Download Butz AM, Huss K, Mudd K, Donithan M, Rand C, Bollinger ME. Asthma management practices at home in young inner-city children. J Asthma. 2004;41(4): p.433-44.

JOURNAL OF ASTHMA
Vol. 41, No. 4, pp. 433–444, 2004
ORIGINAL ARTICLE
Asthma Management Practices at Home in Young Inner-City Children
Arlene M. Butz, Sc.D., R.N.,1,*
Karen Huss, R.N., D.N.Sc., F.A.A.N., F.A.A.A.A.I.,3
Kim Mudd, B.S.N., M.S.N.,4 Michele Donithan, M.H.S.,5
Cynthia Rand, Ph.D.,2 and Mary E. Bollinger, D.O.4
1
Department of Pediatrics and 2Department of Pulmonology and Critical Care,
The Johns Hopkins University School of Medicine,
Baltimore, Maryland, USA
3
National Institute of Nursing Research, NIH, Bethesda, Maryland, USA
4
Department of Pediatrics, University of Maryland School of Medicine,
Baltimore, Maryland, USA
5
The Johns Hopkins University Bloomberg School of Public Health,
Baltimore, Maryland, USA
ABSTRACT
Information on parental asthma management practices for young children is sparse.
The objective of this article is to determine if specific caregiver asthma management
practices for children were associated with children’s asthma morbidity. Caregivers of
100 inner-city children diagnosed with persistent asthma and participating in an
ongoing asthma intervention study were enrolled and interviewed to ascertain
measures of asthma morbidity, medication use, health care use (acute and primary
care), and asthma management practices. Overall, asthma morbidity was high with
almost two thirds of caregivers reporting their child having one or more emergency
department visits within the last 6 months and 63% receiving specialty care for their
asthma. Appropriate medication use was reported predominantly as albuterol and
inhaled steroids (78%). However, only 42% of caregivers reported administering
asthma medicines when their child starts to cough and less than half (39%) reported
having an asthma action plan. There were no significant differences by asthma severity
*Correspondence: Arlene M. Butz, Sc.D., R.N., The Johns Hopkins University School of Medicine, 600 N. Wolfe St. Park
386, Baltimore, MD 21287, USA; Fax: (410) 614-8821; E-mail: [email protected].
433
DOI: 10.1081/JAS-120033985
Copyright D 2004 by Marcel Dekker, Inc.
0277-0903 (Print); 1532-4303 (Online)
www.dekker.com
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Butz et al.
level for any asthma management practice. In conclusion, caregivers lack knowledge
regarding cough as an early asthma symptom. Caregivers should be encouraged to
review asthma action plans with health care providers at each medical encounter.
Key Words: Pediatric asthma; Nebulizer; Parental asthma management practices;
Anti-inflammatory medication.
INTRODUCTION
Asthma is a major cause of childhood morbidity in
the United States (1,2). The burden of pediatric asthma
is associated with high health care costs. Children with
asthma incurred 88% more costs, filled 2.77 times as
many prescriptions, and made 65% more nonurgent
outpatient visits compared with a general pediatric
population attending a health maintenance organization
(HMO) (3). Low-income, minority children have
disproportionately higher rates of prevalence, morbidity, and mortality for asthma than white children (4),
and young children, aged 0– 4 years, had the highest
increase in asthma prevalence from 1980 to 1996 (5).
Some proposed reasons for this increased morbidity
and mortality in young inner-city children with asthma
include a genetic or biological predisposition (6);
increased environmental exposure such as cockroaches,
dust, and pollutants (7,8); undertreatment with antiinflammatory therapy (9); and inadequate home management of asthma by families (10,11). Reasons for the
inadequate asthma management practices in the home
of inner-city patients include lack of early recognition
of asthma symptoms and inadequate treatment of less
severe asthma symptoms, overreliance on emergency
care for asthma, delay or lack of seeking medical care,
and poor adherence with therapy (12 –15).
Optimal asthma management practices in the
home are predicated by the caregiver or child’s ability
to accurately identify asthma symptoms and initiate
appropriate asthma care at home. Early and accurate
identification of asthma symptoms, when linked to
timely and appropriate asthma medication use, is associated with a decrease in asthma morbidity and
mortality (13,16). For young children with asthma in
particular, the ability of the caregiver to accurately
assess the child’s asthma, symptom perception, is
imperative to appropriate management, because young
children may not adequately recognize or verbalize
their symptoms. Treating early asthma symptoms
including cough, use of peak flowmeter, having an
asthma action plan, and contacting the physician before
going to the emergency department (ED) are examples
of specific asthma management practices. Information
on caregiver asthma management practices is sparse for
inner-city children. We were specifically interested in
caregiver asthma management practices for their child
during an acute asthma episode that occurs in the
home. As part of an ongoing longitudinal, asthma intervention study addressing nebulizer use, we collected
baseline information regarding asthma management
practices including identification of asthma symptoms,
pattern of medication use, and decisions for seeking
health care for children with asthma in a cohort of
young children with persistent asthma residing in
Baltimore, Maryland. The objective of this article is
to describe specific asthma management practices in an
inner-city population and to determine if the level of
asthma severity is associated with specific asthma
management practices.
METHODS
Baseline data collected from caregivers (parent or
legal guardian) of children enrolled in an ongoing
longitudinal, nurse home-based, educational asthma
intervention for inner-city children with asthma were
used to examine asthma management practices. The
larger ongoing study is enrolling 220 children with
persistent asthma, and we are reporting data on the first
100 participants. This study was funded by the National
Institute of Nursing Research, National Institutes of
Health to determine if a home-based asthma educational
intervention was associated with improved asthma selfmanagement focusing on symptom perception and
appropriate medication use among inner-city children
with asthma who use a nebulizer to administer at least
one of their asthma medications. The baseline surveys
were conducted between October 2001 and August 2002.
The study was approved by the Institutional Review
Boards of the Johns Hopkins University Medical
Institutions and the University of Maryland School of
Medicine, Baltimore, Maryland. Children were primarily
recruited from the University of Maryland hospital
pediatric allergy/pulmonary and pediatric outpatient
clinics, emergency room, and inpatient unit. Health
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Home Asthma Management of Inner-City Children
Insurance Portability and Accountability Act (HIPAA)
regulations were not instituted at the time of data
collection; thus, HIPAA requirements are not addressed
in this manuscript.
Study Population
All children were identified by attending physicians
in three sites at a large urban hospital including a
pediatric pulmonary and asthma specialty clinic, one
pediatric emergency room, and three community pediatric clinics all serving primarily inner-city children with
asthma in Baltimore, Maryland. Each child and his/her
caregiver were recruited and enrolled in the study after
obtaining caregiver-signed informed consent and child
assent when appropriate. Eligibility criteria included
1) children aged 2 –8 years old, 2) physician-diagnosed
asthma, 3) children who met NAEPP guidelines (17) for
persistent asthma based on daytime and nocturnal
symptoms, 4) subjects reported nebulizer use for administration of one or more asthma medications during
the past month, and 5) children have a caregiver who was
fluent in English.
Procedures for Data Collection
After obtaining informed caregiver consent and
child assent when appropriate, caregivers were interviewed by using a 204-item baseline questionnaire that
included questions focusing on asthma morbidity,
medication use, health care use (acute and primary
care), and asthma management practices. Most of the
interviews (66%) were conducted face-to-face either in
the clinic or in the home, with the remaining interviews
conducted via telephone by trained interviewers. The
child’s biological mother was the respondent for 90%
Table 1.
2.
3.
4.
5.
6.
7.
of the interviews. Families were mailed a $20.00 incentive after completion of the baseline interview.
Measures
Asthma Morbidity and Medication Use
Asthma morbidity was assessed by using the
following items: number of symptom days and nights,
number of days per month, child’s activity was limited,
number of emergency room visits and/or hospitalizations within last 6 months for asthma, and the
number of medical care visits for acute asthma
exacerbations. Asthma symptoms, including cough,
wheeze, or shortness of breath, were calculated by day
symptoms per week and night symptoms per month.
Asthma medication use was assessed by using items
asking the name of each current asthma medication,
frequency of use and mode of administration (i.e., oral,
inhaled, or nebulized), and how the caregiver was told
to administer the medication at home. Use of home
remedies for asthma was also ascertained. In addition,
caregivers were asked if their child was ever evaluated
by a specialist (i.e., allergist or pulmonologist).
Specialty care was verified by medical record review
for each child.
Asthma Severity
National Asthma Education and Prevention Program (NAEPP) criteria (17) were used to rate the
severity of asthma based on two factors including
symptom reports and type of asthma medication use
(use or non-use of anti-inflammatory medications) to
maintain reported symptom control. First, symptom
reports were determined by caregiver responses to
Questions used to ascertain caregiver asthma management practice.
Caregiver asthma care practices used at home
to care for child with nonacute asthma
1.
435
Count number of times my child is breathing
when he/she is coughing or wheezing
Give medications for asthma when my child starts to cough
Give medications for asthma when my child starts to wheeze
Make an appointment to see my child’s physician
for his/her asthma even if my child is not sick
Call physician to ask questions about asthma
Check medications for expiration data
Have a written asthma action plan
When caregiver decides to take their child to the
emergency room for an asthma episode
1. For every asthma episode
2. When child’s chest is sucked in
3. If my child continues to wheeze
4. If my child has shortness of breath
or difficulty breathing
5. If my child has difficulty talking while breathing
6. After a certain number of nebulizer treatments
7. Other symptoms that parent believes
need emergency room treatment
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Butz et al.
1) number of days per week with day symptoms of
cough, wheeze, or shortness of breath and 2) number of
nights per month with symptoms of cough, wheeze, or
shortness of breath. Children were classified into the
following four severity categories: mild intermittent:
day symptoms experienced less than two times per
week or nighttime symptoms less than two times per
month; mild persistent: day symptoms experienced two
or more times per week and/or night symptoms at two
or more times per month; moderate persistent: day
symptoms daily or seven or more times per week and/
or night symptoms more than one time per week; and
severe persistent: continual day symptoms and/or night
symptoms on a daily basis. Severity level was based on
the highest day or night symptom level. After
classifying severity based on symptom reports, we
reclassified 24 children who were initially categorized
as mild intermittent to mild persistent if they reported
taking one or more preventive medications (i.e.,
inhaled steroids, leukotriene modifiers, or cromolyn)
and reported having day symptoms less than two times
per week or night symptoms less than two times per
month. This reclassification of severity was based on
the likelihood of their pretreatment severity level to be
greater than mild intermittent had if they not been
taking the anti-inflammatory medications.
Table 2. Sociodemographic characteristics by severity group.
Sociodemographic characteristic
Ethnicity
African American
White
Other
Child age (mean, SD)
Range
Gender
Male
Medical assistance health insurance
Yes
Parent/guardian
Mother
Father
Grandmother
Other (legal guardian)
Parent/guardian educational level
< 9th grade
Some HS
HS graduate or GED
Some college/trade school
4 yr. college or college grad
Caregiver employed outside the home
Yes
Smoker in household
Yes
Number persons living in
household (range 2 – 12)
2–3
4–5
6 or more
Problems paying for asthma medications
Yes
Relocated or
moved during past 6 months
Yes
Mild persistent
(N = 65) N (%)
Moderate/severe
persistent (N = 31) N (%)
Total
(N = 96) N (%)
30 (97)
1 (3)
0
4.6 (2.2)
2–9
86 (90)
9 (9)
1 (1)
4.4 (2.1)
2–9
0.50
36 (55)
23 (74)
59 (61)
0.08
55 (85)
29 (94)
84 (88)
0.22
58
3
2
2
(89)
(5)
(3)
(3)
29 (94)
1 (3)
1 (3)
0
87
4
3
2
(91)
(4)
(3)
(2)
0.78
1
15
26
19
4
(2)
(23)
(40)
(29)
(6)
1 (3)
11 (35)
10 (32)
9 (29)
0
2
26
36
28
4
(2)
(27)
(38)
(29)
(4)
0.44
38 (58)
14 (45)
52 (54)
0.42
19 (29)
7 (24)
26 (27)
0.61
17 (26)
32 (49)
16 (25)
14 (45)
11 (35)
6 (19)
31 (32)
43 (45)
22 (23)
0.17
4 (6)
3 (10)
7 (7)
0.53
16 (25)
5 (16)
21 (22)
0.35
56
8
1
4.3
2–8
(86)
(12)
(2)
(2.0)
P value
0.27
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Table 3.
Health characteristic
Symptom days
2 times/week (mild intermittent)
> 2 times/week (mild persistent)
Daily, but not continual
(mod persistent)
Continual symptoms (severe persistent
Symptoms Nights
2 times/month (mild intermittent)
> 2 times/month (mild persistent)
Daily, but not continual
(mod persistent)
Continual symptoms
(severe persistent)
Severity (based on symptom days
and nights and medication use
or pretreatment) N = 100
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
Limitation of activity due to asthma
Yes
Number lifetime admissions for asthma
None
1
2
3 or more
Mean (SD)
Range
Number hospital admissions for
asthma last 6 months
None
1
2 or more
Mean (SD)
Range
Number of ED visits last 6 months
(range 0 – 20)
None
1
2
3
4 or more
Mean (SD)
Range
Receives specialty care
Yes
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Health characteristics by severity group.
Mild persistent
(N = 65) N (%)
Moderate/severe
persistent (N = 31) N (%)
Total
(N = 96) N (%)
P value
35 (54)
30 (46)
0
4 (13)
10 (32)
12 (39)
39 (41)
40 (42)
12 (12)
< 0.0001
0
33 (51)
32 (49)
0
0
—
—
—
—
5 (16)
5 (5)
0
4 (13)
17 (55)
33 (34)
36 (38)
17 (18)
10 (32)
10 (10)
—
—
—
—
4 (4)
65 (65)
19 (19)
12 (12)
< 0.0001
—
40 (62)
24 (77)
64 (67)
0.12
22 (34)
14 (21)
7 (11)
22 (34)
3.2 (5.2)
0 – 25
11 (35)
6 (19)
5 (16)
9 (29)
2.4 (3.4)
0 – 13
33 (34)
20 (21)
12 (13)
31 (32)
2.9 (4.6)
0 – 25
43 (66)
17 (26)
5 (8)
0.5 (0.8)
0–3
19 (61)
10 (32)
2 (6)
0.5 (1.0)
0–5
62 (65)
27 (28)
7 (7)
0.5 (0.8)
0–5
0.82
22 (34)
18 (28)
14 (21)
4 (6)
7 (11)
1.7 (2.8)
0 – 20
8 (26)
5 (16)
4 (13)
6 (19)
8 (26)
2.4 (2.7)
0 – 13
30 (31)
23 (25)
18 (19)
10 (10)
15 (15)
1.9 (2.8)
0 – 20
0.06
41 (63)
19 (61)
60 (63)
0.87
0.87
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Butz et al.
Asthma Management Practices
As seen in Table 1, two specific questions were
asked to caregivers to ascertain distinct asthma management practices at home and how parent/guardians
made decisions to take their child to the emergency
room for acute asthma exacerbation. The parent
was asked to select all items that described their
asthma management for their child’s asthma both at
home for nonacute asthma and during acute asthma
episodes; thus, multiple responses could be made for
each question.
Data Analysis
Data were summarized by examining frequency
distributions of all sociodemographic, asthma morbidity, medication use, health care use and asthma
management practice variables. On the basis of the
distribution of severity level, all subjects were dichotomized into two severity level groups: mild persistent
and moderate-to-severe persistent. Four children categorized as mild intermittent were deleted from the
final severity group analysis due to small group size.
The w2 test (of Fisher’s exact test when mandated by
sparse data) was used to compare the distributions of
categorical variables (i.e., gave asthma medication
Table 4.
RESULTS
Between October 2001 and August 2002, 115
eligible children and their caregivers were identified to
have a child with moderate-to-severe persistent asthma
and invited to participate in the ongoing intervention
study. Of these, 15 (13%) refused or could not be
contacted for baseline data collection. We report data
on a sample of 100 (87%) children and their caregivers. For the final analysis, 4 children were excluded
from the analysis due to symptom and medication use
reports compatible with mild intermittent severity level.
Sociodemographic Characteristics
by Severity Level
Most children were African American (90%), male
(61%), received medical assistance type of health
Pattern of current asthma medication use and medication use practices by severity group.
Medication
Albuterol only
Albuterol + oral steroids (short course)
Albuterol + inhaled steroid
Inhaled steroid only
Albuterol + nonsteroidal
anti-inflammatory (Intal, Singulair)*
Medication use practices
Number of steroid courses past 12 months
None
1
2
3
4 or more
Mean (SD)
Range
Have prednisone at home
for asthma attacks
Yes
*
when child starts to cough, Yes or No) for the two
severity groups. For continuous variables, one-way
analysis of variance (ANOVA) was used to perform
two-group comparisons. P <0.05 was considered to be
statistically significant, and all P values were interpreted in a two-tailed manner. All data analysis was
conducted by using SAS 8.1 statistical program (18).
Included no inhaled corticosteroid use.
Mild persistent
(N = 65) N (%)
7
0
51
1
6
(11)
(78)
(2)
(9)
Moderate/severe
persistent (N = 31) N (%)
2
2
24
0
3
(6)
(6)
(77)
(10)
Total
(N = 96) N (%)
9
2
75
1
9
(9.5)
(2)
(78)
(1)
(9.5)
15 (23)
8 (12)
16 (25)
9 (14)
17 (26)
3.1 (4.3)
0 – 24
3 (7)
5 (17)
4 (13)
8 (27)
11 (37)
4.1 (5.8)
0 – 33
18 (19)
13 (14)
20 (20)
17 (18)
28 (29)
3.4 (4.7)
0 – 33
21 (33)
14 (45)
35 (36)
P value
0.28
0.12
0.37
0.24
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439
insurance (88%), and had a mean age of 4.4 years (SD
2.0) as seen in Table 2. In 91% of the cases, the
biological mother was the primary caregiver. Most
caregivers reported a high school or higher level of
education (71%) and over half were employed outside
the home (54%). One or more smokers in the household
were reported by over one quarter (27%) of the
caregivers. Household size was moderate with a mean
of 4.6 persons, yet 23% of the households reported 6
or more persons. Few (7%) caregivers reported having
problems paying for asthma medication within the past
Table 5.
6 months. Over one of five families (22%) reported
moving to a new address within the past 6 months.
There were no significant differences between the two
severity groups (mild persistent vs. moderate-to-severe
persistent) for any sociodemographic characteristic.
Health Characteristics of Child
Participants by Severity Level
In general, there was high asthma morbidity
reported in this group of inner-city children with
Caregiver asthma management practices by severity group.
Asthma management practice
During asthma attack at home: number hours wait
before taking child to ED (median: 4 hours)
None to 30 minutes
1 hour
2 – 4 hours
5 – 12 hours
24 hours
>24 hours
Call asthma physician before going to ED
Yes, always
Yes, sometimes
Yes, try to call
No, never call
When decide to take child to ED for
asthma attack (each separate question)
Every asthma attack
Child chest sucked in
Child continue to wheeze
Child has shortness of breath
Child difficulty talking while breathing
After nebulizer treatment at home
Share nebulizer
Yes
Share with one other family member
Use peak flowmeter to decide asthma treatment
and have peak flowmeter in home
(child age appropriate)
Yes
Specific asthma management practices
Count respirations when coughing/wheezing
Give asthma medicines when child starts to cough
Give asthma medicines when child starts to wheeze
Make appointment to see physician even
when child is not sick
Call physician to ask questions
Check asthma medications for expiration dates
Have written asthma action plan
Mild persistent
(N = 65) N (%)
Moderate/severe
persistent (N = 31) N (%)
Total
(N = 96) N (%)
P value
3
10
17
18
9
8
(5)
(15)
(26)
(28)
(14)
(12)
8
12
8
2
1
(26)
(39)
(26)
(6)
(3)
11
22
25
20
10
8
(12)
(23)
(26)
(21)
(10)
(8)
0.25
32
11
4
18
(49)
(17)
(6)
(28)
8
8
1
14
(26)
(26)
(3)
(45)
40
19
5
32
(42)
(20)
(5)
(33)
13
49
54
59
58
61
(20)
(75)
(83)
(91)
(89)
(94)
2
25
27
29
28
30
(6)
(81)
(87)
(97)
(90)
(97)
15
74
81
88
86
91
(16)
(77)
(84)
(92)
(90)
(95)
0.09
0.56
0.61
0.29
0.83
0.56
0.12
15 (23)
47 (73)
10 (32)
25 (80)
25 (26)
72 (75)
0.33
23 (35)
8 (25)
31 (32)
0.30
36
40
89
69
(38)
(42)
(93)
(72)
0.46
0.07
0.06
0.89
75 (78)
94 (98)
37 (39)
0.91
0.32
0.67
26
23
58
47
(40)
(35)
(89)
(72)
51 (78)
63 (97)
26 (40)
10
17
31
22
(32)
(55)
(100)
(71)
24 (77)
31 (100)
11 (35)
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Butz et al.
asthma. As shown in Table 3, over half (59%) of the
caregivers reported their child had daytime symptoms
of cough, wheeze, or shortness of breath two or more
times a week. Daily or continual daytime symptoms
were reported in 17% of the children. Night symptoms
were reported at a higher frequency with 66% reporting
symptoms two or more times per month and 28%
reporting daily or continual night symptoms. Applying
the NAEPP (17) classification for asthma severity level
modified to include symptom frequency as well as
level of medication use to maintain asthma control,
65% of children met the criterion for mild persistent
asthma followed by 19% for moderate persistent and
12% for severe persistent asthma. Only four children
were categorized as mild intermittent and were
excluded from subsequent analysis by severity level.
Two thirds of caregivers reported their child had a
limitation of activity during the past 6 months. Almost
two thirds reported their child had a previous lifetime
hospitalization for asthma (66%) and one or more
emergency department visits within the last 6 months
(74%). The mean number of lifetime hospitalizations
for asthma was high at 2.9 hospitalizations. Specialty
care by an allergist or pulmonologist was reported by
over half (63%) of the subjects, reflecting the specialty
clinic as one of the major recruitment sites for the
study. Limitation of activity due to asthma, number
of hospital admissions for asthma within the last
6 months or over a lifetime, or receiving specialty care
did not differ by severity group; however, a trend was
noted in more children categorized in the moderate-tosevere group reporting one or more ED visits within
the last 6 months (p = 0.06). Use of home remedies was
reported by 10 (10%) of children and included
primarily use of coffee or tea (N = 4), sugar +onion
(N= 2),‘‘steamy’’ bathroom (N =2) and other (N =2).
There was no difference in home remedy use by
severity group.
Pattern of Asthma Medication Use
and Medication Use Practices by
Severity Level
Generally, most children were prescribed appropriate, guideline-based asthma medications for reported
asthma severity. Use of albuterol and inhaled corticosteroids was the predominant type of asthma medication use (78%) reported during the past 6 months for
all children as shown in Table 4. An additional 10% of
children reported use of albuterol and anti-inflammatory medications including Intal and/or leukotriene
modifiers or use of inhaled steroid only. Use of reliever
medication only (i.e., albuterol only or albuterol and
short course of oral steroids) was reported by 11% of
caregivers. The mean number of steroid courses used
during the past 12 months was 3.4 times (SD 4.7) with
only 19% reporting no steroid courses during the past
6 months. Over one third (36%) reported having
prednisone at home to use for their child’s acute
asthma episodes. There were no significant differences
in medication use or medication use practices by
severity group. Ten percent of the families reported use
of home remedies including coffee, tea, sugar, and a
combination of onion and steam.
Asthma Management Practices
by Severity Level
In general, caregiver-reported asthma management
practices were appropriate for this group of children
with mild-to-severe persistent asthma and did not
significantly differ by severity group (Table 5). When
asked how long the caregiver waits to take their child
to the ED when the child is having an acute asthma
exacerbation, the median number reported was 4 hours,
with a range of 30 minutes to greater than 24 hours.
One of five reported waiting 24 or more hours. Almost
half (42%) reported always calling their child’s
physician prior to going to the ED. When asked what
symptoms would lead the caregiver to seek urgent care
for their child, the response was positive in 77% for
‘‘chest sucked in,’’ 84% for ‘‘continued wheezing,’’
92% for ‘‘shortness of breath,’’ and 90% for ‘‘difficulty talking while breathing.’’ Regarding nebulizer
use for asthma, one of four reported that their child
shared a nebulizer with another family member, with
most (75%) reporting sharing with only one other
family member. Less than one third reported using a
peak flowmeter to determine asthma management
treatment at home, although the mean age of the
group was 4.4 years.
Overall, specific asthma management practices
were good with the exception of administering asthma
medication for cough symptoms. Specific asthma
management practices did not significantly differ by
severity group, with the exception of two trends noted.
All caregivers of children categorized in the moderateto-severe persistent group reported giving their child
medicine for wheeze compared to 89% of caregivers of
mild persistent children (p =0.06). Only 38% of parents
reported counting their child’s respirations during an
asthma attack, not routinely recommended, and only
42% reported administering asthma medicines when
their child starts to cough, with a trend noted in fewer
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Home Asthma Management of Inner-City Children
caregivers of children categorized as mild persistent
reporting giving asthma medicines for cough symptoms
than caregivers of moderate-to-severe children (p= 0.07).
Most parents did report they administer asthma medicines for wheeze symptoms (93%), make appointment
with child’s health care provider even when the child is
not ill (72%), call their child’s physician to ask questions
(78%), and check asthma medications for expiration
dates (98%). However, less than half (39%) reported
having an asthma action plan in the home to follow for
acute asthma exacerbations.
DISCUSSION
Overall, this group of inner-city young children
with persistent asthma experienced a high rate of
asthma morbidity, reported a high rate of inhaled
corticosteroid use and receiving specialty care, yet
reported some deficient asthma management practices.
It is unclear if the inadequate asthma management
practices are a result of ineffective asthma education
(19), nonadherence (20), or competing caregiver life
stressors including maternal depression, quality of life,
or living in an inner-city environment (21 – 24).
Although most families did acknowledge calling their
child’s physician prior to going to the ED and reported
accurate symptom perception concerning the need for
acute care in the ED, less than half of the caregivers
administered asthma medicines for cough symptoms or
reported having an asthma action plan. This most likely
reflects ineffective education or clinical management
rather than poor parental decision making, in that
asthma action plans should be generated as well as
encouraged by the health care provider, not the caregiver. Alternatively, the caregiver may have received
an asthma action plan, but not realized what it was
called. Of note is the fact that almost half of the
caregivers acknowledged calling their child’s physician
prior to going to the ED and may reflect a managed
care requirement for prior authorization to attend the
ED for an acute asthma exacerbation. In addition, this
sample of children may be biased because 63% of
children received specialty care for their asthma that
might explain the lack of difference noted in asthma
care practices between the two severity groups.
It is noteworthy that for the overall sample, less
than half of caregivers of all children with persistent
asthma and just over half of children with moderate-tosevere persistent asthma reported administering asthma
medication for cough symptoms, an important indicator
of chronic asthma (17). Evidence suggests that early
441
treatment of inflammation, possibly indicated by cough
symptoms, may help prevent progression of acute
asthma exacerbations. Although Rietveld reports cough
frequency in adults with asthma was not diagnostically
useful for assessment of airway obstruction (25), we
believe that health care providers need to inquire about
cough symptoms so that parents of children with
asthma perceive that cough is an asthma symptom of
significance to treat. In this study, details of the cause
of the cough could not be determined from the
questionnaire; therefore, children with allergic rhinnitis
may report cough symptoms unrelated to asthma and
not require asthma treatment. Although the updated
NAEPP guidelines (26) recommend use of a peak
flowmeter for children with moderate or severe persistent asthma to increase awareness of status of asthma,
we found that less than one third of the total group
reported using a peak flowmeter to determine asthma
management treatment at home, further supporting the
need for additional caregiver education to recognize
early symptoms of asthma including cough and
clinician education regarding NAEPP guidelines for
prescribing peak flowmeters. Caregiver nonadherence
most likely accounts for the low use of peak flowmeters in adequately aged children to determine
appropriate asthma treatment. Data on which subjects
were actually provided a peak flowmeter by their primary care provider were not available.
Caregiver asthma management practices did not
significantly differ by child asthma severity level. This
is particularly intriguing, because over half of the children received some type of asthma specialty care, and
over three quarters were covered by Medicaid, in theory,
associated with improved access to medical care for
children. This finding suggests that this group of highrisk children with asthma have potentially good access
to medical care, yet may be nonadherent or have
received inadequate asthma education. It is known that
children and their caregivers may not adequately
perceive asthma symptoms, and symptom reports do
not reliably correlate with lung function results in children with asthma and their caregiver reports (27,28).
Lack of early detection of asthma symptoms, such as
cough or rapid breathing, as seen in these data, may lead
to more ED visits and hospitalizations due to disregard
of warning symptoms and delay initiating treatment.
The decisive treatment for asthma requires rapid awareness of symptoms followed by appropriate use of
medications, emphasizing the need for symptom perceptual accuracy (15,28). In a previous report, caregiver
ability to correctly evaluate infant and young children’s
symptoms and severity of these symptoms was a
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442
significant problem for parents and was associated with
ineffective asthma management behaviors (29). Because
the mean age of children in this current study was
4.4 years, most likely many of these children were
recently diagnosed. Consequently, some caregivers may
have less knowledge and experience with asthma than
caregivers of older children (29). In addition, respiratory
infections may play a larger role in exacerbations of
asthma in young children as in this study. Thus, caregivers may have trouble distinguishing between symptoms of colds, flu, and croup compared with early signs
of an asthma exacerbation (i.e., rapid breathing, cough,
and wheeze), resulting in increased uncertainty in
asthma management practices at home (29).
Caregivers of young children with persistent
asthma may require more intensive, interactive asthma
education on a regular basis rather than brief review
of symptoms and medication use during an acute
episode. One asthma education program for caregivers
of young children, Wee Wheezers, includes one
segment addressing caregiver recognition of asthma
symptoms including cough, wheeze, rapid breathing,
retractions, prolonged expiration, and how to accurately
count a child’s respiratory rate (29,30). Furthermore,
parental decision to treat and how to treat symptoms
should be taught and reviewed at each preventive
asthma care visit.
We found a higher rate of anti-inflammatory medication use in this sample (88%) consistent with
NAEPP guidelines for persistent asthma but in contrast
to 39% in East Harlem children recruited from elementary schools (31), and 43% in urban and rural New
York children recruited from primary care settings (9).
Most likely, this increased rate of anti-inflammatory
use reflects the high rate of specialty care in this
sample, similar to reports of low-income children in
Atlanta (81%) who were recruited primarily from
asthma specialty clinics (19). However, we are unable
to determine the contribution of patient adherence to
anti-inflammatory use or the rate of severity misclassification by primary care providers potentially resulting in undertreatment of persistent asthma as suggested
by others (32).
Recently, it was suggested that there is no good
evidence to support that written asthma action plans do
improve outcomes (33). Although the authors conclude
that the benefit is most likely seen in those with more
severe forms of asthma or those with high baseline use
rates (33), we found that the prevalence of asthma action
plans was low, at less than half of all enrolled children,
and the presence of an asthma action plan did not differ
by severity group. Encouraging families to carry a copy
of the child’s asthma action plan to each clinic visit for
Butz et al.
review at each medical encounter may enhance the health
care provider’s ability to teach the parent early warning
symptoms and early appropriate treatment to prevent
progression to more serious asthma episode.
There are some potential limitations of this study.
The relatively small sample size and the geographically
and socioeconomically limited group of patients may
limit the generalizability of these findings beyond
inner-city pediatric populations. Another potential bias
is the self-report of the asthma management practices
data and may have resulted in some inaccuracy of the
data. However, objective measures of asthma management practices would require additional ongoing
observation or monitoring, which was not a component
of this study. The increased rate of children receiving
specialty care increases the bias toward more severe
asthma compared with a community-based sample.
However, even though these findings are limited to
young children with persistent asthma, the fact that
only 40% were administering medication for cough
symptoms and only 39% reported having an asthma
action plan in the home are noteworthy.
In conclusion, caregivers of young inner-city
children with persistent asthma are undertreating early
symptoms of asthma, particularly cough symptoms despite receiving specialty care. Age-appropriate use of a
peak flowmeter to determine asthma management was
reported by just over half of the caregivers; however,
less than half reported having an asthma action plan to
use at home for acute episodes of asthma.
On the basis of these findings, we propose the
following recommendations for asthma education for
caregivers of children with persistent asthma:
.
.
.
Increase caregiver awareness that early signs of
asthma exacerbations include cough, especially
recurrent nocturnal cough, and that treatment
of early signs of asthma may prevent progression from a less serious to more serious acute
asthma episode.
Provide training in communicating with the
child’s health care provider regarding asthma
symptom levels. Encourage age-appropriate use
of peak flowmeters or asthma diaries as a
method of communicating frequency of asthma
symptoms so that physician can accurately
assign severity levels to children for appropriate treatment at health care visits.
Encourage caregivers to carry child’s asthma
action plan to every health care encounter for
review of early symptom recognition and
appropriate treatment. The asthma action plan
should be reviewed with the caregiver and
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Home Asthma Management of Inner-City Children
.
child, when appropriate, by a health care
provider at each medical encounter, including
emergency room, acute care asthma visits, and
regular preventive asthma visits.
Provide specific instructions for when to seek
ED care for acute exacerbations.
443
10.
11.
ACKNOWLEDGMENTS
This research was supported by R01NR05060,
awarded by National Institute of Nursing Research,
National Institutes of Health. We thank the families for
their willingness to participate in this study.
12.
13.
14.
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