Pediatric Annals

EDITORIAL 

A Pediatrician's View: The General Pediatrician's Role in Managing Asthma and Allergies

Robert A Hoekelman, MD

Abstract

This issue of Pediatrie Annals addresses asthma and allergies in pediatrie practice. Our Guest Editor; Jacob Hen, MD, Associate Clinical Professor of Pediatrics at Yale University School of Medicine, has gathered a distinguished group of authors to provide guidelines for practitioners in the care of their patients who suffer from allergic diseases, particularly asthma.

The main focus is appropriately on asthma because it is the most prevalent chronic disease of childhood.1 The prevalence rate of asthma in 1988 for persons in the United States under the age of 18 was 6.3%. 2 National prevalence rates in 1988 of hay fever and of eczema and skin allergies were 6.8% and 7.6%, respectively, but these allergic diseases are less severe than asthma and are much less likely to last as long. Most disturbing is that the prevalence rate for asthma has been on the rise since 1980.3This is reflected in 1) the rising rates of hospitalization for asthma among persons under 18 years of age - from 1.73 per 1000 in 1979 to 2.57 per 1000 in 1987 (an average annual increase of 4.5%)4 and 2) the rising asthma mortality rates for persons 5 to 34 years of age - from 1.6 per million in 1977 to 4.2 per million in 1987.5 The annual rate of increase in mortality between 1 979 and 1987 was much higher for 5 to 14 year olds (10.1%) than for 15 to 34 year olds (6.3%). There has been considerable conjecture regarding the reasons for these disturbing figures including4'7:

* improved diagnostic techniques that better differentiate patients with asthma from those who have other lower respiratory tract diseases,

* adverse effects of newer medications used to treat asthma,

* increases in air pollution (80.2% of deaths from asthma between 1979 and 1987 occurred in urban areas),

* decreased health-care access, availability, and use for many, especially the poor, and

* living in poverty-related, crowded homes.

And I would add three other reasons to this list:

* the increase in the allergic-prone population through inheritance of atopy from parents who survive their own allergic diseases to pass them on to their offspring,

* the increase in our country's acreage of cultivated soil, which enables ragweed to grow in greater amounts and to sensitize more persons, raising their susceptibility to developing asthma, and

* the creation of house-mite heavens in most of our newly built homes with wall-to-wall carpeting and hot air heating and air conditioning systems, which blow dust and molds about in all seasons and dry out patients' nasal, oral, and bronchial mucous membranes in winter months, making them more susceptible to irritation, infection, allergic rhinitis, and asthma.

Some have suggested that race is a factor in increasing prevalence rates for asthma because the prevalence among black children is considerably higher than among white children,8 as are the hospitalization rates4 and the mortality rates,5 but Weitzman et al' attribute these higher rates to social and environmental differences between black and white children in the United States rather than to race.

The role of the general pediatrician in the care of children with asthma is extensive, given these prevalence figures and the short fall in the number of pediatrie allergists practicing in the United States. While this number is not exactly known, only 1613 pediatricians were certified by the American Board of Allergy and Immunology between 1974, when it first began its certification process, and 1989 (Unpublished data. American Board of Allergy and Immunology. September 1991); approximately 75 pediatricians complete allergy/immunology fellowship training each year, barely enough to replace those who retire or die.9 Therefore, the prospect…

This issue of Pediatrie Annals addresses asthma and allergies in pediatrie practice. Our Guest Editor; Jacob Hen, MD, Associate Clinical Professor of Pediatrics at Yale University School of Medicine, has gathered a distinguished group of authors to provide guidelines for practitioners in the care of their patients who suffer from allergic diseases, particularly asthma.

The main focus is appropriately on asthma because it is the most prevalent chronic disease of childhood.1 The prevalence rate of asthma in 1988 for persons in the United States under the age of 18 was 6.3%. 2 National prevalence rates in 1988 of hay fever and of eczema and skin allergies were 6.8% and 7.6%, respectively, but these allergic diseases are less severe than asthma and are much less likely to last as long. Most disturbing is that the prevalence rate for asthma has been on the rise since 1980.3This is reflected in 1) the rising rates of hospitalization for asthma among persons under 18 years of age - from 1.73 per 1000 in 1979 to 2.57 per 1000 in 1987 (an average annual increase of 4.5%)4 and 2) the rising asthma mortality rates for persons 5 to 34 years of age - from 1.6 per million in 1977 to 4.2 per million in 1987.5 The annual rate of increase in mortality between 1 979 and 1987 was much higher for 5 to 14 year olds (10.1%) than for 15 to 34 year olds (6.3%). There has been considerable conjecture regarding the reasons for these disturbing figures including4'7:

* improved diagnostic techniques that better differentiate patients with asthma from those who have other lower respiratory tract diseases,

* adverse effects of newer medications used to treat asthma,

* increases in air pollution (80.2% of deaths from asthma between 1979 and 1987 occurred in urban areas),

* decreased health-care access, availability, and use for many, especially the poor, and

* living in poverty-related, crowded homes.

And I would add three other reasons to this list:

* the increase in the allergic-prone population through inheritance of atopy from parents who survive their own allergic diseases to pass them on to their offspring,

* the increase in our country's acreage of cultivated soil, which enables ragweed to grow in greater amounts and to sensitize more persons, raising their susceptibility to developing asthma, and

* the creation of house-mite heavens in most of our newly built homes with wall-to-wall carpeting and hot air heating and air conditioning systems, which blow dust and molds about in all seasons and dry out patients' nasal, oral, and bronchial mucous membranes in winter months, making them more susceptible to irritation, infection, allergic rhinitis, and asthma.

Some have suggested that race is a factor in increasing prevalence rates for asthma because the prevalence among black children is considerably higher than among white children,8 as are the hospitalization rates4 and the mortality rates,5 but Weitzman et al' attribute these higher rates to social and environmental differences between black and white children in the United States rather than to race.

The role of the general pediatrician in the care of children with asthma is extensive, given these prevalence figures and the short fall in the number of pediatrie allergists practicing in the United States. While this number is not exactly known, only 1613 pediatricians were certified by the American Board of Allergy and Immunology between 1974, when it first began its certification process, and 1989 (Unpublished data. American Board of Allergy and Immunology. September 1991); approximately 75 pediatricians complete allergy/immunology fellowship training each year, barely enough to replace those who retire or die.9 Therefore, the prospect for increasing the number of trained pediatrie allergists is not bright, and most of the care of children with asthma and other allergic diseases will continue to be provided by general pediatricians.

It is important, then, that pediatrie residency program directors ensure that their trainees are adequately prepared to meet this need. Pediatrìe house officers, wherever they may train, most certainly receive heavy exposure to children with asthma and other allergic diseases, given the frequency with which affected patients make visits to ambulatory clinics and emergency departments and are admitted to inpatìent hospital wards and critical care units. However, such exposures are usually cross-sectional rather than longitudinal. Thus, the natural history of allergic diseases in children is not likely to be observed and understood unless some of these children are included in the house officer's continuity clinic panel of patients or unless the house officer is exposed to them during an allergy/immunology or a primary care practice elective. Unfortunately, these longitudinal experiences do not occur often enough, and most practicing pediatricians learn most of what they need to know in managing asthmatic patients after they enter practice.

Eighteen years ago, I wrote an article explaining my views on the general pediatrician's role in managing allergic patients.10 In it, I said that general pediatricians could manage most of their allergic patients, except for certain limitations that included referral to a pediatrie allergist for the following:

1. The infant with severe eczema or asthma who does not respond to dietary restrictions, topical agents, environmental controls, or symptomatic medications (this baby may require allergic immunotherapy injections, as determined by passive transfer tests, or systemic steroid therapy).

2. The child who cannot tolerate a reasonable progression of allergen immunotherapy injections.

3. The child who does not respond to the usual modalities of treatment, including allergen immunotherapy injections.

4. "Hie child for whom long-term steroid therapy is contemplated.

5. The child for whom residential treatment therapy is contemplated.

6. The child with an allergic emergency (status asthmaticus or anaphylaxis).

7. The child with an obscure diagnosis suspected of having an allergic origin.

8. The child whose parents are suspected of being dissatisfied with the treatment rendered or request a consultation.

How do I feel about the statement today? Not too differently,11 mainly because allergic diseases continue to be so prevalent in pediatrie practice and because there are too few pediatrie allergists available to manage all allergic children. In some areas of the country, they are virtually unavailable. I would agree with my pediatrìe allergist colleague, Bob Schwanz, that if general pediatricians have the interest and time and their practice routine and finances allow, they can perform most diagnostic and therapeutic services for their own patients, provided they seek extra training either through continuing medical education courses or miniresidencies.12 Recently, the National Heart, Lung, and Blood Institute's National Asthma Education Program Expert Panel issued a report3 that provided the following guidelines for referral of asthma patients by general practitioners to an allergist or pulmonologist:

* when the patient has a had a life-threatening acute asthma exacerbation, has poor self-management ability, or has difficult family dynamics,

* when signs and symptoms are atypical or there are problems in differential diagnosis (eg, chronic bronchitis versus asthma in adults, chronic cough in children, cystic fibrosis, or bronchopulmonary dysplasia in a child who has a clinically important reactive airway disease component),

* when clinical entities complicate airway disease (eg, sinusitis, nasal polyps, aspergillosis, and severe rhinitis),

* when additional diagnostic testing is indicated (eg, skin testing, rhinoscopy, bronchoscopy, complete pulmonary function studies, and/or provocative challenge),

* when the patient is not responding optimally to the asthma therapy, and

* when the patient requires guidance on environmental control, consideration of immunotherapy, smoking cessation, complications of therapy, or difficult compliance issues.

In general, I agree with these guidelines, except for pediatricians who are far distanced from pediatrìe allergists and those who are adept at skin testing, prescribing and implementing immunotherapy, obtaining and interpreting pulmonary function studies, and dealing with complications of therapy. Furthermore, the general pediatrician, if interested and invested in the care of asthma patients, is in the best position to guide environmental controls and smoking cessation in the home and to deal with issues of noncompliance.

REFERENCES

1. Newacheck PW, Budetti PP, Halfon N. Trends in activity-limiting chronic conditions among children. Am J Public Health. 1986:76:178-184.

2. Child Health Supplement 1988: National Health Interview Survey 1988. Hyatrsville, Md: National Center for Health Statistics; 1990.

3. NHLBI National Asthma Education Program Expert Panel Report, Pediatric Asthma Allergy and Immunology 1991;5:57;63.

4. Gergen PJ, Weiss KB. Changing patterns of asthma hospitaliiation among children: 1979 to 1987. JAMA. 1990; 264: 1688- 1692.

5. Weiss KB, Wagener DK. Changing patterns of asthma mortality: identifying target populations at risk. JAMA. 1990;264:1683-1687

6. Buist AS, Vollmer WM. Reflections on the rise in asthma morbidity and mortality JAMA. 1990;264:1719-1720.

7. Weitzman M, Gortmaker S, Sobol A. Racial, social, and environmental risks for childhood asthma. Am J Dis Child. 1990;144:1189-1194.

8. Gergen PJ. Mullally DI, Evans R III. National survey of the prevalence of asthma among children in the United States. 1876 to 1980. Pediatrics. 1988;81:1-7.

9. Anderson JA. The most important issue racing the specially of allergy and immunology today. J Allergy Clin Immunol. 1 991 ;88: 17-26.

10. Hoekelman RA. Allergy in childhood: a pediatrician's viewpoint, Pediatric Clin North Am. 1974;21:5-21.

11. Hoekelman RA. A department chairman's view of alletgy in childhood. Pediatric Asthma Allergy and Immunologj. 1991;5:287.

12. Schwartz RH. Children with chronic asthma: care by the generalise and the specialist. Pediatr Clin North Am. 1984;3 1:87-105.

10.3928/0090-4481-19920901-04

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