Asthma is one of the most common chronic illnesses encountered by the primary care pedimatrician. Despite major therapeutic advances over the past 10 years, pediatrie asthma morbidity and mortality have not changed. Most authorities believe that we currently have the means to improve pediatrie asthma care. In this issue of Pediatrie Annais, accepted pediatrie asthma therapy is reviewed to update the practicing pediatrician.
For school age children in the United States, asthma prevalence rates are highest (up to 12%) for males, blacks, and hispanice under 12 years of age.1 By late adolescence, this sex difference disappears and prevalence decreases to less than 8%. Most children with asthma develop signs and symptoms before school age: 30% by 1 year of age, 50% by 2 years of age, and 80% by 5 years of age.2
Asthma, often called reactive airway or hyperreactive airway disease, can best be described as a heterogeneous pulmonary disorder characterized by variations in central and/or peripheral airway obstruction over short periods of time, with a decrease in the degree of airway obstruction demonstrated clinically and physiologically as a direct response to bronchodilator drugs. Important causal factors of pediatrie airway hyperreactivity include: viral infections (especially RSV bronchiolitis), various physical and chemical stimuli, specific antigen-antibody reactions (usually inhaled antigens), exercise, non-specific hereditary influences, psychoemotional factors, and various medications (eg, aspirin, beta biockers). The eliciting stimuli, degree of bronchospasm, distribution of airway obstruction, contribution of airway edema and inflammation, abnormalities of glandular secretions and mucociliary clearance, abnormalities of epithelium, pathogenic roles of chemical mediators, imbalances in pulmonary neurologic influences and endocrine functions, and numerous other factors in the maintenance of airway hyperreactivity are different for each patient and differ from one point in time to the next; a discussion of which is beyond the scope of this review. 3
In addition to the child who is wheezing and has other symptoms of classic asthma, children with cough variant asthma and "silent asthma" must also be recognized as having reactive airway disease and need appropriate therapy when indicated.4 Children with other diseases and medical problems such as cystic fibrosis, bronchopulmonary dysplasia, congenital heart disease, IgA deficiency, gastroesophageal reflux with pulmonary aspiration, status post TE fistua repair, and others may have a component of hyperreactive airway disease which requires recognition and appropriate therapy for optimal management. Up to 25% of known asthmatics cannot take aspirin and related chemicals and 10% react to the preservative metabisulfite, a common food preservative.
The goals of asthma therapy listed in this article should be applied to each patient with asthma, reviewed on a regular basis with patient and family, and therapy modified to meet these goals (Table). Despite advances over the past decade in our understanding of the etiology, pathophysiology, and therapy of pediatrie asthma, morbidity (hospital admissions, acute care visits, school absenteeism, parent work days lost, medical and related costs of care, and psychosocial strain) and mortality have not been reduced and many of these goals are not being achieved in today's practice.5,6 The primary care pediatrician can meet this challenge by employing current diagnostic and therapeutic modalities combined with a patient/family education self-management program.
A consistent primary care provider for the asthmatic child and family is essential for optimal care. In a recent survey, the prevalence of asthma among firstgraders in the Baltimore, Maryland public schools was found to be 10.6%. 7 The rates for blacks (12.0%) and for whites (7.9%) when adjusted for sex and socioeconomic status were statistically different (p<0.5). Asthmatic first-grade children were more likely to obtain medical care for their asthma in the emergency room (52%) than in a pediatrie clinic (24%), private physician's office (19%), or allergist's office (5%). Twice as many blacks as whites used the emergency room as their primary source of care. When compared with those going to a private physician, children going to the emergency room or a clinic where they saw a different doctor each visit had a greater number of days missed from school and a higher hospitalization rate and total number of hospitalization days. These observations support the concept that children who do not have access to a single primary care provider experience increased asthma morbidity and higher medical costs.
In the United States in 1982, reactive airway diseases resulted in 388,000 hospitalizations for children under 15 years of age, with an average length of stay of 3.9 days. If we assume a per them cost of hospitalization of $350, this adds up to an annual expenditure of approximately $530 million for hospital room charges alone. In addition, there were 10,677,000 outpatient physician visits for pediatrie asthma; at a charge of $20 per visit, this would add another $213 million, bringing costs to $743 million. After considering medications, emergency room visits, and diagnostic testing, 1982 pediatrie asthma costs were no doubt well over $1 billion.1 In a 3-year study of 25 families' children afflicted by chronic asthma, Marion et al reported asthma related expenditures (not covered by insurance) of 6-4% of total family income.8 With the current concerns over reimbursement and medical cost containment, we must decrease pediatrie asthma care costs without compromising the quality of care.
For more than 10 years, studies have shown that physician education on up-to-date asthma care and properly organized education/self-management programs can reduce pediatrie asthma morbidity, costs, and mortality and improve patient/family compliance and quality of care.9'11 At the Children's Hospital of Pittsburgh, 10% of all asthma admissions in 1970 were related to improper actions taken by the patient, his family, or health care professionals.9 The authors felt that many of these hospitalizations might have been prevented if the patient contacted a physician earlier, if appropriate therapy had been started sooner by the patient, family, or physician, and if currently accepted therapy was used by the health professionals. Compliance with therapeutic programs for most chronic diseases is quite low; up to 50% of patients in several studies failed to comply with physician recommendations and orders.12 The therapeutic regimens prescribed for asthma are often complex, require treatment with several medications for prolonged periods of time as well as patient and parental initiation of additional drug therapy, and mandate close communication between physician and patient/family. Appropriate compliance is also necessary to achieve environmental control and reduce exposure to those stimuli that provoke symptoms (eg, parental smoking, pets, humidity and dust control).
How to best improve compliance and provide education for the asthmatic patient and family has been a major concern for health professionals interested in health education. Fireman and co-workers were able to: 1) improve compliance, 2) reduce frequency and severity of asthma, 3) reduce emergency room visits and hospitalizations (and thereby reduce medical costs), 4) reduce school absenteeism, 5) develop positive family self-help attitudes, and 6) incorporate patient-parent education in a private office or clinic setting using a nurse educator working with middleclass families.13 Pediatrie asthma education/self- management programs have recently been reviewed.10 In 1963, there were 506 beds at 14 facilities for inpatient management and education of asthmatic children. Today, there are only a few such facilities with a limited number of beds for only the most severe asthmatics. In 1981, there were 51 community-sponsored asthma summer camp programs in the United States (providing asthma education, self-management skills, and regular camp activities) with a limited number of openings for children. Many communities have organized ongoing education/support groups through their local American Lung Association, Asthma and Allergy Foundation of America, medical care facilities and teaching hospitals, and local interest groups. Participation in such programs is extremely variable over time; the programs are often inadequate and depend on leaders and members. Three self-management/education programs are currently available to the pediatrician: 1) "Superstuff ' through the American Lung Association, 2) "WOW" (Winning Over Wheezing) through Rohr Pharmaceuticals, and 3) "ACT" (Asthma Care Training) through the Allergy and Asthma Foundation of America. Most ambulatory care facilities or private offices do not have the luxury of an educator to administer such programs. If physicians have the interest and time, and practice routines and finances allow it, they can perform most of these services with the proper training, experience, and materials. Currently the American Lung Association with the help of the NIH and private pharmaceutical grants are exploring the development of regional programs for the future. The ideal program combines education with self-management and decision- making skills for both patient and family in a support group format.
Asthma care is changing so rapidly that the practicing pediatrician may find it difficult to keep up with current therapeutic recommendations. Many pediatricians are unfamiliar with the use of sodium cromolyn and beta-2 agonists which have replaced theophylline as first line drugs for most asthmatics. Far too much epinephrine is still used in outpatient settings to treat status asthmaticus. The emphasis in many pediatrie training programs is on acute asthma care with minimal instruction in outpatient care including education and self-management skills. Pulmonary function testing is essential to proper asthma care; unlike our colleagues in internal medicine, most pediatricians have had little exposure to clinical pediatrie pulmonary function testing.
Childhood asthma is one of the leading causes of school absenteeism. Parents are often afraid to let the child who is wheezing and/or coughing leave the house, and many school nurses and gym teachers do not want to be responsible for having such a child in the classroom or gym class. As a result, asthmatic children may fall behind academically and their sense of isolation increases. Adolescents pose a special problem. Peer pressure and fear of social rejection force many to smoke and stop taking medications. Proper medical management should allow the patient to exercise, participate in sports, and enjoy a relatively normal lifestyle. It is the responsibility of the pediatrician to educate school nurses and gym teachers as well as patients and parents to allow current therapy to be employed at school and to encourage exercise on a regular basis.
While the majority of children with asthma will improve as they get older, prospective studies have shown that the optimistic view that "most children outgrow their asthma" is not true.2'14,15 Children who have "mild" asthma in early childhood have better than a 50% chance to go into long-term remission between 14 and 21 years of age; the likelihood that they will become worse is less than 5% while the remaining children (45%) will continue to have problems into early adulthood. When asthma is "severe" at 14 years of age, the chances of long-term remission are less than 5%. Half of these adolescents will improve but remain active asthmatics into adulthood while the remainder continue to have severe asthma. The prognosis into later adulthood is not presently known. Aggressive therapy in early childhood, reducing the frequency and severity of asthma, has the most favorable influence on long-term prognosis and improving the chances of "outgrowing" asthma.
The articles in this issue of Pediatrie Armais are intended to update the pediatrician, thereby improving asthma care, reducing morbidity and mortality, and improving long-term prognosis for the more than 3 million US school-age children with hyperreactive airway disease.
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