I spied this bulletin board in the back hallway of the Children’s Hospital Primary Care Clinic. It lets us know about asthma triggers to be aware of:
- Mold and Dust from Ornaments: People get all their ornaments out of their basements and closets and they’re covered in dust.
- Cold Air: Drives the lungs out and makes the chest tighten during cold weather. Have your child wear a scarf when she or he’s outside.
- Viruses from large gatherings of people: Wash hands frequently, get your influenza vaccine.
- Candles, Fragrances: Avoid scented candles, air fresheners and artificial snow sprays.
- Cigarette smoke: Maintain your home as a smoke-free environment, ask family members to smoke outside.
- The Christmas tree all lit up with warm lights and decorated with old bulbs is a perfect recipe for asthma trouble in kids. So wipe it down with a damp cloth before you set it up in the middle of your living room to remove outdoor allergens.
- Before you drag your holiday storage containers out of the basement, give them a good dusting so they’re free of mites, pest droppings, and other unpleasant holiday treats. And wash decorations before you put them on the tree.
- Trees: Christmas trees usually have leftover mold on them, or pollen, and many people with asthma have an increased difficulty breathing when they bring a live tree in the house and warm it up.
One of the most common questions I hear is, “Will my child have asthma?” or “Does my child have asthma?” This is a common concern when preschool children have asthma symptoms such as wheezing or cough.
Approximately 30% of children with preschool wheezing develop asthma when they are school age. But it’s hard to predict which preschool children who wheeze will go on to have asthma.
A recent study just published in the Journal of Allergy and Clinical Immunology validates and improves a prediction model, the Prevention and Incidence of Asthma and Mite Allergy (PIAMA) risk score.
Here’s the test. Add up the points that go into the prediction score.
1. Is your child male?
If yes, add 2 points.
2. Was your child born post-term, after 42 weeks gestation?
If yes, add 1 point.
3. Is the educational level of one parent less than the level of a bachelor’s/master’s degree?
If yes, add 1 point.
4. Does one of the parents of your child have asthma?
If yes, add 4 points.
5. Has your child had wheezing during a time when he or she did not have a cold, flu, or chest infection?
If yes, add 7 points.
6. How frequently has your child wheezed during the past 12 months?
If never, add 0 points
If 1-3 times/year, add 4 points.
If ≥ 4 times/year, add 7 points.
7. Does your child have eczema?
If yes, add 6 points.
Add up all of the points.
According to this study, if the preschooler’s score is
- ≥2, then the risk of asthma is 2%.
- ≥6, then the risk of asthma is 4%
- ≥10, then the risk of asthma is 9%
- ≥14, then the risk of asthma is 18%
- ≥18, then the risk of asthma is 34%
- ≥22, then the risk of asthma is 54%
While this risk score is moderately discriminative, it’s far from being perfect. At the low score cut-off points, the risk score will find most of the kids who go on to develop asthma, but it will also predict that many preschoolers will have asthma when they won’t. At the higher score cut-off points, everyone who has a positive score will go on to develop asthma, but many preschoolers who will develop asthma will not be detected.
This risk score is not ready for clinical use; however, I think it’s interesting to see which factors made it into the prediction score. In the future, adding additional predictors, such biomarkers and genomic markers, will likely improve asthma prediction.
Today’s post is from Alexander Ryu, third year Harvard Medical Student and CEO/co-founder of LifeGuard Games. My kids (one has asthma, one doesn’t) were in the first group who tested the mobile game, and they loved the experience. They couldn’t wait for the next beta testing…which is now!
How often do you get to play a virtual pet game and give feedback to improve the game? These creators really care what the kids say.
From Alex Ryu….
Have you heard about Wellapets?
Wellapets is a new educational mobile game (with virtual pets!) that teaches kids ages 6 -11 to manage asthma and builds kids’ self-confidence. Wellapets follows the story of a Wellapet who wants to blow fire like its mentor, but can’t, because it has asthma. It’s up to kids to care for their Wellapet and manage its asthma, eventually teaching their Wellapet to blow fire, defeat foes, and collect decorations for its home. Wellapets has been developed by LifeGuard Games with input from asthma specialist physicians in Boston.
The team is currently looking for kids ages 6-11 years to try their app in beta and provide feedback. Kids with and without asthma are welcomed; iPhone 5 and later, iPad and iPad mini are supported in this release. Your feedback would meaningfully contribute to improving our game for kids everywhere.
To sign up for the beta, visit: http://tflig.ht/15MjeM6
Once you’ve signed up there, simply visit www.tesflightapp.com on your mobile device and you’re ready to go! You’ll receive an email in January when the app is available for download.
More information is available at www.wellapets.com. Email co-founder Alex Ryu at firstname.lastname@example.org with questions, comments, or suggestions. We would love to hear from you!
**Also, a little bit of text from our Wellapets.com site:
Wellapets is created by LifeGuard Games, a company based in Boston. We believe in the fun, social and educational spark of games to help develop a healthier generation of kids. As a team, we share a love for pets, games with a purpose, and the smiles of Wellapet adopters.
And thanks for these fun bracelets, Wellapets!
Treatment with inhaled corticosteroids (i.e. Flovent, Pulmicort, etc) appears to modify the effect of genetic polymorphisms on lung function. This was one of the findings of a study
that I led that was published online today in the Journal of Allergy and Clinical Immunology.
Genetic polymorphisms influence a patient’s response to inhaled corticosteroids and beta agonistis (i.e. albuterol), and the effect of treatment with inhaled corticosteroids is synergistic with the effect of beta-agonists. Thus, we hypothesized that the use of inhaled corticosteroids could influence the effect of genetic polymorphisms associated with bronchodilator response.
The goal of our study was to assess whether the association of genetic polymorphisms with bronchodilator response is different between patients with asthma who are treated with inhaled corticosteroids versus those on placebo.
We conducted a genome-wide association analysis in children who participated in the Childhood Asthma Management Program (CAMP) clinical trial. We conducted a gene by environment analysis with inhaled corticosteroid treatment as the environmental exposure and bronchodilator response as the outcome measures. We took the top 12 single nucleotide polymorphisms that looked promising in CAMP and replicated them in a clinical trial of adults called the Leukotriene Modifier or Corticosteroid or Corticosteroid-Salmetereol Trial (LOCCS).
We identified a region on chromosome 19 that appears to influence the effect of inhaled corticosteroids on asthma. On particular gene on chromosome 19, the zinc finger protein gene, ZNF432, may play an important role in this relationship. Currently, the function of ZNF432 is unknown, but other zinc fingers have been found to play a role in asthma.
In summary, inhaled corticosteroids apear to influence the effect of genetic information on lung function. ZNF432 appears to modulate the effect on inhaled corticosteroids on lung function in adults and children with asthma.
I asked these kids with asthma to draw what asthma feels like. Here’s what they have to say….
In the November 15th issue of the American Journal of Respiratory and Critical Care Medicine,” Joe G. Zein MD wrote an editorial on the study that Sze Man Tse MD, co-investigators, and I published on the association of statins and emergency department visits from asthma. The summary of our study is [here].
In the editorial, Dr. Zein reviews strengths and weaknesses of our large observational study.
I’d like to quote the last few sentences here as I believe Dr. Zein makes important points.
"There are many questions that need to be answered before expanding the indication of statins to all patients with asthma. Clinicians should separate the effects of different statins on inflammation in asthma and should be able to identify which statin they need to use. They should know the effect of statins on younger healthy individuals with asthma and on senior citizens with multiple comorbidities, such as those excluded from the analysis in this study."
"They should identify the duration for statin therapy to become effective and the different biomarkers they need to follow to monitor therapy and efficacy. Until additional data is available, clinicians should be prudent and limit the use of statins to patients with asthma who need them for their cholesterol-lowering and cardioprotective effect. On the other hand, they should also have a very low threshold for identifying such patients."
I just returned from Arlington, Virginia and I feel energized. I had the opportunity to sit on the grants review committee for the Patient Centered Outcomes Research Institute (PCORI) for a funding opportunity entitled, Treatment Options for African-Americans and Hispanics/Latinos with Uncontrolled Asthma. I was a scientific reviewer.
Grants are proposals written by researchers who are hoping to obtain funding to conduct their research. Traditional grant review committees are composed of other researchers. So adding patients and stakeholders (including physicians, nurse practitioners, nurses, insurers, social workers, etc) to the review panel is novel and refreshing.
PCORI, a relatively new institute, is authorized by Congress to conduct research to provide information about the best available evidence to help patients and their health care providers make more informed decisions. PCORI’s research is intended to give patients a better understanding of the prevention, treatment and care options available, and the science that supports those options.
And boy do they take this seriously. PCORI has some forward-thinking organizers who are thinking out of the box.
In my conversations with PCORI staff, I heard a lot of excitement about the potential that PCORI has. There’s great promise in the research that will be funded by grants reviewed during this cycle (there were multiple committees reviewing grants), and new connections are being made between researchers, patients, and stakeholders who attend the review.
One of PCORI’s goals is to fund patient-centered outcomes research that helps people and their caregivers communicate and make informed healthcare decisions, allowing their voices to be heard in assessing the value of healthcare options. This research answers patient-centered questions such as (taken from their website):
- “Given my personal characteristics, conditions and preferences, what should I expect will happen to me?”
- “What are my options and what are the potential benefits and harms of those options?”
- “What can I do to improve the outcomes that are most important to me?”
- “How can clinicians and the care delivery systems they work in help me make the best decisions about my health and healthcare?”
PCORI is all about the patient. While supporting great science.
The review committee I participated in included scientists, patients and stakeholders who provided unique viewpoints. Conversations I had during meals and the review session during these two days will influence how I think about my research and how I care for my patients.
It’s rare for me to have the opportunity to sit and talk with a rural practitioner, social worker, or a professional patient advocate about research. Even the researchers I met had very diverse portfolios and I wouldn’t have met most of them if it weren’t for this review meeting.
PCORI plans to give out $500 million in grant funding in the next year for many research areas (in asthma and other fields). Most of you probably have not heard of PCORI until now. I believe the fruits of PCORI research will likely affect all of us in one way or other.
Today’s guest post is from Dan Engelhard, MD, Professor of Pediatrics at Hadassah University Hospital, Ein-Kerem, Jerusalem, Israel. He writes….
Asthma, as we know, is increasingly a condition that can be managed, allowing those it affects to lead a normal life. Inappropriate asthma management, however, has major impact on the physical, social and emotional health of the child, as well as significant effect on family finances and the nation’s health-care budget.
We wondered whether children with asthma feel their illness is optimally controlled — and, critically, whether their assessment of its control matches that of their parents and doctors. We suspected that parents may underestimate symptoms in their asthmatic children, and we wanted to know whether the treating physician is influenced more by the perception of the parent or of the child.
Last month we (Shefer et al. Pediatr Pulmonol. Oct 25 2013) reported our findings concerning 354 asthmatic children, their parents and their doctors in Israel clinics and at Hadassah University Hospital, Jerusalem last year (2011/2012). The children were aged 4-11 and their asthma was moderate to severe. We measured the degree to which parents and children felt the asthma was controlled with the seven-item Childhood Asthma Control Test questionnaire (C-ACT). The pediatric pulmonologists, who cared for just under two thirds of these children gave their assessment via the Global Initiative for Asthma (GINA) guidelines; the pediatricians, who looked after the remaining third, had no access to spirometry, and based their assessment of their young patients’ asthma-control on physical examination and information from parent and child.
First, we found that the reliable C-ACT test showed that asthma was, in fact, uncontrolled in more than half (53 percent) of the 354 children. Next, we compared the assessments of asthma-control made by the children, their parents and their doctors, and immediately found wide discrepancies. Of the 229 children who indicated in the C-ACT that their asthma was uncontrolled, more than half of their parents (54 percent) described the condition as under control, as did close to half their physicians (42 percent).
There are important messages here for those who care for children with asthma — both their parents and their doctors. One striking fact is the discord between how the physicians and the children assessed the degree of asthma-control. When we add into this mix the fact that half the parents of youngsters with uncontrolled asthma mistakenly believed the condition was sufficiently managed, we must consider the role of the parents. Perhaps physicians are misled by the parents into underestimating asthma control, prescribing suboptimal treatment, and thus explaining why in so many of the children we studied (over half), their asthma was not well managed.
Another key finding is the discord between parents and children — parents judging the asthma under control, while the child does not. This is the more remarkable since parents answered their C-ACT questions after their children had done so, and could hear and see their child’s responses. They even had an opportunity of talking to the child about complaints of which they may have been unaware. This can perhaps be explained by their lack of knowledge about asthma symptoms and their consequent failure to realize what their child’s answers indicate.
There are important conclusions to be drawn from what our study uncovered.
- One is that parents of asthmatic children must be taught not only to recognize symptoms in their children, but also to be aware of and attuned to these symptoms, and to understand the importance of inhaled corticosteroid treatment.
- Discrepancies between the answers of parent and child to the C-ACT questionnaire suggest that a helpful strategy for treating-physicians is to encourage parents and children to discuss their different perceptions of asthma control.
- Lastly, pediatricians, pediatric pulmonologists and asthma educators, must ask the questions essential for properly assessing the degree of control — specifically for details of both day- and nighttime symptoms, interference with activity, disturbed sleep, missed school, bronchodilator use for acute symptoms and unscheduled medical care. As well as the information given them by parents, asthma doctors/educators should themselves pose all these questions to the children to avoid unwitting misinformation or underestimation.
Today’s post is from Sean Palfrey, MD. Dr. Palfrey is a Clinical Professor of Pediatrics and Public Health at the Boston University School of Medicine and a volunteer for the American Lung Association in Massachusetts’ Healthy Air Campaign
Every time 8-year-old Mia leaves the house to play outside with friends, her mother, Rachael, worries that her daughter might suffer a serious asthma attack. Although she knows it would be unfair and unhealthy to keep Mia trapped inside every day after school or prevent her from participating in sleepovers and school field trips, it is sometimes hard for Rachael to let go of the memory of Mia’s early years.
Mia, like an ever-increasing number of Massachusetts children, has had to endure more than her fair share of severe asthma attacks. During one attack, she coughed so hard that she burst blood vessels in her eyes. Although these attacks are somewhat less frequent now, countless visits to the emergency room hardened her family to the harsh realities of raising a child with asthma, which can be deadly at worst and terrifying at best.
Because air pollution can be a recipe for disaster for Mia, Rachael continues to be vigilant about checking air quality forecasts and has often changed her family’s plans if an unhealthy air quality day is on the horizon. On days when the air quality is going to enter the code orange or red zones, Rachael knows it’s safer to keep Mia indoors than to risk her having an acute asthma attack.
One in ten people in the Bay State suffer with asthma, which is higher than the national average. We are seeing and treating an increasing number of children like Mia whose lives could be so much safer, happier and more successful if only we could only write a prescription for healthy air.
While those of us in the medical community do not have the power to write such a prescription, the U.S. Environmental Protection Agency (EPA) does. Much to its credit, the EPA has finally taken necessary steps to clean up the most prolific stationary source of air pollution in this country—coal-fired power plants. No other industry produces more carbon pollution, and as temperature trends continue to rise, the dangers of carbon pollution increase exponentially because of this simple equation: heat plus carbon pollution equals smog.
Nearly a third of our state’s residents live in failing or near-failing air quality zones, according to the American Lung Association’s 2013 State of the Air report. Massachusetts is not only threatened by pollution from its own coal-fired power plants but from other downwind sources that grant us the loathsome distinction of being know as America’s “tailpipe”. It’s no wonder Rachael has struggled at times to keep Mia’s asthma attacks at bay. No matter how aggressive Massachusetts healthy air laws are, our children and adults will continue to suffer until a national solution is established.
The EPA’s current proposal applies to all new coal-fired power plants, but should also stimulate technological advances that could one day dramatically reduce pollution from our nation’s expansive fleet of power plants. As a country that prides itself on ambitious innovation, we certainly have the ability to make clean energy and healthy air a reality for our children’s and for all future generations, if and when we have the will.
The truth is, we can’t afford not to. Pollution from coal-fired power plants alone costs hard working people, including the Murphy family, tens of millions of dollars every year in health care expenses from hospital bills to costly co-pays. Taxpayers also shoulder the burden of these increases health care costs.
The bottom line is that air pollution kills and makes healthy living difficult for many. Dirty air not only triggers childhood asthma attacks, but is also known to cause the cancers, strokes and heart attacks that take from us those closest to us and most vulnerable—older adults and people with chronic lung and heart disease.
Shouldn’t we be asking the EPA when our country will finally begin to clear the air?
My favorite clinic days are when I have the luxury to turn a 10 minute visit into a 30 minute visit of face-face time. Recently I saw a 16 year old girl who was being seen for asthma for the third time in 2 weeks. She had been seen in urgent care, then the ED, and now was being seen for follow up.
She was on oral steroids, and finally better.
I wondered what could have prevented her from having this exacerbation. So, I asked, “Do you take your Flovent daily?”
“No, she doesn’t take Flovent at all,” her mother stated.
“Why?” I asked, certain that the answer was she could never remember, she didn’t know she was supposed to take it daily, she’s only supposed to take it when she’s sick, etc.
Her mother said, “I don’t know. You’ll have to ask her.”
As I turned to the 16 year old, she said, “I don’t want to gain weight.”
I looked down at her chart and happened to see her weight of 99 kg (218 pounds).
And with that we were off on a discussion on how:
- Weight gain is not a major side effect of inhaled steroids.
- Oral steroids are more likely to cause weight gain, so it would be better to take the inhaled steroids to prevent need for oral steroids.
- If oral steroids are needed, it’s more important to be able to breath than to risk gaining weight.
- And of course, we ventured into a conversation about her diet and exercise.
And during the entire conversation, mom and daughter were wide-eyed, smiling, and claiming they never knew any of this information. Nobody had ever taken the time to explain all of this.
Nobody had had the luxury to turn a 10 minute visit into a 30 minute one.