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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 ORDER REPRINTS 434 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 ORDER REPRINTS 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 ORDER REPRINTS 436 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 ORDER REPRINTS Home Asthma Management of Inner-City Children 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 437 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 ORDER REPRINTS 438 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 ORDER REPRINTS Home Asthma Management of Inner-City Children 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) ORDER REPRINTS 440 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 ORDER REPRINTS 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 ORDER REPRINTS 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. 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