Asthma and obesity are public health problems that disproportionately affect underserved children. Urban children with asthma may be limited in their participation in physical activity, further ...increasing their risk for overweight.
To determine the prevalence of overweight and obesity among high-risk children with persistent asthma, to assess physical activity and activity restrictions by level of asthma control, and to evaluate whether activity is associated with weight status.
We analyzed baseline data from 324 urban children with poorly controlled asthma (3-10 years old) enrolled in the School-Based Telemedicine Enhanced Asthma Management program in Rochester, New York. Caregivers reported their child's asthma symptoms, physical activity, and activity limitation, and height and weight were measured.
Most children were black (59%), and 69% had Medicaid. Almost half (47%) of children had symptoms that indicated poorly controlled asthma, 15% were overweight, and 31% were obese. Few children (39%) participated in 1 or more hour of physical activity per day. In addition, most (85%) did not walk to and from school, 38% did not have any recess in school, and 35% reported no safe place to exercise. More children with very poorly controlled asthma symptoms, compared with children with more mild symptoms, reported limitation in gym class (58% vs 43%, P = .01) and even in mild activities (28% vs 14%, P = .004). Children with activity limitation were at significantly greater odds of being overweight or obese (odds ratio, 2.1; 95% confidence interval, 1.2-3.8).
Many children with persistent asthma are overweight or obese, have limited opportunity for activity, and experience activity limitations. Efforts are needed to optimize asthma control and provide opportunity for increased physical activity in and outside school.
ClinicalTrials.gov Identifier: NCT01650844.
To determine caregiver ability to name their child's inhaled asthma medications, and examine whether perceived ease of remembering names is associated with accurate naming and asthma outcomes.
As ...part of the School-Based Telemedicine-Enhanced Asthma Management trial in Rochester, New York, we asked caregivers of children with persistent asthma to: 1) name their child's inhaled medications, and 2) indicate agreement with the statement, "it is easy to remember the names of my child's asthma medications." We limited analyses to subjects with 1 inhaled medication. Reported names were compared with canisters available during a home visit; complete matches were considered concordant. We compared ease of remembering names with concordance, asthma symptoms, and adherence using bivariate and multivariate analyses.
Overall, 141 caregivers (87%) had children with 1 inhaled medication (62% black race, 68% Medicaid). Most (74%) perceived it easy to remember medication names, yet only 46% reported names concordant with medications at home. Caregivers who did not easily remember medication names were less likely to concordantly name available medications (23% vs 54%; P = .002), and more likely to report that their child experienced >2 symptom days per week (33% vs 16%; P = .03), >2 symptom nights per month (31% vs 12%; P = .02), and missed >1 dose(s) of preventive medication in the previous 2 weeks (52% vs 28%; P = .03). Findings were consistent in multivariate regression analyses.
Caregivers of urban children with persistent asthma who considered medication names difficult to remember were less able to accurately name available medications, and reported worse control and medication adherence. Greater attention to medication identification might improve outcomes in this population.
Objective To test the feasibility and preliminary effectiveness of the School-Based Preventive Asthma Care Technology (SB-PACT) program, which includes directly observed therapy of preventive asthma ...medications in school facilitated by Web-based technology for systematic symptom screening, electronic report generation, and medication authorization from providers. Study design We conducted a pilot randomized trial of SB-PACT versus usual care with 100 children (aged 3-10 years) from 19 inner-city schools in Rochester, New York. Outcomes were assessed longitudinally by blinded interviewers. Analyses included bivariate statistics and linear regression models, adjusting for baseline symptoms. Results There were data for 99 subjects for analysis. We screened all children using the Web-based system, and 44 of 49 treatment group children received directly observed therapy as authorized by their providers. Treatment group children received preventive medications 98% of the time they were in school. Over the school year, children in the treatment group experienced nearly 1 additional symptom-free day over 2 weeks versus the usual care group (11.33 vs 10.40, P = .13). Treatment children also experienced fewer nights with symptoms (1.68 vs 2.20, P = .02), days requiring rescue medications (1.66 vs 2.44, P = .01), and days absent from school due to asthma (0.37 vs 0.85, P = .03) compared with usual care. Further, treatment children had a greater decrease in exhaled nitric oxide (−9.62 vs −0.39, P = .03), suggesting reduction in airway inflammation. Conclusion The SB-PACT intervention demonstrated feasibility and improved outcomes across multiple measures in this pilot study. Future work will focus on further integration of preventive care delivery across community and primary care systems.
In the spirit of Dr. Haggerty's teachings, we present an overview of our work to improve care for children with asthma in the context of 3 lessons learned: 1) the importance of providing integrated ...services across disciplinary boundaries for children with chronic illness, 2) the need to move from a care model focused only on the individual child to a model focused on the child, family, and community, and 3) the need to expand beyond the local community and take a broad perspective on improving health on a national level. The goal of our program is to develop sustainable models to overcome the multiple obstacles to effective preventive care for urban children with asthma. The primary intervention for our original School-Based Asthma Therapy program was directly observed administration of preventive asthma medications in school (with dose adjustments on the basis of National Heart, Lung, and Blood Institute guidelines). We found that children who received preventive medications in school through directly observed therapy had improved outcomes across multiple outcome measures. Our subsequent asthma programs have focused on dissemination and sustainability, with the incorporation of communication technology to enhance the system of care. We are currently testing the 'School-Based Telemedicine Enhanced Asthma Management' program, including 400 children with persistent asthma from the Rochester City School District. This program includes directly observed administration of preventive asthma medication at school, and school-based telemedicine to assure appropriate evaluation, preventive medication prescription, and follow-up care. It is designed to implement and sustain guideline-based asthma care through existing community infrastructure, and could serve as a model for the integration of services in rural as well as urban communities.
To describe which National Heart Lung and Blood Institute preventive actions are taken for children with persistent asthma symptoms at the time of a primary care visit and determine how care delivery ...varies by asthma symptom severity.
We approached children (2 to 12 years old) with asthma from Rochester, NY, in the waiting room at their doctor's office. Eligibility required current persistent symptoms. Caregivers were interviewed via telephone within 2 weeks after the visit regarding specific preventive care actions delivered. Bivariate and regression analyses assessed the relationship between asthma symptom severity and actions taken during the visit.
We identified 171 children with persistent asthma symptoms (34% black, 64% Medicaid) from October 2009 to January 2011 at 6 pediatric offices. Overall delivery of guideline-based preventive actions during visits was low. Children with mild persistent symptoms were least likely to receive preventive care. Regression analyses controlling for demographics and visit type (acute or follow-up asthma visit vs non-asthma-related visit) confirmed that children with mild persistent asthma symptoms were less likely than those with more severe asthma symptoms to receive preventive medication action (odds ratio OR 0.34, 95% confidence interval CI 0.14-0.84), trigger reduction discussion (OR 0.39, 95% CI 0.19-0.82), recommendation of follow-up (OR 0.40, 95% CI 0.19-0.87), and receipt of action plan (OR 0.37, 95% CI 0.16-0.86).
Many children with persistent asthma symptoms do not receive recommended preventive actions during office visits, and children with mild persistent symptoms are the least likely to receive care. Efforts to improve guideline-based asthma care are needed, and children with mild persistent asthma symptoms warrant further consideration.
The aim of this study was to describe nocturnal asthma symptoms among urban children with asthma and assess the burden of sleep difficulties between children with varying levels of nocturnal ...symptoms.
We analyzed baseline data from 287 urban children with persistent asthma (aged 4-10 years) enrolled in the School-Based Asthma Therapy trial; Rochester, New York. Caregivers reported on nocturnal asthma symptoms (number of nights/2 weeks with wheezing or coughing), parent quality of life (Juniper's Pediatric Asthma Caregivers Quality of Life Questionnaire), and sleep quality by using the validated Children's Sleep Habits Questionnaire. We used bivariate and multivariate statistics to compare nocturnal asthma symptoms with sleep quality/quantity and quality of life.
Most children (mean age, 7.5 years) were black (62%); 74% had Medicaid. Forty-one percent of children had intermittent nocturnal asthma symptoms, 23% mild persistent, and 36% moderate to severe. Children's average total sleep quality score was 51 (range, 33-99) which is above the clinically significant cutoff of 41, indicating pervasive sleep disturbances among this population. Sleep scores were worse for children with more nocturnal asthma symptoms compared with those with milder symptoms on total score, as well as several subscales, including night wakings, parasomnias, and sleep disordered breathing (all P < .03). Parents of children with more nocturnal asthma symptoms reported their child having fewer nights with enough sleep in the past week (P = .018) and worse parent quality of life (P < .001).
Nocturnal asthma symptoms are prevalent in this population and are associated with poor sleep quality and worse parent quality of life. These findings have potential implications for understanding the disease burden of pediatric asthma.
Premature infants are at high risk for respiratory disease, and secondhand smoke (SHS) exposure further increases their risk for developing respiratory illness and asthma. Yet, SHS exposure remains ...problematic in this vulnerable population. Our objective was to evaluate the effects of brief asthma education plus motivational interviewing counseling on reducing SHS exposure and improving respiratory outcomes in premature infants compared to asthma education alone.
Caregivers and their infants ≤32 weeks' gestational age were enrolled after discharge from a neonatal intensive care unit in Rochester, New York, from 2007 to 2011. Participants (N = 165, 61% Medicaid insurance, 35% Black, 19% Hispanic, 59% male) were stratified by infant SHS exposure and randomly assigned to treatment or comparison groups.
Caregivers in the treatment group reported significantly more home smoking bans (96% vs 84%, P = .03) and reduced infant contact with smokers after the intervention (40% vs 58%, P = .03), but these differences did not persist long term. At study end (8 months after neonatal intensive care unit discharge), treatment group infants showed significantly greater reduction in salivary cotinine versus comparison (-1.32 ng/mL vs -1.08 ng/mL, P = .04), but no significant differences in other clinical outcomes.
A community-based intervention incorporating motivational interviewing and asthma education may be helpful in reducing SHS exposure of premature infants in the short term. Further efforts are needed to support sustained protections for this high-risk group and ultimately, prevent acute and chronic respiratory morbidity. Strategies for successfully engaging families during this stressful period warrant attention.
It is unclear how often adolescents with persistent asthma know when to use different inhaled medications (as-needed rescue vs. daily controller; ‘accurate use’), or whether this knowledge is ...associated with clinical asthma outcomes. This study aimed to characterize adolescent knowledge of accurate use; examine whether accurate use is associated with controller medication adherence, asthma symptoms, or exacerbations requiring acute health care services; and determine whether knowledge of accurate use improves following regular exposure to controller medications with school-based directly observed therapy (DOT).
We analyzed baseline and 7-month data from the School-Based Asthma Care for Teens trial. Adolescents (12–16 years) identified inhaled medications on a chart and stated when each is used. We compared accurate use with adolescent-reported adherence, recent symptoms, and asthma-related acute health care visits; and exposure to DOT. Analyses were limited to subjects with controller medication.
Of 430 participants, 252 had controller medication at baseline. Knowledge of accurate use was described by 62%, and associated with adherence (odds ratio OR: 2.06, 95% confidence interval CI: 1.12–3.83). By 7 months, 313 adolescents had controller medication; 75% described accurate use, which was associated with adherence (OR: 3.46, 95% CI: 1.83–6.54), health care (OR: 0.39, 95% CI: 0.20–0.79), and DOT exposure (OR: 1.83, 95% CI: 1.10–3.32). Associations with adherence and health care at 7 months persisted in adjusted analyses.
Adolescent knowledge of accurate medication use was linked with greater adherence (baseline, 7 months), less acute health care (7 months), and exposure to in-school DOT. Interventions to support adolescents with persistent asthma should consider school-based care strategies and facilitate adolescent understanding of when to use different medications.
To test the effectiveness of a telemedicine-based program in reducing asthma morbidity among children who present to the emergency department (ED) for asthma, by facilitating primary care follow-up ...and promoting delivery of guideline-based care.
We included children (3-12 years of age) with persistent asthma who presented to the ED for asthma, who were then randomly assigned to Telemedicine Enhanced Asthma Management through the Emergency Department (TEAM-ED) or enhanced usual care. TEAM-ED included (1) school-based telemedicine follow-ups, completed by a primary care provider, (2) point-of-care prompting to promote guideline-based care, and 3) an opportunity for 2 additional telemedicine follow-ups. The primary outcome was the mean number of symptom-free days (SFDs) over 2 weeks at 3, 6, 9, and 12 months.
We included 373 children from 2016 through 2021 (participation rate 68%; 54% Black, 32% Hispanic, 77% public insurance; mean age, 6.4 years). Demographic characteristics and asthma severity were similar between groups at baseline. Most (91%) TEAM-ED children had ≥1 telemedicine visit and 41% completed 3 visits. At 3 months, caregivers of children in TEAM-ED reported more follow-up visits (66% vs 48%; aOR, 2.07; 95% CI, 1.28-3.33), preventive asthma medication actions (90% vs 79%; aOR, 3.28; 95% CI, 1.56-6.89), and use of a preventive medication (82% vs 69%; aOR, 2.716; 95% CI, 1.45-5.08), compared with enhanced usual care. There was no difference between groups in medication adherence or asthma morbidity. When only prepandemic data were included, there was greater improvement in SFDs over time for children in TEAM-ED vs enhanced usual care.
TEAM-ED significantly improved follow-up and preventive care after an ED visit for asthma. We also saw improved SFDs with prepandemic data. The lack of overall improvement in morbidity and adherence indicates the need for additional ongoing management support.
NCT02752165.
School based asthma programs have demonstrated that preventive asthma therapy administered in school reduces asthma morbidity. The burden of co-morbid allergic disease on asthma outcomes in a large ...school based asthma cohort has been unexplored.
Evaluate the prevalence of allergic rhinitis (AR) in historically minoritized school children with persistent asthma, and determine if AR is an independent risk factor for asthma morbidity.
We evaluated the prevalence of AR in children enrolled in 3 NIH funded school based asthma programs in Rochester, NY. We used linear regression and multivariate analyses to compare asthma outcomes for children whose caregivers did and did not report AR.
We used data from 1,029 children with asthma (mean age 7.4, 60.4% Black, 29.5% Hispanic, 72.8% insured with Medicaid). 63% of children reported AR. Children with AR had significantly fewer symptom free days over 2 weeks compared to children without AR (7.2 vs. 8.3, p < 0.001). Children with AR also had more daytime symptoms, (4.7 vs. 3.7, p < 0.001), more rescue medication use (4.5 vs. 3.4, p < 0.01), and more activity limitation due to asthma (3.6 vs. 2.5, p < 0.001). Only 44% of children with AR reported allergy medication use.
Among a large school-based cohort of minoritized children with asthma, we found that the majority of children have comorbid allergic rhinitis, which was associated with increased asthma morbidity. Inadequate recognition and treatment for allergic rhinitis likely represents substantial preventable morbidity for this group.
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