Adherence to national asthma guidelines is poor among high-risk population of children

December 03, 2001

Philadelphia, Pa. -- Children suffering from asthma are not following the National Heart, Lung, and Blood Institute's (NHLBI) guidelines on home asthma management, say researchers from The Children's Hospital of Philadelphia. As asthma rates among young children continue to increase, the Children's Hospital research team found that asthmatic children from an urban environment are not using appropriate preventive medications and devices, are not adhering to NHLBI guidelines during asthma flare-ups and under utilize asthma specialists.

The study, published in the December issue of Pediatrics, gathered data from 433 children ranging in age from two to 18 years, who presented symptoms of acute asthma in Children's Hospital's emergency department. Ninety-three percent of the children were African American, a population with the highest risk of developing asthma and the highest death rate from the disease in the United States. The researchers used a detailed questionnaire to evaluate the children and the impact of asthma on their daily life, access to medical care, strategies used to prevent flare-ups, and adherence to NHLBI guidelines during an asthma attack.

"The NHLBI guidelines, implemented in 1991, were designed to impact asthma's increasing morbidity and mortality rates among the U.S. population and yet our study found an alarming rate of non-adherence to those recommendations," says Richard Scarfone, M.D., an emergency medicine physician at Children's Hospital and lead author of the study. "Because asthma is a chronic illness with ongoing treatment needs, it is important to assess how well families are managing children at home."

Among the most alarming findings of the study is that the majority of children do not take appropriate preventive measures to reduce frequency and severity of acute asthma attacks. Only 38 percent of children take daily anti-inflammatory medication, with only 18 percent receiving daily inhaled corticosteroids to prevent flare-ups.

Further, the researchers found that children with persistent asthma are more likely to take daily doses of the fast-acting medication, albuterol, even in the absence of symptoms, than to take daily inhaled steroids as a preventive treatment. The NHLBI advises using rescue medication only for acute asthma flare-ups, because prolonged daily use may decrease the drug's effectiveness.

In addition, the majority of families do not maintain a written action plan or symptom diary, both of which are recommended by the NHLBI guidelines. Of the five steps recommended by the NHLBI as actions to take at the onset of an asthma attack, the only step followed by most children was to inhale a fast-acting medication to ease symptoms. One-third or fewer children were adherent to the other steps recommended by the NHLBI at the onset of symptoms including, using a peak flow meter, beginning oral corticosteroids, calling or going to see the doctor, or going to the emergency department if the response to other measures is poor.

Access to appropriate care is also a major issue raised by the study. Though two-thirds of the patients enrolled have persistent asthma, only 4 percent are cared for by an allergist or pulmonologist. A far greater number of the children could benefit from seeing an asthma specialist than are currently receiving specialized care, says Dr. Scarfone.

Asthma was found to have a profound and detrimental impact on the quality of life of these children and that of their families. More than half of the children had been hospitalized in the previous year and three quarters had at least one emergency room visit. Fifty-five percent of children missed at least one day of daycare or school in the previous month and 48 percent of parents missed at least one day of work due to their child's asthma. Many children are also restricted from physical activities at home or in school.

"Effective asthma management needs to be an ongoing partnership between the primary care physician, the family and the child, where education and reinforcement are key components to keeping these children healthy," says Dr. Scarfone. "The guidelines are there, but it is our role as physicians to empower and enable patients and families to gain control over their illness."
Dr. Scarfone is an attending physician in Children's Hospital's Division of Emergency Medicine. Co-authors of the study were Joseph J. Zorc, M.D., also from The Children's Hospital of Philadelphia and Geoffrey A. Capraro, M.D., an emergency physician at Boston Medical Center.

Founded in 1855 as the nation's first pediatric hospital, The Children's Hospital of Philadelphia is ranked today as the best pediatric hospital in the nation by a comprehensive Child Magazine survey. Through its long-standing commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals and pioneering major research initiatives, Children's Hospital has fostered many discoveries that have benefited children worldwide. Its pediatric research program is among the largest in the country, ranking second in National Institutes of Health funding. In addition, its unique family-centered care and public service programs have brought the 381-bed hospital recognition as a leading advocate for children and adolescents from before birth through age 19.

Children's Hospital of Philadelphia

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