Identifying asthma-related risks during hospitalization using the child asthma risk assessment tool

Objective: The Child Asthma Risk Assessment Tool (CARAT) identifies risk factors for asthma morbidity. We hypothesized that CARAT-identified risk factors (using a CARAT adapted for inpatient use) would be associated with future healthcare utilization and would identify areas for intervention.Methods: We reviewed CARAT data collected during pediatric asthma admissions from 2010-2015, assessing for risk factors in environmental, medical, and social domains and providing prompts for inpatient (specialist consultation or social services engagement) and post-discharge interventions (home care visit or home environmental assessment). Confirmatory factor analysis identified groups of CARAT-identified risk factors with similar effects on healthcare utilization (latent factors). Structural equation models then evaluated relationships between latent factors and future utilization.Results: There were 2731 unique patients admitted for asthma exacerbations; 1015 (37%) had complete CARAT assessments and were included in analyses. Those with incomplete CARAT assessments were more often younger and privately-insured. CARAT-identified risk factors across domains were common in children hospitalized for exacerbations. Risks in the environmental domain were most common. Inpatient asthma consults by pulmonologists or allergists and home care referrals were the most frequent interventions indicated (62%, 628/1015, and 50%, 510/1015, respectively). Two latent factors were positively associated with healthcare utilization in the year after index stay - social stressors and known/suspected allergies (both p < 0.05). Stratified analyses analyzing data just from those children with prior healthcare utilization also indicated known/suspected allergies to be positively associated with future utilization.Conclusions: Inpatient interventions to address social stressors and allergic profiles may be warranted to reduce subsequent asthma morbidity.

Rhinoviruses A and C elicit long-lasting antibody responses with limited cross-neutralization

Rhinoviruses (RVs) can cause severe wheezing illnesses in young children and patients with asthma. Vaccine development has been hampered by the multitude of RV types with little information about cross-neutralization. We previously showed that neutralizing antibody (nAb) responses to RV-C are detected twofold to threefold more often than those to RV-A throughout childhood. Based on those findings, we hypothesized that RV-C infections are more likely to induce either cross-neutralizing or longer-lasting antibody responses compared with RV-A infections. We pooled RV diagnostic data from multiple studies of children with respiratory illnesses and compared the expected versus observed frequencies of sequential infections with RV-A or RV-C types using log-linear regression models. We tested longitudinally collected plasma samples from children to compare the duration of RV-A versus RV-C nAb responses. Our models identified limited reciprocal cross-neutralizing relationships for RV-A (A12-A75, A12-A78, A20-A78, and A75-A78) and only one for RV-C (C2-C40). Serologic analysis using reference mouse sera and banked human plasma samples confirmed that C40 infections induced nAb responses with modest heterotypic activity against RV-C2. Mixed-effects regression modeling of longitudinal human plasma samples collected from ages 2 to 18 years demonstrated that RV-A and RV-C illnesses induced nAb responses of similar duration. These results indicate that both RV-A and RV-C nAb responses have only modest cross-reactivity that is limited to genetically similar types. Contrary to our initial hypothesis, RV-C species may include even fewer cross-neutralizing types than RV-A, whereas the duration of nAb responses during childhood is similar between the two species. The modest heterotypic responses suggest that RV vaccines must have a broad representation of prevalent types.

Safety of Live Attenuated Influenza Vaccine in Children With Asthma

BACKGROUND AND OBJECTIVES

Asthma is considered a precaution for use of quadrivalent live attenuated influenza vaccine (LAIV4) in persons aged ≥5 years because of concerns for wheezing events. We evaluated the safety of LAIV4 in children with asthma, comparing the proportion of children with asthma exacerbations after LAIV4 or quadrivalent inactivated influenza vaccine (IIV4).

METHODS

We enrolled 151 children with asthma, aged 5 to 17 years, during 2 influenza seasons. Participants were randomly assigned 1:1 to receive IIV4 or LAIV4 and monitored for asthma symptoms, exacerbations, changes in peak expiratory flow rate (PEFR), and changes in the asthma control test for 42 days after vaccination.

RESULTS

We included 142 participants in the per-protocol analysis. Within 42 days postvaccination, 18 of 142 (13%) experienced an asthma exacerbation: 8 of 74 (11%) in the LAIV4 group versus 10 of 68 (15%) in the IIV4 group (LAIV4-IIV4 = -0.0390 [90% confidence interval -0.1453 to 0.0674]), meeting the bounds for noninferiority. When adjusted for asthma severity, LAIV4 remained noninferior to IIV4. There were no significant differences in the frequency of asthma symptoms, change in PEFR, or childhood asthma control test/asthma control test scores in the 14 days postvaccination between LAIV4 and IIV4 recipients. Vaccine reactogenicity was similar between groups, although sore throat (P = .051) and myalgia (P <.001) were more common in the IIV4 group.

CONCLUSIONS

LAIV4 was not associated with increased frequency of asthma exacerbations, an increase in asthma-related symptoms, or a decrease in PEFR compared with IIV4 among children aged 5 to 17 years with asthma.

554 Utilization of Pediatric Sleep Questionnaire to Screen for Obstructive Sleep Apnea in a Difficult-to-treat Asthma Cohort

Introduction

Early detection and management of obstructive sleep apnea(OSA) could improve asthma control in children with difficult-to-treat(DTT) asthma. The purpose of this study was to assess the effectiveness of the pediatric sleep questionnaire(PSQ) to screen for OSA in children with DTT asthma, and to compare clinical characteristics between those with positive and negative PSQ scores.

Methods

A prospective study of 81 children with DTT asthma was completed from 2015–2017. The PSQ, Epworth sleepiness scale(ESS), Pediatric Quality of Life(PQL), and the academic performance questionnaires(APQ) were administered during clinic visits. Polysomnography(PSG) was recommended for PSQ score&gt;0.33. Medical records were reviewed for asthma clinical characteristics. The cohort was separated into positive(PSQ&gt;0.33) and negative PSQ score(PSQ≤0.33) groups for analysis.

Results

The mean age of the cohort was 11.3±4.5 years and the mean body mass index was 22±7.6 kg/m2. Sixty-two percent were male and 68% were African-American. Forty-nine(53%) subjects had positive PSQ (0.5[0.4 – 0.7]). The positive group had higher ESS score (10.5[8 – 13] vs. 6[2 – 8], p&lt;0.0001) and lower total PQL score (58.7[47.8–72.8] vs. 79.4[70.7 – 87], p&lt;0.0001) than the negative group. There was no difference between APQ scores(p=0.07). The positive group had lower asthma control test(ACT) scores than the negative group (17.5[15 – 20.5] vs. 21[19 – 22], p&lt;0.0001). Furthermore, the positive group was more likely to have gastroesophageal reflux (OR: 3.97, 95%CI: 1.7 to 9.1, p=0.0018). Twenty-nine(59%) subjects in the positive group had subsequent PSG, and 17(58.6%) subjects were diagnosed with OSA (14 mild OSA, 1 moderate OSA, 2 severe OSA). The mean obstructive index in the positive group was 3±5.5 events/hour. There was 1 subject with central apnea and alveolar hypoventilation. Of the 17 subjects with OSA, all received treatment with nasal steroids, 3 were treated with non-invasive positive pressure ventilation, and 4 had surgical intervention.

Conclusion

Children with DTT asthma who have positive PSQ have higher degree of daytime sleepiness, lower quality of life and worse asthma control. The positive group was more likely to have GERD, which may suggest a relationship between nighttime asthma symptoms and OSA. Further studies are needed to evaluate the effects of OSA treatment on asthma control.

Support (if any):

Enhanced Neutralizing Antibody Responses to Rhinovirus C and Age-Dependent Patterns of Infection

Rationale: Rhinovirus (RV) C can cause asymptomatic infection and respiratory illnesses ranging from the common cold to severe wheezing.Objectives: To identify how age and other individual-level factors are associated with susceptibility to RV-C illnesses.Methods: Longitudinal data from the COAST (Childhood Origins of Asthma) birth cohort study were analyzed to determine relationships between age and RV-C infections. Neutralizing antibodies specific for RV-A and RV-C (three types each) were determined using a novel PCR-based assay. Data were pooled from 14 study cohorts in the United States, Finland, and Australia, and mixed-effects logistic regression was used to identify factors related to the proportion of RV-C versus RV-A detection.Measurements and Main Results: In COAST, RV-A and RV-C infections were similarly common in infancy, whereas RV-C was detected much less often than RV-A during both respiratory illnesses and scheduled surveillance visits (P < 0.001, χ2) in older children. The prevalence of neutralizing antibodies to RV-A or RV-C types was low (5-27%) at the age of 2 years, but by the age of 16 years, RV-C seropositivity was more prevalent (78% vs. 18% for RV-A; P < 0.0001). In the pooled analysis, the RV-C to RV-A detection ratio during illnesses was significantly related to age (P < 0.0001), CDHR3 genotype (P < 0.05), and wheezing illnesses (P < 0.05). Furthermore, certain RV types (e.g., C2, C11, A78, and A12) were consistently more virulent and prevalent over time.Conclusions: Knowledge of prevalent RV types, antibody responses, and populations at risk based on age and genetics may guide the development of vaccines or other novel therapies against this important respiratory pathogen.

Enterovirus D68 Infection Among Children With Medically Attended Acute Respiratory Illness, Cincinnati, Ohio, July-October 2014

Background

Enterovirus D68 (EV-D68) caused a widespread outbreak of respiratory illness in the United States in 2014, predominantly affecting children. We describe EV-D68 rates, spectrum of illness, and risk factors from prospective, population-based acute respiratory illness (ARI) surveillance at a large US pediatric hospital.

Methods

Children <13 years of age with ARI and residence in Hamilton County, Ohio were enrolled from the inpatient and emergency department (ED) settings at a children's hospital in Cincinnati, Ohio, from 1 July to 31 October 2014. For each participant, we interviewed parents, reviewed medical records, and tested nasal and throat swabs for EV-D68 using real-time reverse- transcription polymerase chain reaction assay.

Results

EV-D68 infection was detected in 51 of 207 (25%) inpatients and 58 of 505 (11%) ED patients. Rates of EV-D68 hospitalization and ED visit were 1.3 (95% confidence interval [CI], 1.0-1.6) and 8.4 per 1000 children <13 years of age, respectively. Preexisting asthma was associated with EV-D68 infection (adjusted odds ratio, 3.2; 95% CI, 2.0-5.1). Compared with other ARI, children with EV-D68 were more likely to be admitted from the ED (P ≤ .001), receive supplemental oxygen (P = .001), and require intensive care unit admission (P = .04); however, mechanical ventilation was uncommon (2/51 inpatients; P = .64), and no deaths occurred.

Conclusions

During the 2014 EV-D68 epidemic, high rates of pediatric hospitalizations and ED visits were observed. Children with asthma were at increased risk for medically attended EV-D68 illness. Preparedness planning for a high-activity EV-D68 season in the United States should take into account increased healthcare utilization, particularly among children with asthma, during the late summer and early fall.

The nasal methylome and childhood atopic asthma

BACKGROUND

Given the strong environmental influence on both epigenetic marks and allergic asthma in children, the epigenetic alterations in respiratory epithelia might provide insight into allergic asthma.

OBJECTIVE

We sought to identify DNA methylation and gene expression changes associated with childhood allergic persistent asthma.

METHODS

We compared genomic DNA methylation patterns and gene expression in African American children with persistent atopic asthma (n = 36) versus healthy control subjects (n = 36). Results were validated in an independent population of asthmatic children (n = 30) by using a shared healthy control population (n = 36) and in an independent population of white adult atopic asthmatic patients (n = 12) and control subjects (n = 12).

RESULTS

We identified 186 genes with significant methylation changes, differentially methylated regions or differentially methylated probes, after adjustment for age, sex, race/ethnicity, batch effects, inflation, and multiple comparisons. Genes differentially methylated included those with established roles in asthma and atopy and genes related to extracellular matrix, immunity, cell adhesion, epigenetic regulation, and airflow obstruction. The methylation changes were substantial (median, 9.5%; range, 2.6% to 29.5%). Hypomethylated and hypermethylated genes were associated with increased and decreased gene expression, respectively (P < 2.8 × 10^-6 for differentially methylated regions and P < 7.8 × 10^-10 for differentially methylated probes). Quantitative analysis in 53 differentially expressed genes demonstrated that 32 (60%) have significant methylation-expression relationships within 5 kb of the gene. Ten loci selected based on the relevance to asthma, magnitude of methylation change, and methylation-expression relationships were validated in an independent cohort of children with atopic asthma. Sixty-seven of 186 genes also have significant asthma-associated methylation changes in nasal epithelia of adult white asthmatic patients.

CONCLUSIONS

Epigenetic marks in respiratory epithelia are associated with allergic asthma and gene expression changes in inner-city children.

Lack of a relation between serum 25-hydroxyvitamin D concentrations and asthma in adolescents

BACKGROUND

Decreased 25-hydroxyvitamin D [25(OH)D] concentrations have been associated with an increased prevalence and severity of asthma and a lower response to inhaled corticosteroids.

OBJECTIVE

The objective was to determine the association between serum 25(OH)D concentrations and asthma prevalence, severity, and response to asthma treatment.

DESIGN

Secondary analyses were conducted in 2 samples of adolescents 12-20 y of age: 1) NHANES 2001-2006 (n = 6487), a cross-sectional nationally representative sample of the US population, and 2) a cohort of inner-city adolescents with asthma managed prospectively for 46 wk with guidelines-based therapy in the Asthma Control Evaluation (ACE; n = 226) trial.

RESULTS

Mean (±SD) serum 25(OH)D concentrations in the NHANES and ACE samples were lower in African Americans than in non-African Americans (NHANES: 14.9 ± 6.5 compared with 23.0 ± 8.4 ng/mL, P < 0.0001; ACE: 11.2 ± 6.9 compared with 15.8 ± 7.1 ng/mL, P < 0.0001). In the NHANES sample, mean concentrations did not differ between participants without and with asthma (African Americans: 14.9 ± 6.4 compared with 15.0 ± 6.6 ng/mL, respectively, P = 0.87; non-African Americans: 23.0 ± 8.5 compared with 23.6 ± 8.2 ng/mL, respectively, P = 0.16). In the ACE models that used either a predefined cutoff (<20 ng/mL) or linear regression, 25(OH)D concentrations showed either no relation or minor contradictory correlations with indicators of asthma severity, treatment requirements, spirometry, or atopy/inflammation.

CONCLUSION

In 2 samples of adolescents, overall serum 25(OH)D concentrations were low and were not consistently associated with the presence of asthma, multiple asthma characteristics, asthma morbidity, or response to treatment. The ACE trial was registered at clinicaltrials.gov as NCT0011441.

Design of the asthma treat smart system in a pediatric institution

Asthma is one of the most common chronic pediatric conditions. Providing evidence-based, guideline-appropriate care for asthma is complex. A computerized system may help providers with guideline compliance. The AsthmaTreatSmart application is a stand-alone web-based system developed in Pulmonary medicine with a multidisciplinary team based on national asthma guidelines. The application collects history and symptom information to assign a severity categorization. Medication reconciliation of asthma medications is performed with input from the patient. Severity and medication recommendation are provided for the provider. A personalized action plan and medication summary including medications, etc. is created. The system is successfully used in 6 outpatient clinics and current work is focused on integration with the electronic health record.

The Greater Cincinnati Pediatric Clinic Repository: A Novel Framework for Childhood Asthma and Allergy Research

BACKGROUND: Allergic disorders, including asthma, allergic rhinitis, atopic dermatitis, eosinophilic esophagitis, and food allergy, are a major global health burden. The study and management of allergic disorders is complicated by the considerable heterogeneity in both the presentation and natural history of these disorders. Biorepositories serve as an excellent source of data and biospecimens for delineating subphenotypes of allergic disorders, but such resources are lacking. METHODS: In order to define subphenotypes of allergic disease accurately, we established an infrastructure to link and efficiently utilize clinical and epidemiologic data with biospecimens into a single biorepository called the Greater Cincinnati Pediatric Clinic Repository (GCPCR). Children with allergic disorders as well as healthy controls are followed longitudinally at hospital clinic, emergency department, and inpatient visits. Subjects' asthma, allergy, and skin symptoms; past medical, family, social, diet, and environmental histories; physical activity; medication adherence; perceived quality of life; and demographics are ascertained. DNA is collected from all participants, and other biospecimens such as blood, hair, and nasal epithelial cells are collected on a subset. RESULTS: To date, the GCPCR has 6,317 predominantly Caucasian and African American participants, and 93% have banked DNA. This large sample size supports adequately powered genetic, epidemiologic, environmental, and health disparities studies of childhood allergic diseases. CONCLUSIONS: The GCPCR is a unique biorepository that is continuously evaluated and refined to achieve and maintain rigorous clinical phenotype and biological data. Development of similar disease-specific repositories using common data elements is necessary to enable studies across multiple populations of comprehensively phenotyped patients.

Comparison of measures of marker informativeness for ancestry and admixture mapping

BACKGROUND

Admixture mapping is a powerful gene mapping approach for an admixed population formed from ancestral populations with different allele frequencies. The power of this method relies on the ability of ancestry informative markers (AIMs) to infer ancestry along the chromosomes of admixed individuals. In this study, more than one million SNPs from HapMap databases and simulated data have been interrogated in admixed populations using various measures of ancestry informativeness: Fisher Information Content (FIC), Shannon Information Content (SIC), F statistics (FST), Informativeness for Assignment Measure (In), and the Absolute Allele Frequency Differences (delta, δ). The objectives are to compare these measures of informativeness to select SNP markers for ancestry inference, and to determine the accuracy of AIM panels selected by each measure in estimating the contributions of the ancestors to the admixed population.

RESULTS

FST and In had the highest Spearman correlation and the best agreement as measured by Kappa statistics based on deciles. Although the different measures of marker informativeness performed comparably well, analyses based on the top 1 to 10% ranked informative markers of simulated data showed that In was better in estimating ancestry for an admixed population.

CONCLUSIONS

Although millions of SNPs have been identified, only a small subset needs to be genotyped in order to accurately predict ancestry with a minimal error rate in a cost-effective manner. In this article, we compared various methods for selecting ancestry informative SNPs using simulations as well as SNP genotype data from samples of admixed populations and showed that the In measure estimates ancestry proportion (in an admixed population) with lower bias and mean square error.

Longitudinal predictors of maternal stress and coping after very low-birth-weight birth

OBJECTIVE

To determine longitudinal outcomes and contributors to parental stress and coping in mothers of very low-birth-weight (VLBW) children.

DESIGN

Prospective cohort follow-up of high-risk VLBW children (n = 113), low-risk VLBW children (n = 80), and term children (n = 122) and their mothers from birth to 14 years.

SETTING

Recruitment from level III neonatal intensive care and term nurseries in a large Midwestern region with follow-up at an academic medical center.

PARTICIPANTS

A total of 315 mother-infant dyads enrolled from November 8, 1989, to February 22, 1992.

MAIN EXPOSURES

High-risk VLBW infants had bronchopulmonary dysplasia. Comparison groups were demographically similar low-risk VLBW children (without bronchopulmonary dysplasia) and term children.

MAIN OUTCOME MEASURES

Child IQ and self-report measures of parenting stress, family impact, maternal coping, education, and social support.

RESULTS

After VLBW birth, mothers attained fewer additional years of education than term mothers (P = .04). Mothers of high-risk VLBW children felt more personal stress (P = .006) and family stress (P = .009) under conditions of low social support and had greater child-related stress than term mothers; however, they also expressed the highest levels of parenting satisfaction at 14 years. They became less likely to use denial (P = .02) and mental disengagement (P = .03) as coping mechanisms over time. Except for education attainment, mothers of low-risk VLBW infants did not differ from mothers of term children and at 14 years reported the lowest stress.

CONCLUSIONS

Parenting a VLBW child had both positive and negative outcomes, dependent on child medical risk, child IQ, social support, and maternal coping mechanisms, suggesting that mothers experience posttraumatic growth and resilience after significant distress post partum.

Adherence to pediatric asthma treatment in economically disadvantaged African-American children and adolescents: an application of growth curve analysis

OBJECTIVES

The primary aims of the study were to: (a) describe the trajectories of adherence to daily inhaled corticosteroid (ICS) medication for a year in economically disadvantaged, African-American youth with asthma based on growth curve modeling; and (b) test the relationship of treatment adherence to symptom control, quick-relief medication, and healthcare utilization.

METHODS

This prospective study measured adherence to daily ICS treatment using electronic monitoring in 92 children and adolescents with moderate to severe asthma for 9-12 months and assessed clinical outcomes, including asthma-related symptoms, quick-relief medication, and healthcare utilization.

RESULTS

Youth showed a decrement in treatment adherence to less than half of prescribed corticosteroid treatment over the course of the study, which related to increased healthcare utilization (p < .04), but not to asthma symptoms or albuterol use.

CONCLUSION

Economically disadvantaged youth with asthma demonstrate high rates of chronic nonadherence that warrant identification and intervention to reduce asthma-related healthcare utilization.

Exhaled nitric oxide in the diagnosis and management of childhood asthma

The management of asthma in children and adolescents is currently guided by assessment of clinical symptoms, exacerbation risk and spirometric measure of lung function. The use of biomarkers, an objective measure which indicates normal or pathophysiologic processes and/or the response to a treatment intervention, could greatly enhance the efficacy and safety of current algorithms. Measurement of the fraction of expired nitric oxide in exhaled air (FeNO) has been suggested as a readily determined biomarker that can aid in the diagnosis and management of asthma. FeNO has been used to identify steroid responsive patients, adjust the dose of controller medications, most notably inhaled corticosteroids, and predict relapse during medication taper. In spite of early enthusiasm for the utility of this measure, more recent data suggest a more limited role for FeNO. This review will focus on the use of FeNO in the diagnosis and management of asthma in children and adolescents.

Adherence to combined montelukast and fluticasone treatment in economically disadvantaged african american youth with asthma

High rates of asthma treatment nonadherence have been reported, particularly in economically disadvantaged African American youth. The relationship between adherence to combined medication treatment and asthma outcomes has potential clinical significance but is not well understood. Using electronic monitoring, we describe the pattern of adherence to daily corticosteroid (fluticasone) and leukotriene receptor antagonist (montelukast) medication over the course of 1 year in a population of African American youth with moderate to severe asthma. On average, adherence to montelukast was higher than adherence to fluticasone (p < 0.01); however, for both medications, adherence rates significantly declined over the course of the study. After 1 year, participants took only 31% of prescribed doses of montelukast and 23% of prescribed doses of fluticasone. The decline in adherence to both fluticasone (p < 0.05) and montelukast (p < 0.001) was related to increased healthcare utilization. Furthermore, asthma symptom ratings were related montelukast (p < 0.001), but not fluticasone adherence. These results suggest that adherence promotion intervention strategies are warranted to improve health-related outcomes in families who are at-risk for treatment nonadherence.

Strategic plan for pediatric respiratory diseases research: an NHLBI working group report

The Division of Lung Diseases of the National Heart, Lung and Blood Institute (NHLBI) recently held a workshop to identify gaps in our understanding and treatment of childhood lung diseases and to define strategies to enhance translational research in this field. Leading experts with diverse experience in both laboratory and patient-oriented research reviewed selected areas of pediatric lung diseases, including perinatal programming and epigenetic influences; mechanisms of lung injury, repair, and regeneration; pulmonary vascular disease (PVD); sleep and control of breathing; and the application of novel translational methods to enhance personalized medicine. This report summarizes the proceedings of this workshop and provides recommendations for emphasis on targeted areas for future investigation. The priority areas identified for research in pediatric pulmonary diseases included: (1) epigenetic and environmental influences on lung development that program pediatric lung diseases, (2) injury, regeneration, and repair in the developing lung, (3) PVD in children, (4) development and adaptation of ventilatory responses to postnatal life, (5) nonatopic wheezing: aberrant large airway development or injury? (6) strategies to improve assessment, diagnosis, and treatment of pediatric respiratory diseases, and (7) predictive and personalized medicine for children.

Relationships of family functioning, self-esteem, and resourceful coping of Thai adolescents with asthma

Within the context of Rosenbaum's theory of learned resourcefulness, this correlational study examined the relationships among family functioning, self-esteem, and resourceful coping in Thai adolescents with asthma. A convenience sample of 132 Thai adolescents (aged 12-17 years) with asthma was recruited from the outpatient asthma clinics of four hospitals in Bangkok. Self-administered questionnaires included an assessment of demographic information and asthma status, the revised Family APGAR, the Rosenberg Self-Esteem Scale, and the Children's Self-Control Scale. Hierarchical multiple regression analysis was used to examine the relationships among variables. Effective family functioning had a significant positive effect on self-esteem (beta = .27, p < .01) and resourceful coping (beta = .30, p < .01), controlling for gender and age. However, self-esteem was not significantly correlated with resourceful coping (beta = .15, p = .08). The findings suggest that nursing interventions should take into account the role of family functioning in promoting self-esteem and resourceful coping in Thai adolescents with asthma. Recommendations for future research include replication of the study with a larger sample of adolescents with asthma and with adolescents with other chronic illnesses.

An interdisciplinary intervention for undertreated pediatric asthma

STUDY OBJECTIVES

To examine the effectiveness of an interdisciplinary intervention for pediatric asthma.

DESIGN

Randomized, controlled study.

SETTING

Urban tertiary-referral pediatric hospital.

PARTICIPANTS

One hundred seventy-five patients with asthma lacking written treatment plans and presenting with asthma-related emergency department visits (two or more) and/or hospitalizations (one or more) in the past year were randomized to a comparison group receiving medical care alone (n = 86) or to an interdisciplinary intervention group receiving medical care, asthma education, and problem-solving therapy (n = 89)

INTERVENTION

All participants received written asthma management plans, peak flow meters, and spacer devices. The intervention group also received asthma education, an asthma risk profile assessment, brief problem-solving therapy, and access to a 24-h nurse advice line. The primary outcome measure was change in asthma symptoms, and secondary outcomes included health-care utilization and asthma-related quality of life.

RESULTS

Both groups demonstrated significant reductions in asthma symptoms and improvements in quality of life without any between-group differences identified over the course of follow-up. In contrast, the intervention group demonstrated less frequent health-care utilization than the comparison group, with 28% of the intervention group requiring emergency department or inpatient services for asthma compared to 41% of the comparison group (adjusted odds ratio, 1.92; 95% confidence interval, 1.00 to 3.69) over the 12-month follow-up period.

CONCLUSIONS

This study examined the effectiveness of an interdisciplinary intervention for undertreated asthma. The intervention did not result in improvements in asthma symptoms, but accomplished modest reductions in the utilization of acute medical care.

Predicting attrition in a pediatric asthma intervention study

OBJECTIVES

To operationalize a comprehensive description of attrition, including pre-inclusion, dropout, and attrition due to intermittent missing data, and to test a predictive model of attrition using a data set from a randomized controlled intervention in pediatric asthma.

METHODS

Participants included children, ages 4-12, diagnosed with asthma and their caregivers. Demographic variables and outcome measures of asthma morbidity were examined in 327 families to determine their association with attrition.

RESULTS

Families who did not complete randomization and the intervention tended to have younger caregivers than did completers. Caregiver age emerged as the most consistent predictor of pre-inclusion and dropout attrition. There were no significant predictors of attrition due to intermittent missing data.

CONCLUSION

Younger caregivers may be at particular risk for attrition in pediatric asthma intervention studies and warrant special attention by investigators.

Cognitive and academic consequences of bronchopulmonary dysplasia and very low birth weight: 8-year-old outcomes

OBJECTIVE

To examine the effects of bronchopulmonary dysplasia (BPD) and very low birth weight (VLBW) on the cognitive and academic achievement of a large sample of 8-year-old children.

METHODS

Infants who were VLBW and had BPD (n = 98) or did not have BPD (n = 75) and term infants (n = 99) were followed prospectively to age 8. Groups were compared on measures assessing 4 broad areas of functioning: intelligence, achievement, gross motor, and attentional skills. Measures included the Wechsler Intelligence Scale for Children III, the Woodcock Johnson Test of Achievement-Revised, the Bruininks-Oseretsky Test of Motor Proficiency, the Tactual Performance Test (spatial memory), and the Continuous Performance Test (attention). School outcomes were assessed by parent and teacher report, as well as from school records. Groups were comparable on socioeconomic status, sex, and race. The total sample of BPD, VLBW, and term children was compared on all outcome measures. In addition, neurologic risk was assessed in the present sample and included the following: intraventricular hemorrhage, echodense lesions, porencephaly, hydrocephalus, ventriculoperitoneal shunt, meningitis, and periventricular leukomalacia. Individual difference analyses were conducted for neurologically intact children in all 3 groups. Finally, treatment effects were examined by comparing BPD children who had received steroids as part of their treatment with BPD children who had not.

RESULTS

The BPD group demonstrated deficits compared with VLBW and term children in intelligence; reading, mathematics, and gross motor skills; and special education services. VLBW children differed from term children in all of the above areas, except reading recognition, comprehension, and occupational therapy. Attentional differences were obtained between BPD and term children only. The BPD group (54%) was more likely to be enrolled in special education classes than VLBW (37%) or term children (25%). In addition, more BPD children (20%) achieved full-scale IQ scores <70, in the mental retardation range, compared with either VLBW (11%) or term (3%) children, with all VLBW children significantly more likely than term children to achieve IQs in the subaverage category. After controlling for birth weight and neurologic problems, BPD and/or duration on oxygen predicted lower performance IQ, perceptual organization, full-scale IQ, motor and attentional skills, and special education placement. The qualitative classification of BPD (present or absent) was a significant predictor for lower scores on measures of applied problems; motor skills; and incidence of speech-language, occupational, and physical therapies. Individual difference analyses were performed to ascertain whether differences between the risk groups were primarily attributable to neurologic complications. Even with the neurologically intact sample of BPD and VLBW children, differences between the term comparison group and both the BPD and VLBW groups were found for many outcome measures. When birth weight and neurologic complications were controlled, BPD and severity of BPD were associated with lower performance and full-scale IQ, poorer perceptual organization, attention, and motor skills, as well as lower school achievement and greater participation in special education, including occupational, physical, and speech-language therapies. Treatment protocol may in part be responsible for differences observed in our BPD sample. Steroid and nonsteroid groups of BPD children differed significantly in performance IQ (72.8 vs 84.8) and full-scale IQ (77.0 vs 85.2); perceptual organization (74.0 vs 85.2); Bruininks-Oseretsky Test of Motor Proficiency score (36.6 vs 44.7); and participation in special education (78% vs 48%), occupational therapy (71% vs 44%), and physical therapy (71% vs 41%). In every instance, BPD children who received steroids fared more poorly than BPD children who did not receive steroids.

CONCLUSIONS

BPD and duration on oxygen have long-term adverse effects on cognitive and academic achievement above and be beyond the effects of VLBW. The problems that have been identified at 8 years of age highlight the need for continued monitoring of the learning, behavior, and development of BPD children to intervene with children who are at risk for school problems.

Development and validation of school-based asthma and allergy screening instruments for parents and students

BACKGROUND

The increasing morbidity attributable to asthma among school-aged children suggests the potential utility of school-based asthma screening programs.

OBJECTIVE

We report our efforts to develop and validate culturally sensitive and clinically useful screening questionnaires (parent and child versions) for asthma and allergies among urban US school children.

METHODS

Instrument development was accomplished through literature review, expert medical and child developmental input, focus group feedback, and a rigorous trial of the instruments in a public school setting. Questionnaires were distributed to 2,800 children and their families in an urban public school system (grades kindergarten through 6). Validity was evaluated by blinded comparison of results against a standardized clinical evaluation in 107 children, with final designations determined by an expert panel.

RESULTS

Questionnaires pertaining to 2,083 children were returned (participation rate of 74%). A moderate level of agreement was observed between parent and student questionnaire responses (r values = 0.36 to 0.50; P values < 0.001). The highest frequency of asthma-like symptoms was reported for African-American boys and the lowest for Caucasian girls. The items from the parent questionnaire that best predicted asthma were "breathing problems" (occurring rarely or more; odds ratio 12.8; 95% confidence interval, 4.5 to 36.1) and "problems coughing" (sometimes or more; odds ratio 9.7; 95% confidence interval, 3.6 to 26.5). Considering the presence of cough (sometimes or more) and/or breathing problem (rarely or more) yielded a sensitivity of 80%; a specificity of 75%, a positive predictive value of 50%, and a negative predictive value of 92%. Similar levels of prediction were observed for the items "trouble breathing" and "noisy breathing" as directly reported by the students. Allergic rhinitis was best predicted by report of a runny/stuffy no se (sometimes or more; sensitivity of 83%, specificity of 61%). Allergic conjunctivitis was best predicted by "itchy eyes."

CONCLUSIONS

Administration of a school-based questionnaire is feasible, with a high response rate and excellent internal consistency. A high sensitivity and acceptable specificity was achieved by using one to two questions for asthma, allergic rhinitis, and allergic conjunctivitis. Among the children in grades 2 or above, comparable levels of prediction could be achieved with the student or parent version.

The allocation of family responsibility for asthma management tasks in African-American adolescents

The allocation of responsibilities for asthma management within African-American families was examined in 60 adolescents and their primary caretakers. Separate structured interviews were conducted with adolescents and primary caretakers, and perceptions of family management, adherence to asthma treatment regimen, and functional morbidity were assessed. Support for the primary hypothesis that higher levels of nonadherence and functional morbidity would be observed in families where caretakers overestimated the level of adolescent involvement in asthma self-care was found. Implications for family-based asthma management in ethnic minority adolescents are discussed.

A randomized clinical trial to reduce asthma morbidity among inner-city children: results of the National Cooperative Inner-City Asthma Study

OBJECTIVE

To evaluate a family-focused asthma intervention designed for inner-city children 5 to 11 years old with moderate to severe asthma.

STUDY DESIGN

Randomized, multisite, controlled trial to minimize symptom days (wheeze, loss of sleep, reduction in play activity) measured by a 2-week recall assessed at 2-month intervals over a 2-year follow-up period. The intervention was tailored to each family's individual asthma risk profile assessed at baseline.

RESULTS

Averaged over the first 12 months, participants in the intervention group (n = 515) reported 3.51 symptom days in the 2 weeks before each follow-up interview compared with 4.06 symptom days for the control group (n = 518), a difference of 0.55 (95% CI, 0.18 to 0.92, P =.004). The reduction among children with severe asthma was approximately 3 times greater (1.54 d/2 wk). More children in the control group (18.9%) were hospitalized during the intervention compared with children in the intervention group (14. 8%), a decrease of 4.19% (CI, -8.75 to 0.36, P =.071). These improvements were maintained in the intervention group during the second year of follow-up, during which they did not have access to the asthma counselor.

CONCLUSIONS

We demonstrated that an individually tailored, multifaceted intervention carried out by Masters-level social workers trained in asthma management can reduce asthma symptoms among children in the inner city.

Patient-provider communication during the emergency department care of children with asthma. The National Cooperative Inner-City Asthma Study, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD

OBJECTIVES

Poor children's reliance on emergency facilities is one factor implicated in the rise of morbidity attributed to asthma. Although studies have examined doctor-patient communication during routine pediatric visits, little data are available about communication during emergency care. This study sought to describe communication during emergency treatment of childhood asthma to learn if a "patient-centered" provider style was associated with increased parent satisfaction and increased parent and child participation.

METHODS

This cross-sectional, observational study examined 104 children aged 4 to 9 years and their guardian(s) attending emergency departments in seven cities. Quantitative analysis of provider-family dialogue was performed. Questionnaires measured satisfaction with care, provider informativeness, and partnership.

RESULTS

Providers' talk to children was largely supportive and directive; parents received most counseling and information. Children spoke little to providers (mean: 20 statements per visit versus 156 by parents). Providers made few statements about psychosocial aspects of asthma care (mean: three per visit). Providers' patient-centered style with parents was associated with more talk from parents and higher ratings for informativeness and partnership. Patient-centered style with children was associated with five times the amount of talk from children and with higher parent ratings for "good care," but not for informativeness or partnership.

CONCLUSIONS

Communication during emergency asthma care was overwhelmingly biomedical. Children took little part in discussions. A patient-centered style correlated with increased parent and child participation, but required directing conversation toward both parents and children.

Reported difficulties in access to quality care for children with asthma in the inner city

OBJECTIVE

To characterize perceived access and barriers to quality health care for asthma among the caregivers of children in the inner city.

DESIGN

Multicenter, cross-sectional survey.

SETTING

Eight sites in 7 major metropolitan US inner cities.

PARTICIPANTS

A systematic sample of children with asthma, aged 4 to 9 years, and their caregivers who resided in census tracts in which at least 30% of the households were below the 1990 federal poverty guidelines, recruited from 25 primary care clinics and 13 emergency departments (EDs) from November 1, 1992, through October 31, 1993.

RESULTS

Of the 1528 children enrolled, 1376 had physician-diagnosed asthma and form the basis of this report. This group was further divided into 284 children (20.6%) who met all recruitment criteria for severe asthma and 207 (15.0%) with mild asthma who met none. Of parents in the total sample, 95.6% reported a usual place for short-term asthma care for their child; 75.4% used the ED. Children with severe asthma were significantly more likely to use the ED than those with mild asthma (84.3% vs 63.0%; P<.01). A usual place for follow-up asthma care was reported by 96.7% of subjects. There were no differences in access or type of facility used by asthma severity. More than half the study group reported difficulty in accessing care for acute asthma attacks and for follow-up care with no differences by asthma severity. Among those with severe asthma, 47.5% used inhaled steroids or cromolyn, 52.8% used a spacer device if they had been prescribed a metered dose inhaler, and 21.2% of children older than 6 years were prescribed a peak flowmeter. Patients with mild asthma were significantly less likely to report use of all 3 items (steroids or cromolyn, 1.4%; spacer device, 15.4%; and peak flowmeter, 3.1%, respectively; P<.01).

CONCLUSION

Although access to asthma care among children in US inner cities appears adequate as determined by the traditional measure of reporting a regular source of care, barriers are frequently reported, as are deficiencies in the quality of medical care.

Psychosocial characteristics of inner-city children with asthma: a description of the NCICAS psychosocial protocol. National Cooperative Inner-City Asthma Study

Previous research has demonstrated a significant reciprocal relationship between psychosocial factors and asthma morbidity in children. The National Cooperative Inner-City Asthma Study investigated both asthma-specific and non-specific psychosocial variables, including asthma knowledge beliefs and management behavior, caregiver and child adjustment, life stress, and social support. This article presents these psychosocial characteristics in 1,528 4-9-year-old asthmatic urban children and their caretakers. Caretakers demonstrated considerable asthma knowledge, averaging 84% correct responses on the Asthma Information Quiz. However, respondents provided less than one helpful response for each hypothetical problem situation involving asthma care, and most respondents had more than one undesirable response, indicating a potentially dangerous or maladaptive action. Both adults and children reported multiple caretakers responsible for asthma management (adult report: average 3.4, including the child); in addition, children rated their responsibility for self-care significantly higher than did adults. Scores on the Child Behavior Checklist indicated increased problems compared to normative samples (57.3 vs. 50, respectively), and 35% of children met the criteria for problems of clinical severity. On the Brief Symptom Inventory, adults reported elevated levels of psychological distress (56.02 vs norm of 50); 50% of caretakers had symptoms of clinical severity. Caretakers also experienced an average of 8.13 undesirable life events in the 12 months preceding the baseline interview. These findings suggest that limited asthma problem-solving skills, multiple asthma managers, child and adult adjustment problems, and high levels of life stress are significant concerns for this group and may place the inner-city children in this study population at increased risk for problems related to adherence to asthma management regimens and for asthma morbidity.

Design and methods of the National Cooperative Inner-City Asthma Study

The National Cooperative Inner-City Asthma Study (NCICAS) was established to identify and then intervene on those factors which are related to asthma morbidity among children in the inner-city. This paper describes the design and methods of the broad-based initial Phase I epidemiologic investigation. Eight research centers enrolled 1,528 children, 4 to 9 years of age, from English- or Spanish-speaking families, all of whom resided in major metropolitan inner-city areas. The protocol included an eligibility assessment and an extensive baseline visit, during which symptom data, such as wheezing, lost sleep, changes in activities of daily living, inpatient admissions, and emergency department and clinic visits were collected. A comprehensive medical history for each child was taken and adherence to the medical regimen was assessed. Access, as well as barriers, to the medical system were addressed by a series of questions including the location, availability, and consistency of treatment for asthma attacks, follow-up care, and primary care. The psychological health of the caretaker and of the child was also measured. Asthma knowledge of the child and caretaker was determined. Sensitization to allergens was assessed by skin-prick allergen testing and exposure to cigarette smoke and the home environment were assessed by questionnaire. For more than a third of the families, in-home visits were conducted with dust sample allergen collection and documentation of the home environment, such as the presence of pets and evidence of smoking, mildew, and roaches. Urine specimens were collected to measure passive smoke exposure by cotinine assays, blood samples were drawn for banking, and children age 6 to 9 years were given spirometric lung function assessment. At 3, 6 and 9 months following the baseline assessment, telephone interviews were conducted to ask about the child's symptoms, unscheduled emergency department or clinic visits, and hospitalizations. At this time, peak flow measurements with 2-week diary symptom records were collected.

Characteristics of inner-city children with asthma: the National Cooperative Inner-City Asthma Study

Asthma morbidity has increased dramatically in the past decade, especially among poor and minority children in the inner cities. The National Cooperative Inner-City Asthma Study (NCICAS) is a multicenter study designed to determine factors that contribute to asthma morbidity in children in the inner cities. A total of 1,528 children with asthma, ages 4 to 9 years old, were enrolled in a broad-based epidemiologic investigation of factors which were thought to be related to asthma morbidity. Baseline assessment included morbidity, allergy evaluation, adherence and access to care, home visits, and pulmonary function. Interval assessments were conducted at 3, 6, and 9 months after the baseline evaluations. Over the one-year period, 83% of the children had no hospitalizations and 3.6% had two or more. The children averaged 3 to 3.5 days of wheeze for each of the four two-week recall periods. The pattern of skin test sensitivity differed from other populations in that positive reactions to cockroach were higher (35%) and positive reactions to house dust mite were lower (31%). Caretakers reported smoking in 39% of households of children with asthma, and cotinine/creatinine ratios exceeded 30 ng/mg in 48% of the sample. High exposure (> 40 ppb) to nitrogen dioxide was found in 24% of homes. Although the majority of children had insurance coverage, 53% of study participants found it difficult to get follow-up asthma care. The data demonstrate that symptoms are frequent but do not result in hospitalization in the majority of children. These data indicate a number of areas which are potential contributors to the asthma morbidity in this population, such as environmental factors, lack of access to care, and adherence to treatment. Interventions to reduce asthma morbidity are more likely to be successful if they address the many different asthma risks found in the inner cities.

Short-term compliance with peak flow monitoring: results from a study of inner city children with asthma

The objective of the study was to assess the feasibility of initiating daily peak flow monitoring in a research study of asthma in inner city children. We performed a descriptive study of patterns of peak flow monitoring in children randomized to receive a simple mini-Wright (SM) or an electronic recording meter (ERM). The ERM served as a "covert" meter, providing objective documentation of actual peak flow use. Sixty-five Hispanic or African-American children, ages 5-9 years, with a history of physician-diagnosed asthma participated in the study. All children resided in census tracts with 40% or more of the population living at or below the poverty level. Subjects were instructed to use a peak flow meter (the SM or ERM) at least twice daily over a 3 week period, and to record peak flow values in a paper diary. Subjects who received the ERM were not made aware that measurements were also recorded electronically. Differences in patterns of use of the SM and ERM were assessed with the Wilcoxon signed rank test and Wilcoxon sum rank test. Adherence to peak flow monitoring was evaluated by comparing the percent days with missing values in the manually completed diary with those obtained by computer record. The Friedman statistic was used to compare changes in compliance (percent of days with missing peak flow entries) over time. Accuracy of peak flow readings was assessed by comparing the manual and electronic recordings with paired and unpaired t-tests and with Pearson product moment correlations. The percent of days with missing peak flow entries on diaries increased from 1.4% to 10.6% from the first to third week of monitoring (P < 0.004). The ERMs indicated a significantly greater percent of missing data than did the manual records (P < 0.0002). The difference in the percent of missing data for the electronic and manual records was most notable during the third study week, when the ERM and the manually completed records indicated that 52% and 15% of days, respectively, were without peak flow measures. Large inter-subject variations in the relationship between manually and electronically recorded peak flow measurements were observed, suggesting that errors in reading and transcribing peak flow rates occur in a subset of asthmatics. We conclude that children and caretakers in the inner city may have considerable difficulty initiating and maintaining peak flow recordings. Data obtained by manual records may considerably overestimate actual use. Compliance with monitoring decreases markedly between the first and third week of monitoring.

Developmental sequelae of long-term infant tracheostomy

The records of 130 children who had had a tracheostomy for more than one month between 1972 and 1982 were reviewed for birth, medical and demographic characteristics, and 32 who were not severely physically or mentally handicapped were followed up at a mean age of 5.5 years. Rates of mortality and morbidity were high, and half of the survivors had moderate to severe intellectual and physical impairments. Even those with the most optimal outcome had significant developmental problems, including slower growth-rate and higher than normal incidences of behavior problems and speech difficulties. Most survivors needed special educational intervention or rehabilitative therapies.

Safety and efficacy of flexible endoscopy in children with bronchopulmonary dysplasia

Because concern has been raised about the efficacy and safety of flexible fiberoptic bronchoscopy (FFB) in pediatric patients with chronic cardiopulmonary disorders, we reviewed the results of 129 flexible endoscopies performed on 47 children with a history of bronchopulmonary dysplasia (BPD) at our institution over a 44-month period. Indications for FFB; weight and age of the patient; and procedure format, including medication usage, findings, specimen results, and complications, were analyzed. Evaluation of previously diagnosed subglottic stenosis and airway abnormalities were the two most common indications (33% and 32%, respectively). Persistent or recurrent infiltrates or atelectasis, need for cultures, stridor, failure to extubate, hoarseness, and persistent wheeze were also cited. Endoscopic diagnoses included adenoidal hypertrophy, laryngomalacia, vocal cord abnormalities, interarytenoid membrane, subglottic stenosis, granulomas, tracheobronchomalacia, stenosis, obstruction, generalized inflammation/edema, polyps, tracheal bronchi, and anomalous bronchial anatomy. Cytomegalovirus, pneumococcus, nontypeable Haemophilus influenzae, Pseudomonas, or mixed gram-negative flora were isolated from some patients without tracheostomy. Minor complications (transient bradycardia, mild nasopharyngeal bleeding, and mild worsening of upper airway obstruction) occurred in 3.1% of procedures, but no severe complications occurred. Management was directly affected by procedure results in 41% of procedures. We concluded that the FFB can be a safe, useful procedure in the management of children with BPD.