recognise prodromal signs? (2) are instructions to increase inhalation medication followed? (3) will frequency and severity of asthma attacks diminish subsequently? Due to physicians' changed attitude towards prescription of ICS, fewer children could be recruited who were "ICS-naive" than expected. Twenty-nine children of the age of 4-11 years with moderate asthma, participated in a one year prospective randomised study. Structured information was given to all patients on asthma, symptoms and medication. The experimental group received additional information on recognising prodromal signs and doubling ICS during one week. Only in 25% of the patients who recognised prodromal signs the dose of ICS was doubled (as prescribed), in 75% inadequately or not at all. Recognition of prodromal signs was poor as well as compliance to increase as-needed medication. No significant decrease of asthma symptoms occurred in the experimental group. Clinical implications are important for self-treatment instructions: an individually tailored and multi-component program should be offered by health care providers in order to help the patient to recognise early alarm symptoms, comply to self-treatment instructions and to make adaptations for continuous self-regulation.

The social and economic consequences of childhood asthma across the lifecourse: a systematic review

BACKGROUND

Asthma prevalence rates are high, and may be increasing in the Western world, particularly among children. The aim of this study was to evaluate the longer-term social and economic consequences of having asthma as a child and to determine whether adverse consequences are more severe for poorer children.

METHODS

Results from published and unpublished, quantitative and qualitative studies were synthesized narratively to examine the impact of childhood-onset asthma on school attendance, academic achievement and employment in adulthood. The question of whether the impact differed for different social groups was also examined.

FINDINGS

Twenty-nine good quality studies were identified, including in total 12 183 children with asthma or wheeze. Compared with asymptomatic children, those with asthma missed more days of school (additional absence as a result of asthma ranged from 2.1 to 14.8 days). Studies of academic achievement found that children with asthma performed as well as their healthy peers. The existing evidence on labour market performance is sparse, but there is an indication that people with asthma during childhood experience disadvantage in later employment. In an examination of consequences by social position, children with asthma from deprived areas were more likely to miss school than their more affluent peers, and minority ethnic children were also more likely to have poor school attendance. The only qualitative study suggested that children with asthma strove to participate fully in every aspect of their daily lives.

INTERPRETATION

Although asthma limits children's daily activities and affects their social activities, this research synthesis found little evidence of major, adverse long-term social and economic consequences in studies reviewed. Further longitudinal research using comparison groups is needed to fill key gaps in the existing evidence base.

The effect of chronic or intermittent hypoxia on cognition in childhood: a review of the evidence

OBJECTIVE

A review of the evidence concerning the effect of chronic or intermittent hypoxia on cognition in childhood was performed by using both a systematic review of the literature and critical appraisal criteria of causality. Because of the significant impact of behavioral disorders such as attention-deficit/hyperactivity disorder on certain cognitive functions as well as academic achievement, the review also included articles that addressed behavioral outcomes.

METHODS

Both direct and indirect evidence were collected. A structured Medline search was conducted from the years 1966-2000 by using the OVID interface. Both English- and non-English-language citations were included. Significant articles identified by the reviewers up to 2003 were also included. To be included as direct evidence, an article needed to be an original report in a peer-reviewed journal with data on cognitive, behavioral, or academic outcomes in children up to 14 years old, with clinical conditions likely to be associated with exposure to chronic or intermittent hypoxia. Indirect evidence from other reviews and publications in closely related fields, including experimental studies in adults, was used to help formulate conclusions. Two reviewers screened abstracts and titles. Each article included as direct evidence received a structured evaluation by 2 reviewers. Adjudication of differences was performed by a group of 2 reviewers and a research consultant. After this review, tables of evidence were constructed that were used as the basis for group discussion and consensus development. Indirect evidence assigned by topic to specific reviewers was also presented as part of this process. A formal procedure was used to rank the studies by design strength. The critical appraisal criteria for causation described in Evidence Based Pediatrics and Child Health (Moyer V, Elliott E, Davis R, et al, eds. London, United Kingdom: BMJ Books; 2000:46-55) were used to develop consensus on causality.

RESULTS

A total of 788 literature citations were screened. For the final analysis, 55 articles met the criteria for inclusion in the direct evidence. Of these, 43 (78.2%) reported an adverse effect. Of the 37 controlled studies, 31 (83.8%) reported an adverse effect. Adverse effects were noted at every level of arterial oxygen saturation and for exposure at every age level except for premature newborns. The studies were classified into 5 clinical categories: congenital heart disease (CHD), sleep-disordered breathing (SDB), asthma, chronic ventilatory impairment, and respiratory instability in infants. Two of these categories, CHD and SDB, which accounted for 42 (76.4%) of the included articles, fulfilled the Evidence Based Pediatrics and Child Health criteria for causation. The indirect evidence included 8 reviews, 1 meta-analysis, and 10 original reports covering the fields of adult anoxia, animal research, SDB in adults, natural and experimental high-altitude studies, perinatal hypoxic-ischemic encephalopathy, anemia, and carbon-monoxide poisoning. The studies of high-altitude and carbon-monoxide poisoning provided evidence for causality.

CONCLUSIONS

Adverse impacts of chronic or intermittent hypoxia on development, behavior, and academic achievement have been reported in many well-designed and controlled studies in children with CHD and SDB as well as in a variety of experimental studies in adults. This should be taken into account in any situation that may expose children to hypoxia. Because adverse effects have been noted at even mild levels of oxygen desaturation, future research should include precisely defined data on exposure to all levels of desaturation.

[Relationship between asthma or asthma-related symptoms and school problems among French children attending kindergarden]

BACKGROUND

The impact of chronic respiratory symptoms on school performance has been studied less than its impact on children's health. Our survey explored the relationship between chronic respiratory symptoms and school problems among children attending kindergarten. It assessed the impact of school absenteeism, sport practise in a club and health care access for school problems among pupils with chronic respiratory symptoms.

METHODS

A population-based study was carried out by school physicians on a representative sample of pupils attending third-year kindergarten, in Alsace - France. Assessments included school problems, sociodemographic and health care access characteristics. Health conditions, notably chronic respiratory symptoms, were asked to include the pupils in one of the three study groups: physician-diagnosed asthma, asthma-related symptoms not associated with diagnosed asthma, and without current health problems (controls). Logistic regression was used to compare the odds ratio of school problems for the three study groups, overall and stratified by income.

RESULTS

The 2,632 included pupils aged 5 to 6 Years, were assigned to the three groups according to their respiratory status: 179 with diagnosed asthma, 176 with asthma related symptoms and 2,277 healthy pupils. Diagnosed asthma was not linked with school problems. The overall association between asthma related symptoms and school problems was significant (OR=1.5, 95% CI: 1.0-2.2). After adjustment, this association persisted among pupils whose mother's education level was intermediary (technical or vocational diploma) (OR=2.3, 95% CI: 1.2-4.6). Among the diagnosed asthma group, pupils practising a sport in a club had less school problems than those not taking part in sports (ORadjusted=0.2, 95% CI: 0.03-0.8).

CONCLUSION

In our study, asthmatic children were not at higher risk of school problems. So developing programs preventing school problems which focus on asthmatic children is not needed. Among the pupils having a mother with an intermediary education level, asthma-related symptoms were associated with school problems. It is important to identify unknown asthmatics to institute to treatment for their respiratory symptoms in order to prevent the consequences of the functional impact of asthma on their scholarship.

Childhood overweight and academic performance: national study of kindergartners and first-graders

OBJECTIVE

To examine the association between children's overweight status in kindergarten and their academic achievement in kindergarten and first grade.

RESEARCH METHODS AND PROCEDURES

The data analyzed consisted of 11,192 first time kindergartners from the Early Childhood Longitudinal Study, a nationally representative sample of kindergartners in the U.S. in 1998. Multivariate regression techniques were used to estimate the independent association of overweight status with children's math and reading standardized test scores in kindergarten and grade 1. We controlled for socioeconomic status, parent-child interaction, birth weight, physical activity, and television watching.

RESULTS

Overweight children had significantly lower math and reading test scores compared with non-overweight children in kindergarten. Both groups were gaining similarly on math and reading test scores, resulting in significantly lower test scores among overweight children at the end of grade 1. However, these differences, except for boys' math scores at baseline (difference = 1.22 points, p = 0.001), became insignificant after including socioeconomic and behavioral variables, indicating that overweight is a marker but not a causal factor. Race/ethnicity and mother's education were stronger predictors of test score gains or levels than overweight status.

DISCUSSION

Significant differences in test scores by overweight status at the beginning of kindergarten and the end of grade 1 can be explained by other individual characteristics, including parental education and the home environment. However, overweight is more easily observable by other students compared with socioeconomic characteristics, and its significant (unadjusted) association with worse academic performance can contribute to the stigma of overweight as early as the first years of elementary school.