10 Quick Facts: Pediatric Asthma

Here are 10 important facts--the who, what, when, where, and why of pediactric asthma--to help pharmacists target thier efforts and provide up-to-the-minute care for their young patients.

Pharmacists Can Help Children with Asthma and Their Parents Cope with This Condition

Pediatric asthma is a common subject in the medical literature, with most reports emphasizing the presence of, adherence to, and recent changes in national guidelines. Many pharmacists don’t have the time to comb through guidelines that can be long and detailed to find the information most important to them at the dispensing counter.

We’ve assembled 10 important facts—the who, what, when, where, and why of pediatric asthma—to help pharmacists target their efforts and provide up-to-the-minute care for their young patients.

1. Asthma’s prevalence is highest among children aged 5 to 17 years, and that has been the case since 1999. Approximately 8.7 million American children (around 9% of the population younger than 18 years) have been diagnosed with this chronic inflammatory lung disease. Sometimes, these children may be symptom-free for days or weeks. At other times, they experience airflow obstruction, bronchial hyper-responsiveness, and/ or underlying airway inflammation. Some children only experience symptoms when exercising or when exposed to allergens or viral respiratory tract infections. Some cough, wheeze, gasp, and feel like rubber bands are tightening around their chests constantly. Asthma is a disability in the most basic sense of the word: It limits the child’s movements, senses, and activities. Soccer? Not today. Basketball? Maybe, if symptoms are controlled.¹

2. Uncontrolled asthma is epidemic in American children.² This is a great concern because kids who struggle to breathe miss activities and events that contribute to their normal development. For example, children with asthma missed 14 million days of school in 2008.¹ Missing school disrupts their routine, causes them to miss lessons, and decreases important social time with peers. The 2008 US National Heart, Lung, and Blood Institute (NHLBI) Global Strategy for Asthma Management and Prevention issued the following goals for patients and health care providers to address this epidemic³:

• Achieve and maintain control of asthma symptoms
• Maintain normal activity levels, including exercise
• Maintain pulmonary function as close to normal as possible
• Prevent asthma exacerbations
• Avoid adverse effects from asthma medications
• Prevent asthma mortality Pharmacists can help achieve these goals, especially in the area of monitoring for adverse drug reactions.

3. Life is not fair: Asthma affects African American children among the urban poor disproportionately.^2,4 In African American children, asthma’s prevalence is 60% higher than in other groups. The emergency department visit rate is 260% higher, and the hospitalization rate is 250% higher. More frightening, the death rate is 500% higher than in white children. ⁵ More than one-quarter of African American adolescent males have asthma.⁶ Experts indicate that there are several explanations for this disparity. There tend to be more environmental offenders (pollution, dust, mold, cockroach particles) in disadvantaged minority communities, and access to care is often compromised. Although it is documented that minority children tend to come to treatment later and manage their asthma less successfully, the reasons for these disparities are unclear. There is ample opportunity for pharmacists to help, either in their primary practice sites or as volunteers at clinics and schools in disadvantaged communities.

4. In children, allergies contribute more to their disease than in adults. Seventy percent of people (children and adults) who have asthma also have allergies. Among common allergens are tree, grass, and weed pollens; mold; animal dander; dust mites; and cockroach particles. Children exposed to high levels of cockroach droppings at home are 4 times more likely to have asthma than children with less exposure. Counseling patients and their families to avoid allergens when possible is best. Sometimes, avoidance is impossible. Allergy medication can help some patients.

Clinicians should consider starting children on allergy immunotherapy if a vaccine to the allergen is available and:

• They can establish a clear relationship between the patient’s symptoms and exposure to an unavoidable allergen.
• The patient experiences symptoms all year or during a major portion of the year.
• Pharmacologic management is ineffective, multiple medications are required, or the patient refuses medication.³

5. The pharmacist can make a difference. More than 10 years ago, the NHLBI guidelines recommended that after the asthma patient’s lead clinician introduces key messages, “Different members of the health care team should reinforce and expand on these messages during office visits and telephone calls or in more formal education sessions.”⁷ This is still true today. Pharmacists see patients more frequently than other health care providers—and they have multiple, consistent, and repeated opportunities to reinforce messages.

6. Patients don’t always listen, learn, and apply information health care professionals provide. In fact, health care professionals often assume that educating asthma patients about the disease will lead to fewer acute symptoms and improved medication adherence, but that is not necessarily the case.^8,9 Instead of focusing on broad education about asthma, clinicians need to target their interventions to very specific areas:

• Teaching patients to monitor symptoms or peak flow can reduce asthma morbidity; peak flow meters can indicate airway tightening hours or days before asthma symptoms occur.¹⁰
• Self-management approaches, which teach patients to identify their own adherence barriers, monitor their own medication use, set goals, and solve asthma-related problems as they arise, can reduce urgent care visits and help improve short-term adherence. This type of teaching often requires significantly more time than most pharmacists can commit.^9,11 Pharmacists can, however, emphasize a different key point at each counseling session.
• Comprehensive asthma education in programs—that is, several hours of education spread over several weeks— tailored to young children can improve quality of life and reduce urgent care visits. It can also help children become more self-sufficient.¹²

Most asthma education is provided by diagnosing and treating clinicians or via health plans’ disease management programs. Nevertheless, pharmacists need to increase their involvement in counseling asthma patients so that important messages are reinforced constantly.

When they dispense asthma medications, many pharmacists truncate counseling because they lack time, perceive parents as disinterested, or have no placebo devices to demonstrate inhalation techniques.¹³ Pharmacists need to be knowledgeable about the basic medications used to control asthma and provide relief during exacerbations (Table 1). They also need to be prepared and equipped to deliver counseling efficiently and effectively. They should ask medical sales representatives to provide demonstration inhalers or contact the manufacturer directly.

7. Correct inhaler use is a difficult skill to learn, and even when mastered, children’s skills may falter over time. Inhalers are the mainstay drug delivery method for asthmatics. When patients have poor inhaler technique, they receive suboptimal doses of the prescribed drug, resulting in poor asthma control. The best way to ensure that children and their parents know how to use an inhaler is to demonstrate its use when they fill new prescriptions—and when they pick up refills. Pharmacists should know the correct names for each part of the inhaler: pressurized canister, metering valve and stem, and mouthpiece actuator. They should discuss every step, regardless of how simple (removing the cap) or intuitive (rinsing or brushing teeth after steroids) the step may seem. It is also important to ask patients if their prescriber gave them a face mask or spacer to use with the inhaler; if so, the directions for use will be different.

8. Pharmacists’ abilities to demonstrate correct inhaler technique vary, and often need improvement or review. Pharmacists who demonstrate inhaler technique often are more likely to retain their skills. Those who don’t have the opportunity to keep this skill fresh need to find ways to stay abreast of changes.¹⁴ Reviewing the patient information provided with inhalers or finding directions on the Internet; handling demonstration inhalers to become familiar with all of the parts; and asking an asthma specialist for one-on-one training can bring skills up to speed.

9. Engaging the child in inhaler education is imperative. Younger children will feel important and begin to establish skills needed to be more self-sufficient later if they are included in counseling. Adolescents have a well-deserved reputation for being difficult as they deal with “developmental transitions,” so pharmacists need to find age-appropriate ways to communicate with them.¹⁵ Table 2 describes general teaching principles for patients who are prescribed inhalers. Actively engaging children and adolescents is different from just teaching—it means communicating with them so they feel like a partner in their care, and become invested in using medication properly. With young children, having a playful approach and challenging them to show you what they’ve learned or to teach you the skill is often useful. Asking them to keep a record of their adherence using stars or stickers often helps, too.

Pharmacists need to be particularly vigilant with adolescents. The rate of nearfatal episodes rises in the 12-to-15-year age range, probably as teens try to distance themselves from caregivers and self-manage.¹⁵ Preoccupied with how they appear to others, adolescents may become nonadherent because they don’t want to differentiate themselves from others. Emphasizing how treatment adherence allows them to continue to participate in activities is a good approach; telling them that using preventive medication at home will circumvent the need for emergency medication in public also helps. These approaches stress that medications make them more able to blend in rather than making them “different.” Techniques that appeal to their growing independence and love of technology are also useful.

In addition, pharmacists need to keep in mind that smoking is a “pediatric disease.” Individuals who are still nonsmokers by age 19 are unlikely to ever smoke. Nicotine addiction begins when most tobacco users are teenagers, and for asthmatics, smoking seriously complicates disease management. Actively discourage smoking among children with asthma.

10. Stepping down medications after asthma is controlled is uncharted territory. The NHLBI guidelines recommend reducing the inhaled corticosteroid doses by 25% to 50% every 3 months to the lowest dose that maintains control, but this recommendation was made with sparse evidence to support it. Gradual reduction makes sense because people with asthma deteriorate at highly variable rates and intensities. Clinicians need to use their judgment.16 When patients are on tapering doses, pharmacists need to ask questions that will give the patient the opportunity to voice concerns.

One last reminder: Don’t forget that patients need to clean hydrofluoroalkane inhalers regularly to prevent medication build-up and blockages. Remind patients and their parents to schedule cleaning according to the manufacturer’s directions, which usually recommend cleaning inhalers once a week. PT

Ms. Bartok is a medical writer who lives in eastern Connecticut.

References

• American Lung Association, 2009 American Lung Association. Epidemiology and statistics unit research and scientific affairs: Trends in asthma morbidity and mortality. 2010. Available at www.lungusa.org/finding-cures/our-research/trend-reports/asthma-trend-report.pdf.
• Akinbami LJ and National Center for Health Statistics. The state of childhood asthma, United States, 1980-2005. Advance Data 381 (2006), pp. 1—24.
• National Heart Lung and Blood Institute. National Institutes of Health. Guidelines for the Diagnosis and Management of Asthma (EPR-3). 2007. Available at www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf. Accessed July 11, 2011.
• Rastogi D, Shetty A, Neugebauer R, Harijith A. National Heart, Lung, and Blood Institute guidelines and asthma management practices among inner-city pediatric primary care providers. Chest. 2006;129:619-23.
• Akinbami LJ, LaFleur BJ, Schoendorf KC. Racial and income disparities in childhood asthma in the United States. Ambul Pediatr. 2002;2:382-7.
• Saha C, Riner ME, Liu G. Individual and neighborhood-level factors in redicting asthma. Arch Pediatr Adolesc Med. 2005;159:759-63.
• National Heart Lung and Blood Institute. Guidelines for the diagnosis and management of asthma. 1998. National Institutes of Health, Bethesda (MD) (1997) NIH publication no. 97-4051.
• Ho J, Bender BG, Gavin LA, O'Connor SL, Wamboldt MZ, Wamboldt FS. Relations among asthma knowledge, treatment adherence, and outcome. J Allergy Clin Immunol. 2003;111:498-502.
• Walders N, Kercsmar C, Schluchter M, Redline S, Kirchner HL, Drotar D. An interdisciplinary intervention for undertreated pediatric asthma. Chest. 2006;129:292-9.
• Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003;326:1308-9.
• Put C, van den Bergh O, Lemaigre V, Demedts M, Verleden G. Evaluation of an individualised asthma programme directed at behavioural change. Eur Respir J. 2003;21:109-15.
• Cicutto L, Murphy S, Coutts D, O'Rourke J, Lang G, Chapman C, Coates P. Breaking the access barrier: evaluating an asthma center's efforts to provide education to children with asthma in schools. Chest. 2005;128:1928-35.
• Pradel FG, Obeidat NA, Tsoukleris MG. Factors affecting pharmacists' pediatric asthma counseling. J Am Pharm Assoc (2003). 2007;47:737-46.
• Basheti IA, Armour CL, Reddel HK, Bosnic-Anticevich SZ. Long-term maintenance of pharmacists' inhaler technique demonstration skills. Am J Pharm Educ. 2009;73:32.
• Dinakar C. Update on asthma step-therapy. Allergy Asthma Proc. 2010;31:444-51.
• Bruzzese JM, Bonner S, Vincent EJ, et al. Asthma education: the adolescent experience. Patient Educ Couns. 2004;55:396-406.