- Email: [email protected]
Characteristics of children with asthma who are enrolled in a Head Start program
Asthma diagnosis and treatment
Characteristics of children with asthma who are enrolled in a Head Start program Perla A. Vargas, PhD, Pippa M. Simpson, PhD, J. Gary Wheeler, MD, Rajiv Goel, MS, Charles R. Feild, MD, John M. Tilford, PhD, and Stacie M. Jones, MD Little Rock, Ark
Background: Asthma is an increasing public health concern that disproportionally affects children. In 1998, the Centers for Disease Control identified children aged 0 to 4 years as the ‘‘driving force’’ behind climbing rates of asthma-related emergency department visits and hospitalizations. Despite the significant asthma burden in preschool children, few studies characterize this population. Objective: This study identifies and characterizes children at risk for asthma who are enrolled in a local Head Start program. Methods: Caregivers of 368 children aged 3 to 5 years who were identified by using an asthma survey were recruited. Data were collected on demographics, health care use and access, medication use, symptoms, and trigger exposure. Exposure to tobacco smoke was determined by urinary cotinine and allergen sensitization by skin prick test. Results: At baseline, 64% of the children had more than 1 emergency department visit for asthma in their lifetime, whereas 31% had more than 1 visit in the previous 6 months. Caretakers reported smoking in 37% of households with cotinine exceeding 20 ng/mg in 27% of the sample. Twenty-one percent reported symptoms consistent with intermittent asthma, and 79% reported symptoms consistent with persistent asthma. Forty-five percent of the children reported nighttime symptoms more than 1 night per week. Seventy-one percent had positive test results for more than 1 allergen, and 42% had positive test results for more than 3 allergens. Only 32% of children with persistent asthma had both rescue and controller medications. Conclusion: Children with asthma enrolled in a Head Start program have significant environmental tobacco smoke exposure, are highly atopic and symptomatic, and do not receive appropriate medication treatment. Overall, children in the study had poor asthma control. This high-risk group could benefit from case management programs. (J Allergy Clin Immunol 2004;114:499-504.) Key words: preschool aged, asthma, minority, low-income, African American, Head Start, environmental tobacco exposure, allergy, atopy, Arkansas
Asthma is the most common chronic disease of childhood. It affects approximately 5 million US children From the Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital. This study received funding from the Agency for Healthcare Research and Quality grant 1U18HS11062. Received for publication November 6, 2003; revised May 7, 2004; accepted for publication May 11, 2004. Available online July 22, 2004. Reprint requests: Perla A. Vargas, PhD, Arkansas Children’s Hospital, Center for Applied Research and Evaluation, Slot 512-26, 800 Marshall Street, Little Rock, AR 72202-3591. E-mail: [email protected]. 0091-6749/$30.00 Ó 2004 American Academy of Allergy, Asthma and Immunology doi:10.1016/j.jaci.2004.05.025
Abbreviations used ED: Emergency department ETS: Environmental tobacco smoke HS: Head Start OTC: Over-the-counter NHLBI: National Heart Lung and Blood Institute
per year, one fourth of whom are aged less than 5 years.1 In the United States, asthma is the most common cause for pediatric hospitalization, the primary diagnosis for one third of all pediatric emergency department (ED) visits, and the fourth most frequent reason for visits to pediatricians.2 The burden of asthma3-6 and the barriers to manage it7-11 seem to be greatest among low-income and disadvantaged children and their families. In 1998, the Centers for Disease Control reported that the most substantial increase in asthma prevalence occurred among children aged 0 to 4 years. These children were also identified as the ‘‘driving force’’ behind the climbing rates of asthma-related ED visits and hospitalizations. Children 0 to 4 years of age had 50% more asthma-related ED visits (120.7 vs 81.3) and more than twice the asthma-related hospitalizations (49.7 vs 18) of their older counterparts.1 Despite significant asthma burden in preschool children, there are few studies characterizing this population. This study identifies and characterizes the children at risk for asthma who are enrolled in a Head Start (HS) program. This report describes the baseline characteristics of HS children enrolled in a prospective, randomized, controlled intervention.
METHODS The study was conducted in collaboration with one HS grantee in the state of Arkansas. The Pulaski County HS program is administered by the University of Arkansas for Medical Sciences. There are more than 1000 children enrolled per year in 32 centers located throughout the county. The HS population in Pulaski County is primarily African American (87%). HS eligibility requires families to be at or below federal poverty level and gives enrollment preference to those children with economic and developmental disabilities.
Head Start program HS is an early childhood program with an enrollment nationwide of more than 822,000 children. HS is operated in each local site in accordance with detailed federal program performance standards. The overall goal of the HS program is to increase the social competence of preschool children aged 3 to 5 years who are from 499
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low-income families. HS emphasizes the connection between health and school readiness and the role of parents and community partners in keeping children healthy and ready to learn. To achieve the overall goal, HS provides services on education, health, nutrition, and parent assistance.12 Asthma diagnosis and treatment
Enrollment procedure From August 2001 to December 2003, as part of the HS enrollment process, primary caregivers of children ages 3 to 5 years were consulted and asked to complete an asthma case-finding survey developed at the University of Southern California.13 This study started during the early stages of the development and validation of the asthma algorithm. The final scoring algorithm developed by Jones and colleagues13 correctly identified children with asthma (>80% probability) with a sensitivity of 87%, specificity of 84%, and misclassification rate of 14%. The survey demonstrated a greater sensitivity for detecting persistent versus intermittent asthma.
Eligibility algorithm Each study child was required to have asthma defined by satisfying at least 1 of the following criteria: 1. The parent was told by a physician that the child had asthma, reactive airway disease, or chronic bronchitis. 2. The child had possible asthma defined by a combination of current symptoms and history of acute problems. Children reporting at least 3 of the following criteria were eligible to participate. (a) Asthma symptoms in the previous 4 weeks: activity limitation, daytime symptoms, or nighttime symptoms. (b) Asthma-related acute problems in the previous 2 years: asthma attacks, chest tightness, ED visits, or missed days at school. Ten percent of the children (n = 264) did not have an asthma diagnosis and were identified as having ‘‘possible asthma’’ on the basis of the eligibility criteria. Assignment of asthma severity was conducted by applying the National Heart Lung and Blood Institute (NHLBI) severity classification to parents’ self-reported asthma symptoms (ie, activity limitation, daytime symptoms, and nighttime symptoms). Per the NHLBI guidelines, individuals were assigned to the most severe grade in which any feature occurred.14
Caregiver interview Primary caregivers of eligible children were invited to participate in an asthma community intervention. The University of Arkansas for Medical Sciences Human Research Advisory Committee approved the study, and informed consent was obtained. Trained research assistants interviewed caregivers to complete a baseline structured questionnaire at the HS centers. The questionnaire included measures developed by the NHLBI Minority Asthma Working Group. Data were collected on demographic characteristics, health care use and access, symptoms, trigger exposure, and medication use.
Allergy testing Skin prick allergy testing was completed at baseline. The test was performed with the prick puncture method on the back by using a MultiTest II device (Lincoln Diagnostics; Decatur, Ill) for dust mites (Der p 1/ Der f 1 mix), cat dander (Fel d 1), cockroach (Bla g 1/ Bla g 2 mix), ragweed mix, bermuda grass, and eastern oak pollens (Greer Laboratories, Inc; Lenoir, NC). Resulting wheal reactions were measured 15 minutes after puncture. Skin tests were considered valid only if the difference in wheal diameter between positive and negative controls was more than 3 mm. Two board-certified allergists reviewed and scored all data. In all cases, sensitivity to an allergen
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was considered positive if the maximum diameter of the wheal was more than 3 mm greater than the saline control.
Urinary cotinine Urinary cotinine levels were used to determined exposure to environmental tobacco smoke (ETS). Urine samples were collected at the time of the baseline interview by using a sterile urine collection cup; the samples were then refrigerated and frozen at 208C at the laboratory within 24 hours. Samples were analyzed by using gas chromatography-mass spectometry and select ion monitoring. Creatinine was determined for each urine specimen and used to normalize the cotinine concentrations (cotinine per milligram of creatinine) by using a methodology similar to that reported by Greenberg et al15 and Perez-Stable et al.16 The limit of quantitation was 3.3 ng/mL, and the limit of detection 1 ng/mL. The laboratory was blind to participant identification and self-reported smoking exposure. All cotinine analyses were performed in accordance with Clinical Laboratory Improvement Act guidelines in the Division of Laboratory Science, National Code for Environmental Health (Centers for Disease Control), and all results were from runs confirmed to be in statistical control by quality control and quality assurance evaluations. Assay validity was periodically confirmed by use of an in-house proficiency-testing program that used National Institute for Standards and Technology cotinine in urine Reference Material 8444 (National Institute of Standards and Technology, Gaithersburg, Md) and blank spiked urine samples. In addition, reliability estimates for split-half urine samples resulted in correlations r = 0.91. Results were reported as cotinine and creatinine ratios. There is evidence indicating that levels between 10 ng/mg and 30 ng/mg17-19 represent ETS exposure or light smoking. Therefore, a middle point of 20 ng/mg was arbitrarily selected as the cutoff to describe exposure.
Statistical analyses Data were analyzed by means of the SAS statistical package.20 Pearson’s v2 statistic and Fisher’s exact test were used to determine the significance of differences in medication use between children with and without an asthma diagnosis.
RESULTS Population The HS population in Pulaski County is unstable and difficult to follow; approximately 10% had no phone at baseline, 30% had disconnected phones within 6 months, and 15% had moved at least once. The population in the study is a mixture of urban and rural families. All of the HS centers are located in Pulaski County. Thirty percent of the county is rural (population < 25,000) with agricultural activities. There are 14 cities and towns in the county, 2 of which are considered urban. Twenty (62%) of the HS centers are located in these 2 urban centers. The asthma case-finding survey was completed for 2533 children with a response rate of 50%. The prevalence of asthma diagnosis or possible asthma by the eligibility algorithm in the overall sample was 32.8% (95% CI, 31% to 37%). A total of 567 children (22.4%) had a physician diagnosis of asthma, reactive airway disease, or chronic bronchitis, and 264 children (10.4%) did not have a diagnosis and were identified as having ‘‘possible asthma’’ on the basis of eligibility criteria. Eligible families were notified and invited to participate by mail. Then, face-to-face enrollment started at the HS centers.
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Symptoms profile According to the NHLBI severity classification (see Table IIa for operationalized criteria), 21% of the children (n = 76) were classified with mild intermittent asthma, and 79% (n = 292) were classified with persistent asthma by self-reported symptoms (Table IIb). Seventy-one percent of the children (n = 261) had nighttime symptoms more than 2 times per month, and 50% of the children (n = 183) had their activity limited by asthma symptoms. Fifty-two percent (n = 178) had missed school the previous year, 27% (n = 99) had missed school the previous month, 76% missed school 1 to 3 days, and 23 children missed school 4 or more days. Thirty-five percent of the parents (n = 122) reported having lost work days because of their children’s asthma. One third (n = 122) of the children received at least 1 burst of oral steroids to treat an exacerbation in the previous 6 months. Medication regimen As Table III shows, medication use was not consistent with NHLBI recommendations. More than one third of the children (n = 134) were not taking any asthma medication. The number of asthma medications reported was different (P < .001) between children with and without an asthma diagnosis; children with an asthma diagnosis reported significantly more asthma prescriptions. Fifteen percent of the children (39/266) with an asthma diagnosis and 70% of the children (71/102) with possible asthma were not taking any medications (P < .001). Ninety-two percent of the children (238/258) with asthma prescriptions had a rescue medication, 46% (119/258) had at least 1 controller, and 38% (99/258) had an inhaled corticosteroid. Table IV shows the breakdown of prescribed asthma medications. Following the NHLBI guidelines, we defined the ‘‘appropriate’’ treatment regimen for persistent asthma as a prescription of rescue medication plus at least 1 controller medication. Fifty-nine percent of the children (45/76) with intermittent asthma had a rescue medication, but only 32% of the children (94/ 292) with persistent asthma had both rescue medication plus at least 1 controller medication, and 15% of the children (39/266) with an asthma diagnosis had no asthma medication. Sixty-five percent of the children (n = 239) had a prescribed inhaler, and most of those with an inhaler had been shown how to use it (208/239). However, 20% of
TABLE I. Demographic characteristics N (%)
Children Race (African American) Age (mean years, range) Gender (male) Family history of asthma (+) Primary caregivers Education (more than high school) Gender (female) Single mothers Age (mean years, range) Household income Below poverty level Working parents Full time Insurance Medicaid State CHIP Private Uninsured
329 4.2 202 168
(89) (3-5) (55) (46)
304 355 240 29
(83) (96) (62) (18-64)
299 (81) 231 (63) 163 (44) 186 110 61 11
(51) (30) (16) (3)
CHIP, Children’s Health Insurance Program.
the children (48/239) with a prescribed inhaler did not have a spacer device, which is critical for adequate medication delivery in this age group. When parents were questioned about other ways to help their children’s asthma, 35% (n = 127) reported using over-the-counter (OTC) medications for symptom control. Significantly more children without an asthma diagnosis reported using OTC medications (P < .001). The OTC medications most commonly mentioned were analgesics (eg, Tylenol and Motrin, McNeill-PPC Inc, Ft Washington, Pa) (n = 22), antitussives and expectorants (eg, Robitussin, Wyeth, Madison, NJ) (n = 50), antihistamines (eg, Benadryl, Pfizer Inc, New York, NY) (n = 31), and combination medicine (eg, Dimetapp, Wyeth; Pediacare and Sudafed; Pfizer Inc) (n = 87). Two families reported using Primatene mist (Wyeth), 1 of whom reported using it almost every day for the past 6 months. Thirty-four percent (n = 127) of the families reported using home remedies (humidifiers and vaporizers n = 39, rubs n = 22, and teas n = 14).
Health care utilization, barriers, and satisfaction Asthma-related emergency care use has been used as a key indicator for asthma control. In our study population, 24% of the children (n = 89) had at least 1 hospitalization for asthma in their life, and 4% (n = 14) had 1 hospitalization in the 6 months before study entry. Approximately one third (n = 116) had at least 1 visit to the ED in the 6 months before study entry (Table V). Only 133 (36%) families reported never going to the ED because of asthma. Overall, few families reported barriers to access health care services. The most significant problem was dissatisfaction with waiting time at the office (n = 72). Only 20 parents reported having a problem obtaining asthma care
Asthma diagnosis and treatment
This recruitment strategy generated a sample of 368 children, 277 (75%) of whom had a physician diagnosis of asthma, reactive airway disease, or chronic bronchitis. Ninety-one children (25%) had a combination of asthmalike symptoms and history of acute asthma-like problems without a physician diagnosis of asthma. Detailed demographic data are depicted in Table I. Most families were African American, 73% (n = 268) had income levels less than $20,000. Eighty-one percent of the children (n = 299) were eligible for the State Medicaid Program, and almost all (n = 337) had medical insurance with pharmacy benefits. Eighty percent (n = 293) reported having a regular primary care provider.
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TABLE IIa. Operationalization of symptoms for severity classification by using the stepwise approach as defined by the National Heart Lung and Blood Institute guidelines14
Asthma diagnosis and treatment
Daytime symptoms Nighttime symptoms Activity level
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
1-2 times/wk < 2 times/mo Rarely affected
3-6 times/wk < 1 time/wk Occasionally affected
Daily symptoms 1 time/wk, but not daily Often affected
< 1 time on most days Every night Limited most of the time
TABLE IIb. Self-reported severity of symptoms and severity classification by using the clinical features in the stepwise approach as defined by the National Heart Lung and Blood Institute guidelines14 N = 368 (%)
Intermittent
Overall severity classification* Daytime symptoms Nighttime symptoms Activity limitation
76 240 107 185
Mild persistent
(21) (65) (29) (50)
115 100 94 143
Moderate persistent
(31) (27) (26) (39)
135 17 137 22
(37) (5) (37) (6)
Severe persistent
42 11 27 18
(11) (3) (7) (5)
*Overall asthma severity was assigned to the most severe symptom reported.
TABLE IV. Self-reported asthma prescriptions by class TABLE III. Medication used for asthma management among all participants Medicationsà used for asthma control
Prescribed medications (Rx)*§ 0 1 2 Rescue plus >1 controller OTC k Only OTC medication No medication (OTC or Rx)
Total No Asthma diagnosis diagnosis n = 368 n = 266 (%) n = 102 (%) (%)
39 109 118 100 70 15 24
(15) (41) (44) (38) (26) (6) (9)
71 24 7 4 57 40 31
(70) (23) (7) (4) (56) (39) (30)
110 133 125 104 127 55 55
(30) (36) (34) (28) (35) (15) (15)
*P < .001, v2. P < .001, two-tailed Fisher’s exact test. àReported by primary caregiver. §All asthma medications reported. kOTC medications included were analgesics, antitussives and expectorants, antihistamines, decongestants, combination medications, and epinephrine. OTC, Over-the-counter; Rx, prescription drug.
in the previous year. Most of the children had well-child visits (n = 343) in the previous year, and more than half (n = 212) reported having asthma checkups (ie, a primary care provider visit for asthma care and not for management of acute symptoms). Twenty-nine percent of the children (n = 105) received their regular asthma care at the pediatric teaching hospital, and 78% of the patients (177/226) received care at the teaching hospital ED. Overall, parents reported that they were satisfied with the health care system (88%) and that doctors treated them respectfully (85%) and explained the asthma regimen (n = 304). Seventy percent regarded their primary care provider and clinic as their best source of asthma information. However, 49% reported that doctors missed information they provided regarding their child’s health. Furthermore, approximately half of the families received written Asthma Action Plans with instructions for intake
Type of prescription
*Short-acting b-agonist (inhaled, oral, or nebulized) *Inhaled corticosteroids àMast cell stabilizer Antileukotriene àLong-acting b-agonist àOral steroids *At least 1 controller Other medications
No Asthma Total diagnosis diagnosis n = 227 (%) n = 31 (%) N = 258§
214 (94) 94 15 21 12 4 112 25
(41) (7) (9) (5) (2) (49) (11)
24 (77) 5 (16) — 2 (6) — — 7 (23) 7 (23)
238 (92) 99 15 23 12 4 119 32
(38) (6) (9) (5) (2) (46) (12)
*P < .05, Fisher’s exact test. P = NS, Fisher’s exact test. àNo test was performed when n < 20. §Children with prescribed asthma medications.
of daily medications (n = 183) and management of acute exacerbations (n = 130). Six percent of those with Asthma Action Plans reported not understanding them, and 13% disagreed with the instructions.
Allergy testing A total of 294 children (80%) had valid tests for aeroallergen sensitivity (Fig 1). Twenty-seven tests (7%) were deemed invalid, 11 families declined the test, and 36 children were not tested because of scheduling problems. Seventy-one percent (n = 210) had positive test results for more than 1 allergen, 42% (n = 122) had positive test results for more than 3 allergens, and 13% (n = 38) had positive test results for all 6 allergens. Twenty percent (n = 59) had positive test results for all 3 perennial allergens, and 20% (n = 58) had positive test results for all 3 pollens. Environmental exposures Self-reported exposure to environmental triggers other than ETS was low. Thirty-two percent (n = 118) reported exposure to roaches, 12% (n = 43) reported exposure to
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Asthma diagnosis and treatment
rats and mice, 10% (n = 38) reported exposure to dogs, 3% (n = 11) reported exposure to cats, and 2% (n = 9) reported exposure to birds. In contrast, ETS exposure was self-reported by 52% (n = 193) of the families with 37% noting exposure at home. Mean cotinine and creatinine concentration was 15.5 ng/mg ± 21 ng/mg (range, 0-188 ng/mg). Cotinine and creatinine ratios exceeded 20 ng/mg in 27% of the sample. Most parents (n = 324) also reported being forewarned about the adverse effects of ETS on asthma. Between April 2002 and March 2003, 300 families in the asthma program were offered free counseling for smoking cessation and free nicotine replacement patches. Only 8 caregivers in the program enrolled in the cessation treatment. FIG 1. Percentage of children with positive skin prick test results.
DISCUSSION This report describes the characteristics of preschool children with asthma who were enrolled in an HS program located in Arkansas. Asthma prevalence in this population is significantly higher than national estimates (4% to 7%).1 There are little data describing the asthma morbidity of preschool-aged children. Another asthma study conducted in an HS population in Massachusetts21 showed a prevalence rate consistent with our estimates (35% vs 33%). These findings are critical for several reasons: (1) Most children with asthma start wheezing before age 5 years22; (2) preschool-aged children account for a large proportion of the asthma-related hospitalizations and visits to the ED1; (3) anti-inflammatory treatment is most beneficial when started early in the course of the disease23-28; and (4) poor asthma control impacts long-term lung health29 and likely growth and development. Because of the HS program support services for parents, most children were enrolled in the Medicaid program, which enables them to complete the well-child visits and immunization schedule. Overall, families in this study report no problem with access to care and have generally high levels of satisfaction with the health care system. However, they do report frequent symptoms that affect the families’ quality of life. Seventy-one percent of the children (n = 261) have nighttime symptoms more than once per week, and 50% of the children (n = 183) have their activity limited by asthma symptoms. Lifetime hospitalization for the children in the study was comparable to that of other children with asthma.30 To our knowledge, this is the first study describing the prevalence of atopy in preschool-aged children. The number of children with positive responses to individual allergens (31% to 43%) was significantly higher than expected,10 indicating a highly atopic group. This finding is especially significant given the limited panel of allergens that might have underestimated the true proportion of atopic children. For lack of a better comparison group, we compared the frequency of positive skin prick test results with that in other studies of school-aged children, and our results showed similar sensitivity rates. Seventy-one percent of the preschool-aged children in
TABLE V. Self-reported health care utilization for acute asthma care
Number
0 1 2 3+
ED visits previous 6 mo n (%)
252 43 31 42
(69) (12) (8) (11)
Lifetime hospitalizations n (%)
279 54 13 22
(76) (15) (3) (6)
Hospitalizations previous 6 mo n (%)
354 10 1 3
(96) (3) (0.2) (0.8)
ED, Emergency department.
the study had positive test results for at least 1 allergen versus 77% of the school-aged children in the National Cooperative Inner-City Asthma Study.9 In addition, there is evidence that atopy increases with age, which highlights the importance of an asthma intervention to reduce exposure and improve asthma control in this group of highly atopic preschoolers. Another major asthma trigger for these children was ETS exposure with a prevalence in our study of 52% compared with 47% in the Massachusetts HS study.21 However, despite high levels of self-reported exposure (52%) and awareness of the negative impact of ETS on asthma (88%), few families (n = 8) took advantage of free services for smoking cessation. These findings indicate the need for effective approaches to reduce ETS exposure in this population. Compared with studies conducted within the past 10 years,9,30 there seems to be an improvement in asthma prescriptions in our population; however, there is still a significant number of children who are inadequately treated. Approximately one third (32%) of the children with persistent asthma were receiving appropriate treatment according to NHLBI guidelines (ie, quick relief plus at least 1 daily controller), and 15% of the children had no asthma medication. Furthermore, 20% of the children receiving inhaled medication did not have a spacer device. There was also high use of OTC drugs and remedies that are not recommended for asthma control and that can be detrimental in some instances (eg, overuse of cough medicine and humidifier).
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In summary, prescription of anti-inflammatory medications seems to be improving. However, despite an increase in the number of children who are taking controller medications, most children with persistent asthma remain inadequately treated. Children with asthma who are enrolled in HS are highly atopic and symptomatic, and have excessive exposure to ETS. These factors place them at high risk for poor asthma outcomes. This population could benefit from an effective case management program addressing these important areas of asthma treatment.
STUDY LIMITATIONS The most important limitation of this study is that information regarding children’s health care use and access, medication use, frequency of asthma symptoms, and trigger exposure was only reported by parents, and no objective measurement was obtained. Another limitation is the operationalization of the NHLBI severity classification by using parents’ report of symptoms alone, without lung function measurements. Furthermore, although the NHLBI guidelines recommend classifying asthma severity before starting treatment, a large proportion of the children in our sample were taking medication at the time of the survey. Finally, asthma diagnosis in children before 5 years of age is difficult; function lung tests are not feasible in this age group, and it is known that some young children experience transient wheezing.22 We appreciate the invaluable help of Delores Brooks, Mark Ayers, Jacqueline Wilburd, Marsha Walton, Sarah Robins, Michael Flick, and all of the staff and parents of Head Start in Pulaski County. We also thank Dr Jimmie Valentine for his work on the cotinine analysis and Anne Parat for her invaluable editorial comments.
REFERENCES 1. Centers for Disease Control. Surveillance for asthma—United States, 1960-1995. Morb Mortal Wkly Rep 1998;47(SS-1):1-28. 2. United States Vital Statistics. Hyattsville (MD): National Center for Health Statistics; 1996. 3. Halfon N, Newacheck PW. Childhood asthma and poverty: differential impacts and utilization of health services. Pediatrics 1993;91:56-61. 4. Malveaux FJ, Houlihan D, Diamond EL. Characteristics of asthma mortality and morbidity in African-Americans. J Asthma 1993;30:431-7. [See comment.] 5. Weitzman M, Gortmaker S, Sobol A. Racial, social, and environmental risks for childhood asthma. Am J Dis Child 1990;144:1189-94. 6. Lang DM, Sherman MS, Polansky M. Guidelines and realities of asthma management. The Philadelphia story. Arch Intern Med 1997;157: 1193-200. 7. Goodman DC, Stukel TA, Chang CH. Trends in pediatric asthma hospitalization rates: regional and socioeconomic differences. Pediatrics 1998;101:208-13. 8. Wood DL, Hayward RA, Corey CR, Freeman HE, Shapiro MF. Access to medical care for children and adolescents in the United States. Pediatrics 1990;86:666-73.
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9. Kattan M, Mitchell H, Eggleston P, Gergen P, Crain E, Redline S, et al. Characteristics of inner-city children with asthma: the National Cooperative Inner-City Asthma Study. Pediatr Pulmonol 1997;24:253-62. 10. Wood RA. Pediatric asthma [review]. JAMA 2002;288:745-7. 11. Fosarelli P, DeAngelis C, Kaszuba A. Compliance with follow-up appointments generated in a pediatric emergency room. Am J Prev Med 1985;1:23-9. 12. Zigler E, Valentine J (editors). Project Head Start. A legacy of the war on poverty. 2nd ed. Alexandria (VA): The National Head Start Association; 1997. 13. Jones CA, Morphew T, Clement LT, Kimia T, Dyer M, Li M, et al. A school-based case identification process for identifying inner city children with asthma: the Breathmobile program. Chest 2004;125: 924-34. 14. National Asthma Education and Prevention Program. Expert panel report 2: guidelines for the diagnosis and management of asthma. [National Institutes of Health Publication No. 97–4051]. Bethesda (MD): National Institutes of Health; 1997. 15. Greenberg RA, Haley NJ, Etzel RA, Loda FA. Measuring the exposure of infants to tobacco smoke. Nicotine and cotinine in urine and saliva. New Engl J Med 1984;310:1075-8. 16. Perez-Stable EJ, Herrera B, Jacob P, III, Benowitz NL. Nicotine metabolism and intake in black and white smokers. JAMA 1998;280: 152-6. [See comment.] 17. Cornelius MD, Goldschmidt L, Dempsey DA. Environmental tobacco smoke exposure in low-income 6-year-olds: parent report and urine cotinine measures. Nicotine Tob Res 2003;5:333-9. 18. Winkelstein ML, Tarzian A, Wood RA. Parental smoking behavior and passive smoke exposure in children with asthma. Ann Allergy Asthma Immunol 1997;78:419-23. [See comment.] 19. Chilmonczyk BA, Salmun LM, Megathlin KN, Neveux LM, Palomaki GE, Knight GJ, et al. Association between exposure to environmental tobacco smoke and exacerbations of asthma in children. New Engl J Med 1993;328:1665-9. [See comment.] 20. SAS 9.1. Cary (NC): Statistical Package SAS Institute Inc; 2004. 21. Ladebauche P, Nicolosi R, Reece S, Saucedo K, Volicer B, Richards T. Asthma in Head Start children: prevalence, risk factors, and health care utilization. Pediatr Nurs 2001;27:396-9. 22. Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen, Morgan WJ. Asthma and wheezing in the first six years of life. The Group Health Medical Associates. New Engl J Med 1995;332:133-8. [See comments.] 23. Haahtela T. The long-term influence of therapeutic interventions in asthma with emphasis on inhaled steroids and early disease. [Review.] Clin Exp Allergy 1998;28(suppl 5):133-40. 24. Haahtela T, Jarvinen M, Kava T, Kiviranta K, Koskinen S, Lehtonen K, et al. Effects of reducing or discontinuing inhaled budesonide in patients with mild asthma. New Engl J Med 1994;331:700-5. [See comment.] 25. Laitinen LA, Laitinen A, Haahtela T. A comparative study of the effects of an inhaled corticosteroid, budesonide, and a beta 2-agonist, terbutaline, on airway inflammation in newly diagnosed asthma: a randomized, double-blind, parallel-group controlled trial. J Allergy Clin Immunol 1992;90:32-42. 26. Haahtela T, Jarvinen M, Kava T, Kiviranta K, Koskinen S, Lehtonen K, et al. Comparison of a beta 2-agonist, terbutaline, with an inhaled corticosteroid, budesonide, in newly detected asthma. New Engl J Med 1991;325:388-92. [See comment.] 27. Blais L, Suissa S, Boivin JF, Ernst P. First treatment with inhaled corticosteroids and the prevention of admissions to hospital for asthma. Thorax 1998;53:1025-9. [See comment.] 28. Blais L, Ernst P, Boivin JF, Suissa S. Inhaled corticosteroids and the prevention of readmission to hospital for asthma. Am J Respir Crit Care Med 1998;158:126-32. 29. Konig P. Irreversible airway obstruction in childhood asthma? A clinician’s viewpoint. Pediatr Pulmonol 2002;33(4):307-10. 30. McGill KA, Sorkness CA, Ferguson-Page C, Gern JE, Havighurst TC, Knipfer, et al. Asthma in non-inner city Head Start children. Pediatrics 1998;102(1 Pt 1):77-83.
Characteristics of children with asthma who are enrolled in a Head Start program Perla A. Vargas, PhD, Pippa M. Simpson, PhD, J. Gary Wheeler, MD, Rajiv Goel, MS, Charles R. Feild, MD, John M. Tilford, PhD, and Stacie M. Jones, MD Little Rock, Ark
Background: Asthma is an increasing public health concern that disproportionally affects children. In 1998, the Centers for Disease Control identified children aged 0 to 4 years as the ‘‘driving force’’ behind climbing rates of asthma-related emergency department visits and hospitalizations. Despite the significant asthma burden in preschool children, few studies characterize this population. Objective: This study identifies and characterizes children at risk for asthma who are enrolled in a local Head Start program. Methods: Caregivers of 368 children aged 3 to 5 years who were identified by using an asthma survey were recruited. Data were collected on demographics, health care use and access, medication use, symptoms, and trigger exposure. Exposure to tobacco smoke was determined by urinary cotinine and allergen sensitization by skin prick test. Results: At baseline, 64% of the children had more than 1 emergency department visit for asthma in their lifetime, whereas 31% had more than 1 visit in the previous 6 months. Caretakers reported smoking in 37% of households with cotinine exceeding 20 ng/mg in 27% of the sample. Twenty-one percent reported symptoms consistent with intermittent asthma, and 79% reported symptoms consistent with persistent asthma. Forty-five percent of the children reported nighttime symptoms more than 1 night per week. Seventy-one percent had positive test results for more than 1 allergen, and 42% had positive test results for more than 3 allergens. Only 32% of children with persistent asthma had both rescue and controller medications. Conclusion: Children with asthma enrolled in a Head Start program have significant environmental tobacco smoke exposure, are highly atopic and symptomatic, and do not receive appropriate medication treatment. Overall, children in the study had poor asthma control. This high-risk group could benefit from case management programs. (J Allergy Clin Immunol 2004;114:499-504.) Key words: preschool aged, asthma, minority, low-income, African American, Head Start, environmental tobacco exposure, allergy, atopy, Arkansas
Asthma is the most common chronic disease of childhood. It affects approximately 5 million US children From the Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital. This study received funding from the Agency for Healthcare Research and Quality grant 1U18HS11062. Received for publication November 6, 2003; revised May 7, 2004; accepted for publication May 11, 2004. Available online July 22, 2004. Reprint requests: Perla A. Vargas, PhD, Arkansas Children’s Hospital, Center for Applied Research and Evaluation, Slot 512-26, 800 Marshall Street, Little Rock, AR 72202-3591. E-mail: [email protected]. 0091-6749/$30.00 Ó 2004 American Academy of Allergy, Asthma and Immunology doi:10.1016/j.jaci.2004.05.025
Abbreviations used ED: Emergency department ETS: Environmental tobacco smoke HS: Head Start OTC: Over-the-counter NHLBI: National Heart Lung and Blood Institute
per year, one fourth of whom are aged less than 5 years.1 In the United States, asthma is the most common cause for pediatric hospitalization, the primary diagnosis for one third of all pediatric emergency department (ED) visits, and the fourth most frequent reason for visits to pediatricians.2 The burden of asthma3-6 and the barriers to manage it7-11 seem to be greatest among low-income and disadvantaged children and their families. In 1998, the Centers for Disease Control reported that the most substantial increase in asthma prevalence occurred among children aged 0 to 4 years. These children were also identified as the ‘‘driving force’’ behind the climbing rates of asthma-related ED visits and hospitalizations. Children 0 to 4 years of age had 50% more asthma-related ED visits (120.7 vs 81.3) and more than twice the asthma-related hospitalizations (49.7 vs 18) of their older counterparts.1 Despite significant asthma burden in preschool children, there are few studies characterizing this population. This study identifies and characterizes the children at risk for asthma who are enrolled in a Head Start (HS) program. This report describes the baseline characteristics of HS children enrolled in a prospective, randomized, controlled intervention.
METHODS The study was conducted in collaboration with one HS grantee in the state of Arkansas. The Pulaski County HS program is administered by the University of Arkansas for Medical Sciences. There are more than 1000 children enrolled per year in 32 centers located throughout the county. The HS population in Pulaski County is primarily African American (87%). HS eligibility requires families to be at or below federal poverty level and gives enrollment preference to those children with economic and developmental disabilities.
Head Start program HS is an early childhood program with an enrollment nationwide of more than 822,000 children. HS is operated in each local site in accordance with detailed federal program performance standards. The overall goal of the HS program is to increase the social competence of preschool children aged 3 to 5 years who are from 499
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low-income families. HS emphasizes the connection between health and school readiness and the role of parents and community partners in keeping children healthy and ready to learn. To achieve the overall goal, HS provides services on education, health, nutrition, and parent assistance.12 Asthma diagnosis and treatment
Enrollment procedure From August 2001 to December 2003, as part of the HS enrollment process, primary caregivers of children ages 3 to 5 years were consulted and asked to complete an asthma case-finding survey developed at the University of Southern California.13 This study started during the early stages of the development and validation of the asthma algorithm. The final scoring algorithm developed by Jones and colleagues13 correctly identified children with asthma (>80% probability) with a sensitivity of 87%, specificity of 84%, and misclassification rate of 14%. The survey demonstrated a greater sensitivity for detecting persistent versus intermittent asthma.
Eligibility algorithm Each study child was required to have asthma defined by satisfying at least 1 of the following criteria: 1. The parent was told by a physician that the child had asthma, reactive airway disease, or chronic bronchitis. 2. The child had possible asthma defined by a combination of current symptoms and history of acute problems. Children reporting at least 3 of the following criteria were eligible to participate. (a) Asthma symptoms in the previous 4 weeks: activity limitation, daytime symptoms, or nighttime symptoms. (b) Asthma-related acute problems in the previous 2 years: asthma attacks, chest tightness, ED visits, or missed days at school. Ten percent of the children (n = 264) did not have an asthma diagnosis and were identified as having ‘‘possible asthma’’ on the basis of the eligibility criteria. Assignment of asthma severity was conducted by applying the National Heart Lung and Blood Institute (NHLBI) severity classification to parents’ self-reported asthma symptoms (ie, activity limitation, daytime symptoms, and nighttime symptoms). Per the NHLBI guidelines, individuals were assigned to the most severe grade in which any feature occurred.14
Caregiver interview Primary caregivers of eligible children were invited to participate in an asthma community intervention. The University of Arkansas for Medical Sciences Human Research Advisory Committee approved the study, and informed consent was obtained. Trained research assistants interviewed caregivers to complete a baseline structured questionnaire at the HS centers. The questionnaire included measures developed by the NHLBI Minority Asthma Working Group. Data were collected on demographic characteristics, health care use and access, symptoms, trigger exposure, and medication use.
Allergy testing Skin prick allergy testing was completed at baseline. The test was performed with the prick puncture method on the back by using a MultiTest II device (Lincoln Diagnostics; Decatur, Ill) for dust mites (Der p 1/ Der f 1 mix), cat dander (Fel d 1), cockroach (Bla g 1/ Bla g 2 mix), ragweed mix, bermuda grass, and eastern oak pollens (Greer Laboratories, Inc; Lenoir, NC). Resulting wheal reactions were measured 15 minutes after puncture. Skin tests were considered valid only if the difference in wheal diameter between positive and negative controls was more than 3 mm. Two board-certified allergists reviewed and scored all data. In all cases, sensitivity to an allergen
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was considered positive if the maximum diameter of the wheal was more than 3 mm greater than the saline control.
Urinary cotinine Urinary cotinine levels were used to determined exposure to environmental tobacco smoke (ETS). Urine samples were collected at the time of the baseline interview by using a sterile urine collection cup; the samples were then refrigerated and frozen at 208C at the laboratory within 24 hours. Samples were analyzed by using gas chromatography-mass spectometry and select ion monitoring. Creatinine was determined for each urine specimen and used to normalize the cotinine concentrations (cotinine per milligram of creatinine) by using a methodology similar to that reported by Greenberg et al15 and Perez-Stable et al.16 The limit of quantitation was 3.3 ng/mL, and the limit of detection 1 ng/mL. The laboratory was blind to participant identification and self-reported smoking exposure. All cotinine analyses were performed in accordance with Clinical Laboratory Improvement Act guidelines in the Division of Laboratory Science, National Code for Environmental Health (Centers for Disease Control), and all results were from runs confirmed to be in statistical control by quality control and quality assurance evaluations. Assay validity was periodically confirmed by use of an in-house proficiency-testing program that used National Institute for Standards and Technology cotinine in urine Reference Material 8444 (National Institute of Standards and Technology, Gaithersburg, Md) and blank spiked urine samples. In addition, reliability estimates for split-half urine samples resulted in correlations r = 0.91. Results were reported as cotinine and creatinine ratios. There is evidence indicating that levels between 10 ng/mg and 30 ng/mg17-19 represent ETS exposure or light smoking. Therefore, a middle point of 20 ng/mg was arbitrarily selected as the cutoff to describe exposure.
Statistical analyses Data were analyzed by means of the SAS statistical package.20 Pearson’s v2 statistic and Fisher’s exact test were used to determine the significance of differences in medication use between children with and without an asthma diagnosis.
RESULTS Population The HS population in Pulaski County is unstable and difficult to follow; approximately 10% had no phone at baseline, 30% had disconnected phones within 6 months, and 15% had moved at least once. The population in the study is a mixture of urban and rural families. All of the HS centers are located in Pulaski County. Thirty percent of the county is rural (population < 25,000) with agricultural activities. There are 14 cities and towns in the county, 2 of which are considered urban. Twenty (62%) of the HS centers are located in these 2 urban centers. The asthma case-finding survey was completed for 2533 children with a response rate of 50%. The prevalence of asthma diagnosis or possible asthma by the eligibility algorithm in the overall sample was 32.8% (95% CI, 31% to 37%). A total of 567 children (22.4%) had a physician diagnosis of asthma, reactive airway disease, or chronic bronchitis, and 264 children (10.4%) did not have a diagnosis and were identified as having ‘‘possible asthma’’ on the basis of eligibility criteria. Eligible families were notified and invited to participate by mail. Then, face-to-face enrollment started at the HS centers.
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Symptoms profile According to the NHLBI severity classification (see Table IIa for operationalized criteria), 21% of the children (n = 76) were classified with mild intermittent asthma, and 79% (n = 292) were classified with persistent asthma by self-reported symptoms (Table IIb). Seventy-one percent of the children (n = 261) had nighttime symptoms more than 2 times per month, and 50% of the children (n = 183) had their activity limited by asthma symptoms. Fifty-two percent (n = 178) had missed school the previous year, 27% (n = 99) had missed school the previous month, 76% missed school 1 to 3 days, and 23 children missed school 4 or more days. Thirty-five percent of the parents (n = 122) reported having lost work days because of their children’s asthma. One third (n = 122) of the children received at least 1 burst of oral steroids to treat an exacerbation in the previous 6 months. Medication regimen As Table III shows, medication use was not consistent with NHLBI recommendations. More than one third of the children (n = 134) were not taking any asthma medication. The number of asthma medications reported was different (P < .001) between children with and without an asthma diagnosis; children with an asthma diagnosis reported significantly more asthma prescriptions. Fifteen percent of the children (39/266) with an asthma diagnosis and 70% of the children (71/102) with possible asthma were not taking any medications (P < .001). Ninety-two percent of the children (238/258) with asthma prescriptions had a rescue medication, 46% (119/258) had at least 1 controller, and 38% (99/258) had an inhaled corticosteroid. Table IV shows the breakdown of prescribed asthma medications. Following the NHLBI guidelines, we defined the ‘‘appropriate’’ treatment regimen for persistent asthma as a prescription of rescue medication plus at least 1 controller medication. Fifty-nine percent of the children (45/76) with intermittent asthma had a rescue medication, but only 32% of the children (94/ 292) with persistent asthma had both rescue medication plus at least 1 controller medication, and 15% of the children (39/266) with an asthma diagnosis had no asthma medication. Sixty-five percent of the children (n = 239) had a prescribed inhaler, and most of those with an inhaler had been shown how to use it (208/239). However, 20% of
TABLE I. Demographic characteristics N (%)
Children Race (African American) Age (mean years, range) Gender (male) Family history of asthma (+) Primary caregivers Education (more than high school) Gender (female) Single mothers Age (mean years, range) Household income Below poverty level Working parents Full time Insurance Medicaid State CHIP Private Uninsured
329 4.2 202 168
(89) (3-5) (55) (46)
304 355 240 29
(83) (96) (62) (18-64)
299 (81) 231 (63) 163 (44) 186 110 61 11
(51) (30) (16) (3)
CHIP, Children’s Health Insurance Program.
the children (48/239) with a prescribed inhaler did not have a spacer device, which is critical for adequate medication delivery in this age group. When parents were questioned about other ways to help their children’s asthma, 35% (n = 127) reported using over-the-counter (OTC) medications for symptom control. Significantly more children without an asthma diagnosis reported using OTC medications (P < .001). The OTC medications most commonly mentioned were analgesics (eg, Tylenol and Motrin, McNeill-PPC Inc, Ft Washington, Pa) (n = 22), antitussives and expectorants (eg, Robitussin, Wyeth, Madison, NJ) (n = 50), antihistamines (eg, Benadryl, Pfizer Inc, New York, NY) (n = 31), and combination medicine (eg, Dimetapp, Wyeth; Pediacare and Sudafed; Pfizer Inc) (n = 87). Two families reported using Primatene mist (Wyeth), 1 of whom reported using it almost every day for the past 6 months. Thirty-four percent (n = 127) of the families reported using home remedies (humidifiers and vaporizers n = 39, rubs n = 22, and teas n = 14).
Health care utilization, barriers, and satisfaction Asthma-related emergency care use has been used as a key indicator for asthma control. In our study population, 24% of the children (n = 89) had at least 1 hospitalization for asthma in their life, and 4% (n = 14) had 1 hospitalization in the 6 months before study entry. Approximately one third (n = 116) had at least 1 visit to the ED in the 6 months before study entry (Table V). Only 133 (36%) families reported never going to the ED because of asthma. Overall, few families reported barriers to access health care services. The most significant problem was dissatisfaction with waiting time at the office (n = 72). Only 20 parents reported having a problem obtaining asthma care
Asthma diagnosis and treatment
This recruitment strategy generated a sample of 368 children, 277 (75%) of whom had a physician diagnosis of asthma, reactive airway disease, or chronic bronchitis. Ninety-one children (25%) had a combination of asthmalike symptoms and history of acute asthma-like problems without a physician diagnosis of asthma. Detailed demographic data are depicted in Table I. Most families were African American, 73% (n = 268) had income levels less than $20,000. Eighty-one percent of the children (n = 299) were eligible for the State Medicaid Program, and almost all (n = 337) had medical insurance with pharmacy benefits. Eighty percent (n = 293) reported having a regular primary care provider.
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TABLE IIa. Operationalization of symptoms for severity classification by using the stepwise approach as defined by the National Heart Lung and Blood Institute guidelines14
Asthma diagnosis and treatment
Daytime symptoms Nighttime symptoms Activity level
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
1-2 times/wk < 2 times/mo Rarely affected
3-6 times/wk < 1 time/wk Occasionally affected
Daily symptoms 1 time/wk, but not daily Often affected
< 1 time on most days Every night Limited most of the time
TABLE IIb. Self-reported severity of symptoms and severity classification by using the clinical features in the stepwise approach as defined by the National Heart Lung and Blood Institute guidelines14 N = 368 (%)
Intermittent
Overall severity classification* Daytime symptoms Nighttime symptoms Activity limitation
76 240 107 185
Mild persistent
(21) (65) (29) (50)
115 100 94 143
Moderate persistent
(31) (27) (26) (39)
135 17 137 22
(37) (5) (37) (6)
Severe persistent
42 11 27 18
(11) (3) (7) (5)
*Overall asthma severity was assigned to the most severe symptom reported.
TABLE IV. Self-reported asthma prescriptions by class TABLE III. Medication used for asthma management among all participants Medicationsà used for asthma control
Prescribed medications (Rx)*§ 0 1 2 Rescue plus >1 controller OTC k Only OTC medication No medication (OTC or Rx)
Total No Asthma diagnosis diagnosis n = 368 n = 266 (%) n = 102 (%) (%)
39 109 118 100 70 15 24
(15) (41) (44) (38) (26) (6) (9)
71 24 7 4 57 40 31
(70) (23) (7) (4) (56) (39) (30)
110 133 125 104 127 55 55
(30) (36) (34) (28) (35) (15) (15)
*P < .001, v2. P < .001, two-tailed Fisher’s exact test. àReported by primary caregiver. §All asthma medications reported. kOTC medications included were analgesics, antitussives and expectorants, antihistamines, decongestants, combination medications, and epinephrine. OTC, Over-the-counter; Rx, prescription drug.
in the previous year. Most of the children had well-child visits (n = 343) in the previous year, and more than half (n = 212) reported having asthma checkups (ie, a primary care provider visit for asthma care and not for management of acute symptoms). Twenty-nine percent of the children (n = 105) received their regular asthma care at the pediatric teaching hospital, and 78% of the patients (177/226) received care at the teaching hospital ED. Overall, parents reported that they were satisfied with the health care system (88%) and that doctors treated them respectfully (85%) and explained the asthma regimen (n = 304). Seventy percent regarded their primary care provider and clinic as their best source of asthma information. However, 49% reported that doctors missed information they provided regarding their child’s health. Furthermore, approximately half of the families received written Asthma Action Plans with instructions for intake
Type of prescription
*Short-acting b-agonist (inhaled, oral, or nebulized) *Inhaled corticosteroids àMast cell stabilizer Antileukotriene àLong-acting b-agonist àOral steroids *At least 1 controller Other medications
No Asthma Total diagnosis diagnosis n = 227 (%) n = 31 (%) N = 258§
214 (94) 94 15 21 12 4 112 25
(41) (7) (9) (5) (2) (49) (11)
24 (77) 5 (16) — 2 (6) — — 7 (23) 7 (23)
238 (92) 99 15 23 12 4 119 32
(38) (6) (9) (5) (2) (46) (12)
*P < .05, Fisher’s exact test. P = NS, Fisher’s exact test. àNo test was performed when n < 20. §Children with prescribed asthma medications.
of daily medications (n = 183) and management of acute exacerbations (n = 130). Six percent of those with Asthma Action Plans reported not understanding them, and 13% disagreed with the instructions.
Allergy testing A total of 294 children (80%) had valid tests for aeroallergen sensitivity (Fig 1). Twenty-seven tests (7%) were deemed invalid, 11 families declined the test, and 36 children were not tested because of scheduling problems. Seventy-one percent (n = 210) had positive test results for more than 1 allergen, 42% (n = 122) had positive test results for more than 3 allergens, and 13% (n = 38) had positive test results for all 6 allergens. Twenty percent (n = 59) had positive test results for all 3 perennial allergens, and 20% (n = 58) had positive test results for all 3 pollens. Environmental exposures Self-reported exposure to environmental triggers other than ETS was low. Thirty-two percent (n = 118) reported exposure to roaches, 12% (n = 43) reported exposure to
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Asthma diagnosis and treatment
rats and mice, 10% (n = 38) reported exposure to dogs, 3% (n = 11) reported exposure to cats, and 2% (n = 9) reported exposure to birds. In contrast, ETS exposure was self-reported by 52% (n = 193) of the families with 37% noting exposure at home. Mean cotinine and creatinine concentration was 15.5 ng/mg ± 21 ng/mg (range, 0-188 ng/mg). Cotinine and creatinine ratios exceeded 20 ng/mg in 27% of the sample. Most parents (n = 324) also reported being forewarned about the adverse effects of ETS on asthma. Between April 2002 and March 2003, 300 families in the asthma program were offered free counseling for smoking cessation and free nicotine replacement patches. Only 8 caregivers in the program enrolled in the cessation treatment. FIG 1. Percentage of children with positive skin prick test results.
DISCUSSION This report describes the characteristics of preschool children with asthma who were enrolled in an HS program located in Arkansas. Asthma prevalence in this population is significantly higher than national estimates (4% to 7%).1 There are little data describing the asthma morbidity of preschool-aged children. Another asthma study conducted in an HS population in Massachusetts21 showed a prevalence rate consistent with our estimates (35% vs 33%). These findings are critical for several reasons: (1) Most children with asthma start wheezing before age 5 years22; (2) preschool-aged children account for a large proportion of the asthma-related hospitalizations and visits to the ED1; (3) anti-inflammatory treatment is most beneficial when started early in the course of the disease23-28; and (4) poor asthma control impacts long-term lung health29 and likely growth and development. Because of the HS program support services for parents, most children were enrolled in the Medicaid program, which enables them to complete the well-child visits and immunization schedule. Overall, families in this study report no problem with access to care and have generally high levels of satisfaction with the health care system. However, they do report frequent symptoms that affect the families’ quality of life. Seventy-one percent of the children (n = 261) have nighttime symptoms more than once per week, and 50% of the children (n = 183) have their activity limited by asthma symptoms. Lifetime hospitalization for the children in the study was comparable to that of other children with asthma.30 To our knowledge, this is the first study describing the prevalence of atopy in preschool-aged children. The number of children with positive responses to individual allergens (31% to 43%) was significantly higher than expected,10 indicating a highly atopic group. This finding is especially significant given the limited panel of allergens that might have underestimated the true proportion of atopic children. For lack of a better comparison group, we compared the frequency of positive skin prick test results with that in other studies of school-aged children, and our results showed similar sensitivity rates. Seventy-one percent of the preschool-aged children in
TABLE V. Self-reported health care utilization for acute asthma care
Number
0 1 2 3+
ED visits previous 6 mo n (%)
252 43 31 42
(69) (12) (8) (11)
Lifetime hospitalizations n (%)
279 54 13 22
(76) (15) (3) (6)
Hospitalizations previous 6 mo n (%)
354 10 1 3
(96) (3) (0.2) (0.8)
ED, Emergency department.
the study had positive test results for at least 1 allergen versus 77% of the school-aged children in the National Cooperative Inner-City Asthma Study.9 In addition, there is evidence that atopy increases with age, which highlights the importance of an asthma intervention to reduce exposure and improve asthma control in this group of highly atopic preschoolers. Another major asthma trigger for these children was ETS exposure with a prevalence in our study of 52% compared with 47% in the Massachusetts HS study.21 However, despite high levels of self-reported exposure (52%) and awareness of the negative impact of ETS on asthma (88%), few families (n = 8) took advantage of free services for smoking cessation. These findings indicate the need for effective approaches to reduce ETS exposure in this population. Compared with studies conducted within the past 10 years,9,30 there seems to be an improvement in asthma prescriptions in our population; however, there is still a significant number of children who are inadequately treated. Approximately one third (32%) of the children with persistent asthma were receiving appropriate treatment according to NHLBI guidelines (ie, quick relief plus at least 1 daily controller), and 15% of the children had no asthma medication. Furthermore, 20% of the children receiving inhaled medication did not have a spacer device. There was also high use of OTC drugs and remedies that are not recommended for asthma control and that can be detrimental in some instances (eg, overuse of cough medicine and humidifier).
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In summary, prescription of anti-inflammatory medications seems to be improving. However, despite an increase in the number of children who are taking controller medications, most children with persistent asthma remain inadequately treated. Children with asthma who are enrolled in HS are highly atopic and symptomatic, and have excessive exposure to ETS. These factors place them at high risk for poor asthma outcomes. This population could benefit from an effective case management program addressing these important areas of asthma treatment.
STUDY LIMITATIONS The most important limitation of this study is that information regarding children’s health care use and access, medication use, frequency of asthma symptoms, and trigger exposure was only reported by parents, and no objective measurement was obtained. Another limitation is the operationalization of the NHLBI severity classification by using parents’ report of symptoms alone, without lung function measurements. Furthermore, although the NHLBI guidelines recommend classifying asthma severity before starting treatment, a large proportion of the children in our sample were taking medication at the time of the survey. Finally, asthma diagnosis in children before 5 years of age is difficult; function lung tests are not feasible in this age group, and it is known that some young children experience transient wheezing.22 We appreciate the invaluable help of Delores Brooks, Mark Ayers, Jacqueline Wilburd, Marsha Walton, Sarah Robins, Michael Flick, and all of the staff and parents of Head Start in Pulaski County. We also thank Dr Jimmie Valentine for his work on the cotinine analysis and Anne Parat for her invaluable editorial comments.
REFERENCES 1. Centers for Disease Control. Surveillance for asthma—United States, 1960-1995. Morb Mortal Wkly Rep 1998;47(SS-1):1-28. 2. United States Vital Statistics. Hyattsville (MD): National Center for Health Statistics; 1996. 3. Halfon N, Newacheck PW. Childhood asthma and poverty: differential impacts and utilization of health services. Pediatrics 1993;91:56-61. 4. Malveaux FJ, Houlihan D, Diamond EL. Characteristics of asthma mortality and morbidity in African-Americans. J Asthma 1993;30:431-7. [See comment.] 5. Weitzman M, Gortmaker S, Sobol A. Racial, social, and environmental risks for childhood asthma. Am J Dis Child 1990;144:1189-94. 6. Lang DM, Sherman MS, Polansky M. Guidelines and realities of asthma management. The Philadelphia story. Arch Intern Med 1997;157: 1193-200. 7. Goodman DC, Stukel TA, Chang CH. Trends in pediatric asthma hospitalization rates: regional and socioeconomic differences. Pediatrics 1998;101:208-13. 8. Wood DL, Hayward RA, Corey CR, Freeman HE, Shapiro MF. Access to medical care for children and adolescents in the United States. Pediatrics 1990;86:666-73.
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9. Kattan M, Mitchell H, Eggleston P, Gergen P, Crain E, Redline S, et al. Characteristics of inner-city children with asthma: the National Cooperative Inner-City Asthma Study. Pediatr Pulmonol 1997;24:253-62. 10. Wood RA. Pediatric asthma [review]. JAMA 2002;288:745-7. 11. Fosarelli P, DeAngelis C, Kaszuba A. Compliance with follow-up appointments generated in a pediatric emergency room. Am J Prev Med 1985;1:23-9. 12. Zigler E, Valentine J (editors). Project Head Start. A legacy of the war on poverty. 2nd ed. Alexandria (VA): The National Head Start Association; 1997. 13. Jones CA, Morphew T, Clement LT, Kimia T, Dyer M, Li M, et al. A school-based case identification process for identifying inner city children with asthma: the Breathmobile program. Chest 2004;125: 924-34. 14. National Asthma Education and Prevention Program. Expert panel report 2: guidelines for the diagnosis and management of asthma. [National Institutes of Health Publication No. 97–4051]. Bethesda (MD): National Institutes of Health; 1997. 15. Greenberg RA, Haley NJ, Etzel RA, Loda FA. Measuring the exposure of infants to tobacco smoke. Nicotine and cotinine in urine and saliva. New Engl J Med 1984;310:1075-8. 16. Perez-Stable EJ, Herrera B, Jacob P, III, Benowitz NL. Nicotine metabolism and intake in black and white smokers. JAMA 1998;280: 152-6. [See comment.] 17. Cornelius MD, Goldschmidt L, Dempsey DA. Environmental tobacco smoke exposure in low-income 6-year-olds: parent report and urine cotinine measures. Nicotine Tob Res 2003;5:333-9. 18. Winkelstein ML, Tarzian A, Wood RA. Parental smoking behavior and passive smoke exposure in children with asthma. Ann Allergy Asthma Immunol 1997;78:419-23. [See comment.] 19. Chilmonczyk BA, Salmun LM, Megathlin KN, Neveux LM, Palomaki GE, Knight GJ, et al. Association between exposure to environmental tobacco smoke and exacerbations of asthma in children. New Engl J Med 1993;328:1665-9. [See comment.] 20. SAS 9.1. Cary (NC): Statistical Package SAS Institute Inc; 2004. 21. Ladebauche P, Nicolosi R, Reece S, Saucedo K, Volicer B, Richards T. Asthma in Head Start children: prevalence, risk factors, and health care utilization. Pediatr Nurs 2001;27:396-9. 22. Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen, Morgan WJ. Asthma and wheezing in the first six years of life. The Group Health Medical Associates. New Engl J Med 1995;332:133-8. [See comments.] 23. Haahtela T. The long-term influence of therapeutic interventions in asthma with emphasis on inhaled steroids and early disease. [Review.] Clin Exp Allergy 1998;28(suppl 5):133-40. 24. Haahtela T, Jarvinen M, Kava T, Kiviranta K, Koskinen S, Lehtonen K, et al. Effects of reducing or discontinuing inhaled budesonide in patients with mild asthma. New Engl J Med 1994;331:700-5. [See comment.] 25. Laitinen LA, Laitinen A, Haahtela T. A comparative study of the effects of an inhaled corticosteroid, budesonide, and a beta 2-agonist, terbutaline, on airway inflammation in newly diagnosed asthma: a randomized, double-blind, parallel-group controlled trial. J Allergy Clin Immunol 1992;90:32-42. 26. Haahtela T, Jarvinen M, Kava T, Kiviranta K, Koskinen S, Lehtonen K, et al. Comparison of a beta 2-agonist, terbutaline, with an inhaled corticosteroid, budesonide, in newly detected asthma. New Engl J Med 1991;325:388-92. [See comment.] 27. Blais L, Suissa S, Boivin JF, Ernst P. First treatment with inhaled corticosteroids and the prevention of admissions to hospital for asthma. Thorax 1998;53:1025-9. [See comment.] 28. Blais L, Ernst P, Boivin JF, Suissa S. Inhaled corticosteroids and the prevention of readmission to hospital for asthma. Am J Respir Crit Care Med 1998;158:126-32. 29. Konig P. Irreversible airway obstruction in childhood asthma? A clinician’s viewpoint. Pediatr Pulmonol 2002;33(4):307-10. 30. McGill KA, Sorkness CA, Ferguson-Page C, Gern JE, Havighurst TC, Knipfer, et al. Asthma in non-inner city Head Start children. Pediatrics 1998;102(1 Pt 1):77-83.