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Case 1 diagnosis: allergy bullying, clinical pearls.

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Case 1: A 12-year-old girl with food allergies and an acute asthma exacerbation

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Lopamudra Das, Michelle GK Ward, Case 1: A 12-year-old girl with food allergies and an acute asthma exacerbation, Paediatrics & Child Health , Volume 19, Issue 2, February 2014, Pages 69–70, https://doi.org/10.1093/pch/19.2.69

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A 12-year-old girl with a history of asthma presented to the emergency department with a three-day history of increased work of breathing, cough and wheezing. She reported no clear trigger for her respiratory symptoms, although she had noted some symptoms of a mild upper respiratory tract infection. With this episode, the patient had been using a short-acting bronchodilator more frequently than she had in the past, without the expected resolution of symptoms.

On the day of presentation, the patient awoke feeling ‘suffocated’ and her mother noted her lips to be blue. In the emergency department, her oxygen saturation was 85% and her respiratory rate was 40 breaths/min. She had significantly increased work of breathing and poor air entry bilaterally to both lung bases, with wheezing in the upper lung zones. She was treated with salbutamol/ipratropium and received intravenous steroids and magnesium sulfate. Her chest x-ray showed hyperinflation and no focal findings.

Her medical history revealed that she was followed by a respirologist for her asthma, had good medication adherence and had not experienced a significant exacerbation for six months. She also had a history of wheezing, dyspnea and pruritis with exposure to peanuts, chickpeas and lentils; she had been prescribed an injectible epinephrine device for this. However, her device had expired at the time of presentation. In the past, her wheezing episodes had been seasonal and related to exposure to grass and pollens; this presentation occurred during the winter. Further history revealed the probable cause of her presentation.

Although reluctant to disclose the information, our patient later revealed that she had been experiencing significant bullying at school, which was primarily related to her food allergies. Three days before her admission, classmates had smeared peanut butter on one of her schoolbooks. She developed pruritis immediately after opening the book and she started wheezing and coughing later that day. This event followed several months of being taunted with peanut products at school. The patient was experiencing low mood and reported new symptoms of anxiety related to school. The review of systems was otherwise negative, with no substance use.

The patient's asthma exacerbation resolved with conventional asthma treatment. Her pulmonary function tests were nonconcerning (forced expiratory volume in 1 s 94% and 99% of predicted) after her recovery. The trigger for her asthma exacerbation was likely multifactorial, related to exposure to the food allergen as well as the upper respiratory infection. A psychologist was consulted to assess the symptoms of anxiety and depression that had occurred as a result of the bullying. During the hospitalization, the medical team contacted the patient's school to provide education on allergy bullying, treatment of severe allergic reactions and its potential for life-threatening reactions with exposure to allergens. The medical team also recommended community resources for further education of students and staff about allergy bullying and its prevention.

Allergy bullying is a form of bullying with potentially severe medical outcomes. In recent years, it has gained increasing notoriety in schools and in the media. Population-based studies have shown that 20% to 35% of children with allergies experience bullying. In many cases (31% in one recent study [ 1 ]), this bullying is related directly to the food allergy. From a medical perspective, there are little published data regarding allergy bullying, and many health care providers may not be aware of the issue.

Allergy bullying can include teasing a child about their allergy, throwing food at a child, or even forcing them to touch or eat allergenic foods. Most episodes of allergy bullying occur at school, and can include episodes perpetrated by teachers and/or staff ( 2 ).

Allergy bullying can lead to allergic reactions, which may be mild or severe (eg, urticaria, wheezing, anaphylaxis), but may also lead to negative emotional consequences (sadness, depression) ( 2 ) and an overall decrease in quality of life measures ( 1 ). Adolescents commonly resist using medical devices, such as injectible epinephrine devices, and bullying may be a contributing factor for this ( 3 ). Attempting to conceal symptoms in a bullying situation may place children at risk for a worse outcome.

Physicians can play a key role in detecting allergy bullying and its health consequences. In many cases, children have not discussed this issue with their parents ( 1 ). Given the prevalence of bullying, its potential to lead to severe harm, including death, and the lack of awareness of this issue, clinicians should specifically ask about bullying in all children and teens with allergies. Physicians can also work with families and schools to support these children, educate their peers and school staff, and help prevent negative health outcomes from allergy bullying.

Online resources

www.anaphylaxis.ca − A national charity that aims to inform, support, educate and advocate for the needs of individuals and families living with anaphylaxis, and to support and participate in research. This website includes education modules for schools and links to local support groups throughout Canada.

www.whyriskit.ca/pages/en/live/bullying.php − A website for teenagers with food allergies; includes a segment that addresses food bullying.

www.foodallergy.org − Contains numerous resources for children and their families, including a significant discussion on bullying and ways to prevent it.

Allergy bullying is common but is often unrecognized as a factor in clinical presentations of allergic reactions.

Physicians should make a point of asking about bullying in patients with allergies and become familiar with resources for dealing with allergy bullying.

Physicians can play roles as advocates, educators and collaborators with the school system to help make the school environment safer for children with allergies who may be at risk for allergy bullying.

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  • Volume 11, Issue 7
  • Management of asthma in childhood: study protocol of a systematic evidence update by the Paediatric Asthma in Real Life (PeARL) Think Tank
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  • http://orcid.org/0000-0002-4675-9616 Alexander G Mathioudakis 1 , 2 , 3 ,
  • Michael Miligkos 4 ,
  • Cristina Boccabella 5 ,
  • Gioulinta S Alimani 3 , 6 ,
  • Adnan Custovic 7 ,
  • A Deschildre 8 ,
  • Francine Monique Ducharme 9 ,
  • Omer Kalayci 10 ,
  • Clare Murray 1 , 2 ,
  • Antonio Nieto Garcia 11 ,
  • Wanda Phipatanakul 12 ,
  • David Price 13 , 14 ,
  • Aziz Sheikh 15 ,
  • Ioana Octavia Agache 16 ,
  • Leonard Bacharier 17 ,
  • http://orcid.org/0000-0001-5639-0528 Apostolos Beloukas 6 , 18 ,
  • Andrew Bentley 2 , 19 ,
  • Matteo Bonini 5 , 20 ,
  • Jose A Castro-Rodriguez 21 ,
  • Giuseppe De Carlo 22 ,
  • Timothy Craig 23 ,
  • Zuzana Diamant 24 , 25 , 26 ,
  • Wojciech Feleszko 27 ,
  • Tim Felton 1 , 2 ,
  • James E Gern 28 ,
  • Jonathan Grigg 29 ,
  • Gunilla Hedlin 30 ,
  • Elham M Hossny 31 ,
  • Despo Ierodiakonou 32 ,
  • Tuomas Jartti 33 ,
  • Alan Kaplan 34 ,
  • Robert F Lemanske 28 ,
  • Peter N Le Souëf 35 ,
  • Mika J Mäkelä 36 ,
  • Georgios A Mathioudakis 3 ,
  • Paolo Matricardi 37 ,
  • Marina Mitrogiorgou 38 ,
  • Mario Morais-Almeida 39 ,
  • Karthik Nagaraju 40 ,
  • Effie Papageorgiou 6 ,
  • Helena Pité 39 , 41 , 42 ,
  • Paulo M C Pitrez 43 ,
  • Petr Pohunek 44 ,
  • Graham Roberts 45 , 46 , 47 ,
  • Ioanna Tsiligianni 32 ,
  • Stephen Turner 48 ,
  • Susanne Vijverberg 49 ,
  • Tonya A Winders 50 ,
  • http://orcid.org/0000-0001-5939-812X Gary WK Wong 51 ,
  • Paraskevi Xepapadaki 52 ,
  • Heather J Zar 53 , 54 ,
  • http://orcid.org/0000-0002-4448-3468 Nikolaos G Papadopoulos 1 , 52
  • 1 Division of Infection, Immunity and Respiratory Medicine , The University of Manchester , Manchester , UK
  • 2 North West Lung Centre, Manchester University NHS Foundation Trust , Manchester , UK
  • 3 Athens Breath Centre , Athens , Greece
  • 4 First Department of Pediatrics, "Aghia Sofia" Children's Hospital , University of Athens , Athens , Attica , Greece
  • 5 Department of Cardiovascular and Thoracic Sciences , Catholic University of the Sacred Heart , Milano , Lombardia , Italy
  • 6 Department of Biomedical Sciences , University of West Attica , Egaleo , Attica , Greece
  • 7 Department of Paediatrics , Imperial College London , London , UK
  • 8 Unité de Pneumologie et Allergologie Pédiatriques, Hôpital Jeanne de Flandre , CHU Lille , Lille , Hauts-de-France , France
  • 9 Pediatrics , University of Montreal , Montreal , Quebec , Canada
  • 10 Pediatric Allergy and Asthma Unit , Hacettepe Universitesi , Ankara , Turkey
  • 11 Pulmonology and Allergy Unity , La Fe University and Polytechnic Hospital , Valencia , Comunidad Valenciana , Spain
  • 12 Pediatric Allergy and Immunology , Children's Hospital Boston , Boston , Massachusetts , USA
  • 13 Centre of Academic Primary Care , University of Aberdeen , Aberdeen , UK
  • 14 Observational and Pragmatic Research Institute , Singapore
  • 15 Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics , The University of Edinburgh , Edinburgh , UK
  • 16 Allergy and Clinical Immunology , Transylvania University , Brasov , Romania
  • 17 Department of Allergy, Immunology, and Pulmonary Medicine , University of Washington , Seattle , Washington , USA
  • 18 Institute of Infection and Global Health , University of Liverpool , Liverpool , UK
  • 19 Acute Intensive Care Unit , University Hospital of South Manchester NHS Foundation Trust , Manchester , Greater Manchester , UK
  • 20 National Heart and Lung Institute (NHLI) , Imperial College London , London , UK
  • 21 Department of Pediatrics , Pontifical Universidad Catolica de Chile , Santiago , Chile
  • 22 Allergy and Airway Diseases Patient's Associations , European Federation of Pharmaceutical Industries and Associations , Brussels , Belgium
  • 23 Allergy, Asthma and Immunology , Penn State University , Hershey , Pennsylvania , USA
  • 24 Department of Respiratory Medicine and Allergology, Institute for Clinical Science , Skane University Hospital Lund Hematological Clinic , Lund , Skåne , Sweden
  • 25 Department of Respiratory Medicine , First Faculty of Medicine, Charles University and Thomayer Hospital , Prague , Czech Republic
  • 26 Department of Clinical Pharmacy & Pharmacology , University of Groningen, University Medical Center of Groningen and QPS-NL , Groningen , Netherlands
  • 27 Department of Pediatric Pulmonology and Allergy , Medical University of Warsaw , Warszawa , Poland
  • 28 Department of Pediatrics and Medicine , University of Wisconsin School of Medicine and Public Health , Madison , Wisconsin , USA
  • 29 Centre for Genomics and Child Health, Blizard Institute , Queen Mary University of London , London , UK
  • 30 Department of Women's and Children's Health , Karolinska Institute , Stockholm , Stockholm , Sweden
  • 31 Pediatric Allergy and Immunology Unit , Ain Shams University , Cairo , Egypt
  • 32 Department of Social Medicine, Faculty of Medicine , University of Crete , Rethimno , Greece
  • 33 Department of Paediatrics , University of Turku , Turku , Finland
  • 34 Family Physician, Airways Group of Canada , University of Toronto , Toronto , Ontario , Canada
  • 35 School of Paediatrics and Child Health , University of Western Australia , Perth , Western Australia , Australia
  • 36 Department of Allergy , University of Helsinki , Helsinki , Uusimaa , Finland
  • 37 Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine , Charité - University Medicine , Berlin , Germany
  • 38 Third Department of Paediatrics , National and Kapodistrian University of Athens School of Health Sciences , Athens , Greece
  • 39 Allergy Center , Hospital CUF Descobertas , Lisboa , Portugal
  • 40 Allergy & Asthma , VN , Chennai , India
  • 41 Allergy Center , CUF Infante Santo Hospital , Lisbon , Portugal
  • 42 Chronic Diseases Research Center (CEDOC) , NOVA Medical School / Faculdade de Ciências Médicas, Universidade NOVA de Lisboa , Lisbon , Portugal
  • 43 Laboratory of Respiratory Physiology, Infant Center , School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) , Porto Alegre , Brazil
  • 44 Paediatric Department , Motol University Hospital , Praha , Czech Republic
  • 45 The David Hide Asthma and Allergy Research Centre , St Mary's Hospital , Newport Isle of Wight , UK
  • 46 Faculty of Medicine, Clinical and Experimental Sciences and Human Development in Health Academic Units , University of Southampton , Southampton , UK
  • 47 NIHR Biomedical Research Centre , University Hospital Southampton NHS Foundation Trust , Southampton , UK
  • 48 Department of Child Health , University of Aberdeen , Aberdeen , Aberdeen , UK
  • 49 Department of Respiratory Medicine and Department of Pediatric Pulmonology , University of Amsterdam , Amsterdam , Netherlands
  • 50 Allergy & Asthma , Global Patient Platform , Virginia , Virginia , USA
  • 51 Department of Paediatrics, Faculty of Medicine , The Chinese University of Hong Kong , Sha Tin , Hong Kong
  • 52 Allergy Department, 2nd Paediatric Clinic , National and Kapodistrian University of Athens , Athens , Attica , Greece
  • 53 Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital , University of Cape Town , Rondebosch , Western Cape , South Africa
  • 54 Unit on Child and Adolescent Health , Medical Reaserch Council , Cape Town , South Africa
  • Correspondence to Professor Nikolaos G Papadopoulos; ngpallergy{at}gmail.com

Introduction Clinical recommendations for childhood asthma are often based on data extrapolated from studies conducted in adults, despite significant differences in mechanisms and response to treatments. The Paediatric Asthma in Real Life (PeARL) Think Tank aspires to develop recommendations based on the best available evidence from studies in children. An overview of systematic reviews (SRs) on paediatric asthma maintenance management and an SR of treatments for acute asthma attacks in children, requiring an emergency presentation with/without hospital admission will be conducted.

Methods and analysis Standard methodology recommended by Cochrane will be followed. Maintenance pharmacotherapy of childhood asthma will be evaluated in an overview of SRs published after 2005 and including clinical trials or real-life studies. For evaluating pharmacotherapy of acute asthma attacks leading to an emergency presentation with/without hospital admission, we opted to conduct de novo synthesis in the absence of adequate up-to-date published SRs. For the SR of acute asthma pharmacotherapy, we will consider eligible SRs, clinical trials or real-life studies without time restrictions. Our evidence updates will be based on broad searches of Pubmed/Medline and the Cochrane Library. We will use A MeaSurement Tool to Assess systematic Reviews, V.2, Cochrane risk of bias 2 and REal Life EVidence AssessmeNt Tool to evaluate the methodological quality of SRs, controlled clinical trials and real-life studies, respectively.

Next, we will further assess interventions for acute severe asthma attacks with positive clinical results in meta-analyses. We will include both controlled clinical trials and observational studies and will assess their quality using the previously mentioned tools. We will employ random effect models for conducting meta-analyses, and Grading of Recommendations Assessment, Development and Evaluation methodology to assess certainty in the body of evidence.

Ethics and dissemination Ethics approval is not required for SRs. Our findings will be published in peer reviewed journals and will inform clinical recommendations being developed by the PeARL Think Tank.

PROSPERO registration numbers CRD42020132990, CRD42020171624.

  • paediatrics
  • paediatric thoracic medicine
  • thoracic medicine

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2020-048338

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Strengths and limitations of this study

Broad evidence syntheses on the management of childhood asthma, with a focus on the differential treatment response according to age and disease phenotypes could reveal clinically exploitable information, that will be used in the development of clinical and research recommendations by Paediatric Asthma in Real Life.

A rigorous methodology that includes thorough evaluation of the literature, appropriate evaluation of the methodological quality of individual studies and—when appropriate—of the body of evidence, and presentation of overall effect estimates.

A prospectively published protocol increases the transparency and allowed for peer-review of the methodology used.

A potential limitation of the overview of systematic reviews (SRs) is that the feasibility of conducting the planned subgroup analyses will depend on whether relevant data have been captured in existing SRs.

Introduction

Having a global prevalence that is anticipated to exceed 400 million children by the year 2025, childhood asthma represents a huge health and socioeconomic burden to patients, their families and the society. 1–3 Despite its diverging mechanisms, triggers, outcomes and response to treatment, childhood asthma is often still approached as an extension of adult asthma. 4 It is underaddressed in clinical guidelines, likely due to unclear diagnosis, limited availability of safety, efficacy and effectiveness data in this population. Clinical recommendations are to a large extent informed by data extrapolated from clinical studies conducted in adults. 2–5

Numerous challenges complicate conducting interventional research studies in children with asthma. Besides the lack of consensus on its definition and diagnostic criteria, childhood asthma is highly heterogeneous and our understanding of different paediatric asthma phenotypes is still limited or contradictory. 6 This is further emphasised by significant variability in disease progression, outcomes and treatment response in children with different phenotypes or ages5, 7 potentially complicating interpretation of trials’ findings. In addition, there are regulatory and ethical constraints in conducting interventional research in children. 8 9 However, this results in the administration of treatments that have not been adequately evaluated in relevant (paediatric) populations, that is, evidently suboptimal.

Paediatric Asthma in Real Life (PeARL), an international Think Tank focusing on paediatric asthma, was initiated in the context of the respiratory effectiveness group, to address this evidence deficit. In a recent international, multistakeholder survey, we have identified and prioritised unmet needs on paediatric asthma. 10 A need for systematic evidence updates focusing on the management of asthma in different age groups emerged. Herein, we present the protocol for a series of systematic evidence updates aiming to summarise direct evidence from clinical studies in children with asthma, evaluating the safety and clinical effectiveness of pharmacological interventions for maintenance management and for the treatment of acute severe asthma attacks, defined as those leading to an emergency presentation with/without hospital admission, in different age groups. Our work will be used to inform clinical recommendations being developed by the PeARL Think Tank. Therefore, we need solid evidence on the efficacy on safety of various interventions. It is considered crucial to incorporate evidence derived from real-life observational studies, which may carry a lower strength of evidence than randomised controlled trials (RCTs), but are available in higher abundance and provide a better representation of clinical practice in real life, where for example, treatment compliance or inhaler technique may be problematic.

Methods and analysis

We will conduct two systematic evidence updates, based on protocols prospectively registered in the PROSPERO register (CRD42020132990, 11 CRD42020171624 12 ). The first will evaluate the safety and clinical effectiveness of pharmacological maintenance treatments for childhood asthma, while the other will focus on the pharmacotherapy of acute severe asthma attacks, defined as those requiring a hospital admission or emergency presentation. We will use standard methodology recommended by the Cochrane Collaboration 13 and will follow the Preferred Reported Items for Systematic Reviews and Meta-Analyses statement. 14

Preliminary searches revealed several RCTs evaluating maintenance pharmacotherapy of childhood asthma, which have already been summarised in high-quality systematic reviews (SRs), some conducted by the Cochrane Collaboration. We identified >40 up-to-date SRs evaluating inhaled corticosteroids (ICS), long-acting beta-2 agonists (LABA), long-acting muscarinic antagonists (LAMA), leukotriene receptor antagonists (LTRA) or biologic therapies, as first line or add-on treatment for asthma in children. As a result, we opted to produce an overview of existing SRs of clinical trials and real-life studies. 15 .

We found less up-to-date SRs on the management of acute severe asthma attacks in children, mainly focusing on short-acting beta-2 agonists (SABA), short acting muscarinic antagonists, oral corticosteroids, aminophylline and magnesium that were recently summarised in a Cochrane Overview of SRs. 16 However, when evaluating the literature, we identified several other pharmacological interventions that are tested in small trials or real-life studies, and while they may show promising early results, they have not been assessed further or introduced in clinical practice guidelines. 17–23 For this reason, we will conduct de novo synthesis of comparative clinical studies of any design aiming to identify any pharmacological intervention that has been tested for acute severe asthma attacks, followed by focused meta-analyses of promising interventions not covered by existing high-quality SRs or clinical practice guidelines.

Overview of SRs evaluating maintenance pharmacotherapy for paediatric asthma

Eligibility criteria.

Eligible studies will comprise SRs and meta-analyses of controlled clinical trials or of real-life studies evaluating maintenance treatments that are broadly used in clinical practice for asthma or recurrent wheeze in children and adolescents, aged up to 18 years. More specifically, we will include SRs comparing any combination of ICS, LABA, LAMA, LTRA, biological therapies (namely omalizumab, mepolizumab, reslizumab, benralizumab or dupilumab), or placebo as monotherapy or add-on maintenance therapy for paediatric asthma. We will accept SRs and meta-analyses evaluating any molecule of the above-mentioned categories, administered at any dose and for a duration of at least 6 weeks. SRs comparing asthma maintenance treatment both in children and adults will be included provided that paediatric data are presented separately. We will only include SRs published between 2005 and December 2020 and reported in the English language. Older SRs are probably outdated and will only be considered in the absence of high-quality, newer SRs.

Outcome measures

The primary outcomes of this overview will be the number of acute attacks requiring the administration of oral corticosteroids or an emergency visit, and the number of acute attacks requiring hospitalisation. Secondary outcomes will include lung function measures, acute attacks irrespective of the severity, symptom scores (including symptom free and rescue medication free days), asthma control, asthma-specific quality of life scores, use of rescue medications, withdrawal rates (overall, due to lack of efficacy or adverse events), adverse events and serious adverse events.

Search strategy and study selection

The electronic databases of Medline/PubMed and Cochrane Library will be systematically searched, using appropriate controlled vocabulary and free search terms to identify relevant SRs (terms describing: childhood asthma, LABA, LAMA, LTRA, ICS, biologics, SRs, detailed search strategy is available in online supplemental appendix ). Databases will be searched from 2006 onwards. Titles and abstracts of all identified manuscripts, and the full texts of potentially relevant manuscripts, will be screened by two investigators independently. We will report the reasons of exclusion of studies that will be excluded after full-text review. Disagreement will be resolved through discussion or adjudication by a third investigator, when necessary.

Supplemental material

Data abstraction.

For each of the included SRs, one investigator will extract the full reference and study identifiers, references of the included trials evaluating paediatric populations, eligibility criteria, predefined outcomes, number and baseline characteristics of the participants and details on the outcomes of interest. A second investigator will cross-check for validity.

Risk of bias assessment

A MeaSurement Tool to Assess systematic Reviews, V.2 (AMSTAR 2) tool will be used to evaluate the methodological quality of all included SRs. 24 25 The AMSTAR 2 tool evaluates 16 domains, focusing on the methodological design, interpretation and potential risk of bias involved in the conduct of a SR. It is considered by the AMSTAR 2 team that seven domains could critically affect the validity of the review, while the remaining domains describe non-critical weaknesses. Critical flaws for an SR include (1) lack of prospective protocol registration, (2) inadequate literature searches, (3) lack of justification of excluding individual studies, (4) of risk of bias evaluation or (5) of risk of bias consideration in interpreting the results, (6) of assessment of presence and likely impact of publication bias and (7) inadequate methodology for conducting meta-analysis. We will consider the results of an SR of high quality, if there is only one or none non-critical weakness, and of moderate quality, if there are more than one non-critical weaknesses. If there are one or more critical weaknesses, then we will consider the confidence low or very low, respectively. Two of the SRs will evaluate the risk of bias independently and disagreement will be resolved through discussion, or adjudication by a third reviewer.

Qualitative synthesis

We will summarise descriptively or in a tabulated format the characteristics of the included SRs and outcomes of interest. When several SRs evaluate the same intervention, we will compare their eligibility criteria, included studies and methodological quality as evaluated by the AMSTAR-2 tool, as well as the pertinent subgroup analyses that are presented. We will present in detail the results of the SR that is most recent, more complete and of high methodological quality. If no single SR fulfil these criteria, we will present in detail more than one SRs. From the remaining SRs, we will present pertinent additional information that may include, such as details about additional outcomes, or additional subgroups.

We will specifically report on the differential effectiveness of the interventions across different maintenance treatment steps (severity), age groups or paediatric asthma phenotypes.

SR of clinical studies evaluating the management of acute severe asthma attacks

Over the past decades, several interventions have been tested for the management of acute severe asthma attacks, such as ketamine or macrolide antibiotics. 17–23 Despite promising early findings, some of these interventions were not further tested in robust, prospective controlled clinical trials. This may partially be due to challenges in conducting experimental clinical studies in children, as previously discussed, particularly during acute, life-threatening conditions.

To identify all evaluated treatments, a two-stage approach will be followed. First, a broad search strategy will be used to identify all pharmacological interventions that have been tested as potential treatments for acute severe asthma attacks. Next, medications that showed positive clinical results, but are not yet thoroughly evaluated in clinical studies and meta-analyses and are therefore not recommended by international asthma guidelines (such as the National Institute for Health and Care Excellence asthma guidelines, the British Thoracic Society and Scottish Intercollegiate Guidelines Network asthma guidelines, the National Asthma Education and Prevention Programme or the Global Strategy for Asthma Management and Prevention document), will be selected and further evaluated in individual meta-analyses. The aim will be to identify novel interventions that could be recommended for use in clinical practice, or might require further evaluation in clinical research studies, to confirm their safety and effectiveness profiles.

Medline/PubMed and the Cochrane Library will be searched, using a broad search strategy, aimed to identify any clinical research studies evaluating the management of acute severe asthma attacks (detailed search strategy is available in online supplemental appendix ).

Any study evaluating pharmacological treatments for acute severe asthma attacks in children and adolescents (<18 years of age) will be included. Any comparative clinical research study, including experimental and observational studies, as well as SRs of such studies will be considered eligible for inclusion. We will only include studies published until May 2021 and reported in the English language, without time restrictions.

Eligible studies will be grouped according to the drug category they evaluate and will be presented narratively. Study design, characteristics and outcomes of interest will be reported descriptively or in a tabulated format. Outcomes of interest are the same for this broad SR and individual medication meta-analyses and are detailed in the next section.

Individual medication meta-analyses

These meta-analyses will further evaluate the safety and clinical effectiveness of individual medications that were assessed by the initial broad SR and were found to be of potential clinical value for the treatment of acute severe asthma attacks. In contrast to most preceding SRs and meta-analyses, we will include data from observational comparative effectiveness (real-life) studies, as well as controlled clinical trials.

For each meta-analysis, eligible studies will comprise controlled clinical trials and observational comparative effectiveness studies comparing the index medication with placebo, no treatment or any active control, as an add-on treatment for acute severe asthma attacks. Index medication will be defined based on the pharmacological action, meaning that molecules targeting the same pharmacological target (eg, salbutamol and terbutaline, both being SABA) will be grouped. Only studies evaluating the management of acute severe asthma attacks, defined as those requiring a hospital admission or emergency presentation, in children and adolescents, aged between 1 and 18 years of age will be included. Studies evaluating both children and adults will be included, provided that paediatric data are reported separately or that we will be able to access these data after requesting them from the investigators. We will only include observational studies that meet the primary criteria of the REal Life EVidence AssessmeNt Tool (RELEVANT) tool (see risk of bias). We will include studies published until May 2021 and reported in the English language.

The primary outcome measures will be (1) treatment success or treatment failure rate evaluated at any time point, within 2 weeks from presentation, (2) serious adverse events and (3) need for asthma related hospitalisation evaluated at any tim epoint within 2 weeks from presentation. Treatment success will be defined as a complete resolution of the symptoms, or an improvement in the clinical signs, symptoms and/or laboratory findings that fulfils specific criteria or thresholds prespecified by the study team. Treatment failure will be defined as a significant deterioration of the patients’ clinical conditions that fulfils specific criteria prespecified by the study team. For example, treatment failure may be defined as the need for paediatric intensive care unit admission, ventilation or death. The definitions of treatment success and treatment failure vary significantly across clinical studies evaluating the management of acute asthma in children; for this reason, meta-analyses will only be conducted in cases they are considered meaningful by the investigators. Need for asthma-related hospitalisation will not be relevant for studies only evaluating hospitalised participants. Secondary outcomes will include (1) mortality, (2) duration of asthma-related hospitalisation, (3) need for intensive care unit admission, (4) duration of intensive care unit stay, (5) re-exacerbation rate, (6) rehospitalisation rate and (7) adverse events. All outcomes will be evaluated at a maximum follow-up of 6 months, as longer-term outcomes are less likely to be directly linked with the index acute event.

Using appropriate controlled vocabulary and free search terms, we will systematically search Medline/PubMed, EMBASE and the Cochrane Library to identify controlled clinical trials and observational comparative effectiveness studies evaluating the safety, efficacy and/or clinical effectiveness of the selected medication (sample search strategies are available in the online appendix). We will also search the WHO International Clinical Trials Registry Platform search portal, the abstract proceedings of the European Respiratory Society, the American Thoracic Society, the Asian Pacific Society of Respirology, the European Academy of Allergy and Clinical Immunology, the American Academy of Allergy, Asthma and Immunology, and the World Allergy Organization, as well as the reference lists of all included studies. All sources will be searched from inception, without language limitations. We will follow standard methodology for screening titles, abstracts and the full text of all identified studies, as described previously.

The full study reference, study identifiers, details on the study design, eligibility criteria, predefined outcomes and potential confounding factors that were considered by the investigators, number and baseline characteristics of participants will be extracted by one investigator and will be cross-checked for validity by a second extractor. Details on the outcomes of interest from all included studies will be extracted by two investigators independently. Conflicts will be resolved through discussion and when needed adjudication by a third investigator.

Risk of bias of individual studies

We will use the second version of the Cochrane risk of bias (RoB2) tool for assessing risk of bias in the included RCTs 26 and the RELEVANT for assessing the risk of bias of observational studies. 27 Risk of bias of each included study will be evaluated by two investigators independently.

The RoB2 tool evaluates the following domains for potential risk of bias: (1) bias arising from the randomisation process, (2) bias due to deviations from intended interventions, (3) bias due to missing outcome data, (4) bias in measurement of the outcome, (5) bias in selection of reported results and (6) any other potential source of bias. High risk of bias in any of these domains will result in an overall judgement of high risk of bias. In the absence of high-risk domains, unclear risk in any domain will lead to an overall judgement of unclear risk. All remaining trials will be considered to be of low risk of bias.

RELEVANT evaluates the quality of observational comparative effectiveness research studies across seven domains, which include background, design, measures, analysis, results, discussion/interpretation and conflicts of interest. Each domain includes primary and secondary items. It is suggested that studies not meeting the primary items of RELEVANT are of very low methodological quality (have ‘fatal flaws’) and should not be used to inform clinical recommendations. Therefore, we will exclude studies not meeting these criteria. We will consider of low risk of bias all studies meeting the secondary criteria of RELEVANT as well, and of high risk of bias studies that do not meet any of the secondary criteria.

For every comparison, we will use funnel plots, Egger’s regression and Begg’s rank tests to evaluate publication bias, if we are able to pool more than 10 studies.

Data synthesis

Data from controlled clinical trials or observational studies will be analysed separately. In addition, studies evaluating different comparators, will be analysed separately. If different doses of the index medication or comparator are evaluated across the included studies, we will consider grouping studies using similar doses, providing that their results are not significantly dissimilar.

For every analysis, I 2 statistic will be used to assess statistical heterogeneity. Substantial heterogeneity (I 2 >50%) will be explored using prespecified subgroup analyses (details in the next section). We will not perform meta-analyses in cases of considerable unresolved heterogeneity (I 2 >75%).

When it is considered meaningful, meta-analyses will be performed using the random-effects model, because we anticipate significant heterogeneity in our data. Results will be presented in the form of relative risk (95% CI) for dichotomous data, mean difference (95% CI) for continuous data and (HR, 95% CI) for time to event data. Meta-analyses will be performed using Review Manager V.5 (RevMan, http://community.cochrane.org/tools/review-production-tools/revman-5 ) and R statistics V.3.4.3 or newer (R Foundation for Statistical Computing, Vienna, Austria).

For dichotomous outcomes, the unit of analysis will preferably be participants, rather than events (ie, number of participants admitted to the intensive care unit, rather than number of admissions per participants).

Sensitivity and subgroup analyses

In sensitivity analyses for all comparisons, we will (1) use fixed effects models, (2) only include studies with low risk of bias, (3) exclude studies reporting limited adherence to the study drugs (<80%) and (4) evaluate separately studies assessing different doses of the index medication, which we may pool in the main analysis.

Subgroup analyses according to participants’ age, asthma phenotypes or, possibly, acute attack phenotypes will also by conducted, depending on data availability. In an additional subgroup analysis, we will evaluate separately trials utilising exploratory versus pragmatic study designs.

Certainty of the body of evidence

Certainty of the body of evidence, for every comparison will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. 28 GRADE assesses the certainty in a body of evidence as high, moderate, low or very low after considering the methodological quality of the included studies, imprecision, inconsistency, indirectness, publication bias, the magnitude of effect, dose response and confounders likely to minimise the effect. All decisions to upgrade or downgrade the quality of evidence will be transparent and justified in evidence profile and summary of evidence tables, in accordance with GRADE guidance. GRADEPro Software (2014; www.gradepro.org ) will be used for the development of these tables.

We will use GRADE methodology to assess the risk of bias associated with missing participant outcome data across the body of the available evidence. 29 GRADE suggests repeating the primary meta-analysis, imputing the most extreme assumptions about the values of the missing data, that the investigators consider plausible. Only if the analyses prove robust to this imputation, the risk of bias due to missing participant outcome data should be deemed low.

The impact that the risk of bias of individual studies and the confidence in the body of the evidence has on the results will be presented.

Ethics and dissemination

Ethical approval is not required for these SRs, since no primary data will be collected.

The findings of these evidence updates will be presented in national and international scientific conferences. They will also be submitted for publication in high-impact peer review journals. Plain English summaries of the final reports will be developed and shared with relevant patient organisations. Moreover, our results will be used to inform clinical recommendations that will be developed by the PeARL Think Tank. We anticipate that the overview of SRs will be completed by the end of 2021 and the remaining SRs by June 2022.

Patient and public involvement

The planned SRs were prioritised through a global, multi-stakeholder survey evaluating research priorities in childhood asthma, conducted by the PeARL Think Tank. 10 Among other stakeholders, this survey included responses from patients, patient caregivers and patient organisations. Moreover, two patient representatives (GDC and TAW) have joined the research group and provided input in this study protocol and they will also provide input throughout the study process.

We report on the methodology of a series of planned systematic evidence updates, aiming to evaluate maintenance management of childhood asthma, and the treatment of acute severe asthma attacks. Their design is informed by preliminary searches and the anticipated data availability. These SRs will be conducted by the PeARL group and will be used to inform clinical recommendations and future research needs. The need for high-quality evidence updates and clinical practice guidelines to improve the management of asthma in children is more urgent now, given the pressure that the unfolding COVID-19 pandemic pose on the healthcare systems, forcing us to reconsider our daily clinical practice. 30 31

Major strengths of our evidence update series are the inclusion of a wide evidence base, including data from RCTs and real-life comparative studies, the prospective design and strong methodology. The methodological quality of all available studies will be scrutinised and will aid the interpretation of our findings. Moreover, we will attempt to evaluate differential therapeutic response of different asthma phenotypes and age groups. We believe this analysis will be revealing, if adequate data is available, but may nevertheless reveal important gaps.

Guided by the available evidence, we will follow different strategies for the evidence updates on maintenance treatment of paediatric asthma and on management of acute severe asthma attacks. In view of the availability of ample published, up-to-date SRs on maintenance pharmacotherapy of childhood asthma, we chose to conduct an overview of SRs. We decided to focus on the most frequently used and thoroughly evaluated drug classes (ICS, LABA, LAMA, LTRA and biological therapies) and we expect to identify good quality data, which would inform clinical practice and research needs. Other, less frequently or experimentally used treatments will need to be evaluated in future studies. A potential limitation of this approach is that we might not be able to capture adequate data regarding the differential effectiveness of interventions across different severity groups, age groups or paediatric asthma phenotypes, if these have not been captured in existing SRs. Moreover, existing SRs may not capture some of the most recent studies, that may have been published after the SRs, although preliminary searches have revealed several very recently update meta-analyses.

The second SR, focusing on the management of acute attacks, will first evaluate a multitude of established and experimental treatments. With regard to the latter, this SR will reveal treatments that have been tested, appeared safe and efficacious and it may be worth to be further evaluated, but will also report on interventions that were tested, but did not appear efficacious, and therefore, further evaluation may not be beneficial. This wide approach would aid the prioritisation of interventions to be further validated in future clinical research studies.

Next, meta-analyses of individual pharmacological interventions will be conducted to further assess the safety and clinical effectiveness of treatments for acute severe asthma attacks that will appear efficacious in our broad SR. In contrast to most previous meta-analyses, that may have been conducted, we will include both controlled clinical trials and observational comparative effectiveness studies. Due to limitations that have already been discussed, few controlled clinical trials are conducted in children. This leads several Cochrane SRs to report low or very low confidence in the body of evidence, due to the lack of data. 32–35 We believe that by incorporating data from observational studies we may be able to conclude more robust results. While observational studies are at a higher risk of bias, we will carefully evaluate this risk using the newly developed, thorough RELEVANT tool and we will discuss potential implications on our findings. The GRADE working groups provides transparent guidance for assessing the certainty in a body of evidence including data from different study designs (controlled clinical trials or observational studies); this guidance will be used for interpreting the findings of our meta-analyes.

Overall, we aim to develop evidence updates on the maintenance treatment of asthma and management of acute severe asthma attacks that will cover all available evidence, carefully considering methodological limitations. These will be used by the PeARL Think Tank for the development of clinical recommendations and to guide future clinical research.

Ethics statements

Patient consent for publication.

Not required.

Acknowledgments

AGM was supported by the National Institute of Health Research Manchester Biomedical Research Centre (NIHR Manchester BRC). We thank Mrs Maria Kritikou for excellent administrative support of the study

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

  • Data supplement 1

Twitter @mathioudakisag

AGM and MM contributed equally.

Contributors Study conception: AGM and NGP. Study design: AGM, MM and NGP. Preparation of the manuscript: AGM. Critical revision and final approval of the manuscript: AGM, MM, CB, GSA, AC, AD, FMD, OK, CM, ANG, WP, DP, AS, IOA, LB, AB, AB, MB, JAC-R, GDC, TC, ZD, WF, TF, JEG, JG, GH, EMH, DI, TJ, AK, RFL, PNLS, MJM, GAM, PM, MM, MM-A, KN, EP, HP, PMCP, PP, GR, IT, ST, VS, TAW, GWKW, PX, HJZ and NGP.

Funding This work was supported by the Respiratory Effectiveness Group (REG). REG has received support from AstraZeneca, Novartis and Sanofi for continued work on PeARL. (Award/Grant name: PeARL, Award/Grant Number: N/A). This is an investigator initiated study and the funders were not involved in the selection of the topic, or design of these systematic reviews. AGM was supported by the National Institute for Health Research Manchester Biomedical Research Centre (NIHR Manchester BRC).

Competing interests AGM reports grants from Boehringer Ingelheim outside the submitted work. AC reports personal fees from Novartis, Regeneron / Sanofi, Thermo Fisher Scientific, Boehringer Ingelheim and Philips, outside the submitted work. LB reports personal fees from Aerocrine, GlaxoSmithKline, Genentech/Novartis, Merck, DBV Technologies, Teva, Boehringer Ingelheim, AstraZeneca, WebMD/Medscape, Sanofi/Regeneron, Vectura and Circassia outside the submitted work. TC reports grants and personal fees CSL Behring, Dyax, Takeda, BioCryst, Pharming, personal fees from Grifols, grants and non-financial support from GSK, Regeneron, Novartis/Genetech outside the submitted work. AD reports grants and personal fees from Stallergenes Greer, personal fees from Novartis, ALK, TEVA, GSK, MEDA-MYLAN, CHIESI, AImmune, DBV technologies and Astra Zeneca, outside the submitted work. ZD reports personal fees from academic affiliations, ZD acts as Executive and Scientific Medical Director at a phase I/II pharmacological unit (QPS-NL), which performs clinical studies for pharmaceutical companies. ZD reports personal fees from Astrazeneca, ALK, Aquilon, Boehringer Ingelheim, CSL, HAL Allergy, MSD, and Sanofi-Genzyme outside the submitted work. FMD reports grants from Thorasys; personal fees from Jean-Coutu Pharmaceuticals, unrestricted research funds from Novartis Canada, Teva and Trudell Medical, research grants from GlaxoSmithKline and MEDteq in partnership with Thorasys; honorarium for consultancy work from Covis Pharma and Teva; and honorarium as invited speaker from Covis Pharma, Pharmacy Brunet, outside the submitted work. JEG reports grants from NIH/NIAID, personal fees from Regeneron, Ena Theraputics and MedImmune outside the submitted work; personal fees and stock options from Meissa Vaccines Inc outside the submitted work. JG reports personal fees from GSK, Vifor Pharmaceuticals, Novartis, BV Pharma and AstraZeneca outside the submitted work. AK reports personal fees Astra Zeneca, Behring, Boehringer Ingelheim, Covis, GSK, NovoNordisk, Novartis, Griffols, Pfizer, Sanofi, Teva and Trudel, outside the submitted work. RFL reports grants from NIH, non-financial support from GlaxoSmithKline, Boehringer-Ingelheim, Merck, TEVA, American Academy of Allergy, Asthma and Immunology, grants from Clinical and Translational Science Award (NIH), Childhood Origins of ASThma (COAST) grant, AsthmaNet, personal fees from LSU, Elsevier, UpToDate, the University of Kentucky, ThermoFischer, and Food Allergy Research and Education (FARE) Network, outside the submitted work. CM reports personal fees from Novartis, GSK, Astra Zeneca, Thermo Fisher and Boehringer Ingelheim outside the submitted work. NGP reports personal fees from ALK, Novartis, Nutricia, HAL, Menarini/FAES Farma, Sanofi, Mylan/MEDA, Biomay, AstraZeneca, GSK, MSD, ASIT BIOTECH and Boehringer Ingelheim; grants from Gerolymatos International SA and Capricare outside the submitted work. WP reports grants from NIH; grants and personal fees from Genentech/Novartis, Sanofi/Rgeneron; personal fees GSK; non-financial support from Thermo Fisher, Lincoln Diagnostics, Alk Abello, and Monaghen, outside the submitted work. PP reports grants from Astra Zeneca, Chiesi and TEVA; personal fees from Astra Zeneca, TEVA, Novartis, Mundipharma, S&D Pharma, and GlaxoSmithKline outside the submitted work. DP reports grants from AKL Research and Development, British Lung Foundation, Respiratory Effectiveness Group and the UK National Health Service; grants and personal fees from Boehringer Ingelheim, Chiesi, Circassia, Mylan, Mundipharma, Napp, Novartis, Pfizer, Regeneron Pharmaceuticals, Sanofi Genzyme, TEVA, Theravance and Zentiva (Sanofi Generics); personal fees from Cipla, GlaxoSmithKline, Kyorin and Merck; non-financial support from Efficacy and Mechanism Evaluation programme, Health Technology Assessment, outside the submitted work; DP also reports stock/stock options from AKL Research and Development which produces phytopharmaceuticals; and owns 74% of the social enterprise Optimum Patient Care (Australia and UK) and 74% of Observational and Pragmatic Research Institute (Singapore), outside the submitted work. GR reports personal fees from ALK, Allergen Therapeutics, Meda Plus, Merck; and a patent for the use of sublingual immunotherapy to prevent the development of allergy in at-risk infants, outside the submitted work. IT reports personal fees from Novartis, GSK, Boehringer Ingelheim and Astra Zeneca; grants from GSK Hellas, outside the submitted work. PX reports personal fees from Nutricia, Nestle, Friesland, Uriach, Novartis Pharma AG, and GlaxoSmithkline outside the submitted work.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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College of Health Professions

Asthma Case Study

Asthma affects about 6.1 million children in the US under 18 years of age, making it one of the most common chronic childhood disorders (American Lung Association, 2021). Asthma occurs as a result of a stimulus which can range from allergens, cigarette smoke, changes in temperature, stress, or exercise. In this case we’ll experience an asthma attack and subsequent treatment with 16-year-old Ben Mason.

Module 9: Asthma

case study for asthma in a child

Review structure and functions of the respiratory system...

Asthma - Page 1

case study for asthma in a child

Ben was struggling to breathe when he reached the ER...

Asthma - Page 2

case study for asthma in a child

Ben was also given an additional breathing treatment...

Asthma - Page 3

case study for asthma in a child

Case Summary

Summary of the Case

Asthma - Summary

case study for asthma in a child

Answers to Case Questions

Asthma - Answers

case study for asthma in a child

Professionals

Health Professionals Introduced in Case

Asthma - Professionals

case study for asthma in a child

Additional Links

Asthma - Links

YES WE CAN Children’s Asthma Program

This case study was prepared for CDC by Dr. LaMar Palmer of MAS Consultants. The purpose of the case study is to share the experience of one community as they attempt to address the problem of asthma. It does not represent an endorsement of this approach by CDC.

YES WE CAN Children’s Asthma Program: Operation of the Program

The program is carried out in community primary care settings where the majority of the children receive their asthma care. The YES WE CAN clinic combines the strengths of medicine and public health. A multidisciplinary asthma team guides each child through a care pathway that includes clinic visits, home visits, and clinical assessment follow-up phone calls. The team conducts clinical assessments and provides asthma education based on the NAEPP Guidelines. The CHW carries out an assessment of the home environment and provides guidance for reducing exposure to asthma triggers. An essential component of the model is the social support and the linking of families to community resources. The team takes into account the context of families’ lives so that strategies for improving the child’s asthma are practical and reality-based. The YES WE CAN approach focuses on factors that make an individual child’s asthma hard to manage, and then on ways to improve asthma control. The asthma team, working with the family, develops a care plan. The care plan outlines specific objectives, goals, and interventions designed to address the family’s needs as identified during the asthma clinic and home visits. The care plan proposes steps that the asthma team, other providers, and the family will take to improve the family’s ability to manage their lives and the child’s asthma. The care plan is an active document that changes over time as the family’s needs are addressed and change.

The Program was operated bilingually in English and Spanish, with some educational materials also provided in Cantonese.

The asthma registry is an important management tool that aids the asthma team in carrying out the clinic and managing patient caseload. Basically, the registry incorporates all of the ongoing information about patients in the asthma program. This stand-alone data base is essential for identifying, stratifying, and tracking asthma patients. During clinic visits, the asthma team members input patient health data into the registry (for example, symptoms, morbidity, spirometry, blood pressure, weight and height), asthma diagnosis and severity, and other information such as prescriptions and follow-up appointments. The registry is used to track patients to prevent loss to follow-up from families simply dropping out of the program, and to track interventions for each case. Asthma team members have on-demand access to the registry and input data on laptop computers during the clinic visit.

Entry into the Program

Most children are enrolled into the program following a visit for their asthma to urgent care, the ED, the hospital or their primary care provider. If families do not follow through on the referral, the clinical case manager contacts the family and invites the child and parent/caregiver to enroll in the program. If the family agrees, the child is scheduled for an asthma clinic visit.

Asthma Clinic Visit 1

Orientation In a typical first clinic visit, the CHW meets the caregiver and the child when they arrive at the clinic. The CHW conducts a short orientation that introduces the family to the clinic, the facility, and the program; explains what they can expect during the visit; and tells them the expected length of the visit. The CHW introduces the caregiver to the “team” concept for addressing the child’s asthma, and explains the family’s role as part of the team.

Intake Questionnaire The clinical case manager or designated medical assistant uses the intake questionnaire to question the caregiver (and the child when appropriate) about the child’s asthma in order to complete an asthma history. The questionnaire addresses morbidity, history of asthma and related illnesses, usual asthma symptoms, asthma triggers, home environment, and asthma control. Questions from the family about the child’s asthma are also recorded. The caregiver is asked if there are any social barriers or issues that stand in the way of managing the child’s asthma, and responses are recorded.

Asthma self-management education The family views a KP/NC video titled “Your Child and Asthma,” in English, Spanish or Cantonese. The clinical case manager or the CHW presents asthma self-management instruction and answers questions. The instructional format is one-on-one based on the individual family needs as determined by parent and child asthma knowledge deficits and their individual concerns. The initial educational component is centered on helping the child and caregiver to understand the medications and how they should be administered, to recognize an asthma attack and know what to do if one occurs, and to identify personal triggers and learn how to avoid them. Details about the educational program are described in Section V, Patient and Family Education.

Skin testing and spirometry For children aged 5 years and older, the clinical case manager administers an allergy skin test for mites, cockroaches, cats, dogs, indoor mold, and local grasses and trees. The clinical case manager conducts peak flow test while observing the child’s technique, and assists the child in improving performance. Spirometry testing is also done. Following two-to-four puffs of albuterol and a 20-minute wait, post-bronchodilator spirometry is performed, and the skin test results are read.

Assessment, diagnosis, and treatment The clinician becomes acquainted with the child and caregiver and reviews the child’s asthma health history from the intake questionnaire. The clinician conducts a physical assessment of the child, makes an asthma diagnosis, or confirms the previous asthma diagnosis, and determines asthma severity. The clinician then interprets the spirometry results, prescribes a treatment plan based on the NAEPP guidelines, provides prescriptions, and develops a written Asthma Action Plan for the child. Then the clinician teaches the family how to use the plan.

A medicine box is provided to the family at the first clinic visit. It is a rectangular plastic container with a lid, and is about the size of a shoebox. In addition to storing the asthma medications there, children keep their peak flow meters and spacers in the medicine box.

Follow up Prior to terminating the visit, the CHW schedules the home visit and also schedules the next asthma clinic visit. The CHW answers any questions about asthma education or the program, and discusses the next steps for any urgent social need identified by the family during the visit. The clinical case manager informs the caregiver about the clinical assessment telephone call that will follow the home visit.

Flow Chart 1 shows how a typical patient would go through an initial asthma clinic visit.

Home Visit 1 (1–2 weeks following the 1st clinic visit)

Within a few days following the first asthma clinic visit, the CHW telephones the family to confirm the home visit date and time. In preparation for the visit, the CHW reviews the results of the first clinic visit, including the results of allergy tests or other tests and notes the medications prescribed and the known asthma triggers for the child. The CHW assembles items needed for the visit, which may include copies of the test results, mattress and pillow covers, videos or other educational materials, copies of the child’s Asthma Action Plan, and important phone numbers for the family.

At the home, the CHW goes over a prospective plan for the visit and obtains concurrence from the caregiver before proceeding. The CHW’s objectives are to:

  • describe the role of the CHW as an ally to the family who will help them manage the child’s asthma and as an advocate in the community who will help resolve barriers the family faces to good asthma care
  • answer questions
  • verify that the prescriptions have been filled and the medications are being taken as prescribed
  • observe how the child takes the medicine
  • show the caregiver how to organize the medicine box and where to place the Asthma Action Plan
  • review the results of allergy testing with the caregiver
  • ask questions about triggers of the child’s asthma and when episodes are most likely to occur
  • verify asthma knowledge and review asthma self-management educational materials as needed
  • walk through the house (especially the child’s bedroom) with the caregiver with a trigger checklist, and note any visible asthma triggers
  • if the child is allergic to dust mites, help the caregiver place mattress and pillow covers on the child’s bed
  • determine the caregiver’s strengths and level of self-confidence in dealing with the child’s asthma
  • assess barriers to appropriate care and disease management such as not having a primary care provider, no health insurance, housing issues, employment issues, childcare problems, transportation difficulties, family issues, language barrier
  • ask the caregiver what they want to work on and work with them to develop a plan that includes actions the family can take to reduce triggers in the home

Clinical Assessment Call 1 (one month following 1st clinic visit)

The clinical case manager initiates the clinical assessment telephone call to the child’s caregiver. Clinical assessment calls provide for close monitoring of the clinical progress of each child. This helps to optimize the family’s ability to manage their child’s asthma effectively and to get the child on the right medication at the lowest effective dose before going back to his/her primary care provider for continuing asthma care. Before placing the call, the clinical case manager reviews the child’s medical history, asthma triggers, environmental exposure, medications, Asthma Action Plan, and social/psychological issues. The clinical case manager reviews the case management care plan for specific problems, goals, interventions, and timelines. The clinical case manager’s objectives for the clinical assessment call are to:

  • address any questions or concerns the family may have about asthma or challenges they may be facing
  • assess current asthma control by reviewing peak flow numbers, frequency of symptoms, beta agonist use, and activity limitations
  • if asthma control has not been achieved, assess the child’s self-management skills and try to determine the causative factors. (The Telephone Assessment Protocol contains a set of questions to ask the parent in order to help the clinical case manager determine why the child’s asthma is not under control: not taking medications, not using them correctly, inadequate environmental control, presence of viral infections, allergic rhinitis, sinusitis, family not understanding the Asthma Action Plan, and so on.)
  • assess the family’s readiness to make needed behavior changes that will lead to improved disease control. If the family is ready, the clinical case manager helps caregivers identify realistic solutions to the problems and helps them to set goals to successfully accomplish needed changes.
  • assess the caregiver’s confidence in his or her own ability to manage the child’s asthma
  • review the Asthma Action Plan with the caregiver
  • summarize agreements and next steps with the caregiver

Following the assessment call, the clinical case manager consults with the clinician about the need for medication changes or adjustments, creates a new Asthma Action Plan if needed, arranges for any needed medication refills or equipment, and sends a reminder to the family about the next clinic visit and telephone follow-up call.

Asthma Clinic Visit 2 (at 2–3 months)

During the second clinic visit, the CHW meets the family and follows up on their progress on reaching the goals set at the home visit. The CHW discusses what will occur during the second clinic visit and how long the visit will take. The CHW answers questions about the program or the visit and provides information as needed.

The clinical case manager measures peak flow and spirometry in children aged 5 years and older and administers 2–4 puffs of albuterol as ordered by the clinician. The clinical case manager meets with each child and family to discuss issues and concerns and assess the status of the child’s asthma. If the asthma is not controlled, the clinical case manager explores reasons and works with the family to set goals for improved control. The clinical case manager then assesses self-management skills and provides information on self-management as needed. After 20 minutes, the post-bronchodilator spirometry is administered.

The clinician reviews the child’s records, performs a physical assessment, and interprets the spirometry results. The clinician does a reassessment of asthma control and initiates or makes adjustments to the medications and the Asthma Action Plan as needed. The clinician provides the prescriptions for new medications, metered dose inhalers, and spacers as needed.

The CHW schedules the next home visit, if needed, and also schedules the next asthma clinic visit. The CHW answers questions about self-management and the asthma program, and discusses the next steps for any urgent psychosocial needs the family has identified.

Following the second (and any subsequent clinic visits) the clinical case manager makes clinical assessment telephone calls to the family to answer any questions or concerns the family may have and to assess the status of asthma control. The clinical case manager encourages the caregiver to sustain asthma self-management behaviors and recognizes accomplishments achieved. If self-management is not working, the clinical case manager probes to understand the problems and provides counsel and support to the caregiver as needed. They review the Asthma Action Plan together and resolve problems associated with adherence with medications. Succeeding asthma clinic visits and additional clinical assessment phone calls follow the same process that was described previously in this report. Flow Chart 2 shows how a typical patient would go through a return asthma clinic visit.

Home Visit 2 (1–2 weeks later)

During the follow-up visit to the child’s home, the CHW conducts a self-management education review, a medication review, and an Asthma Action Plan review. The CHW encourages the family and elicits and responds to patient and family questions. The child is asked to demonstrate how he/she takes the medications. A primary objective of this, visit and subsequent visits is to follow up on recommendations made during the first visit to reduce asthma triggers in the home and to encourage and assist families as needed. Another objective is to follow up on referrals and family concerns.

Asthma Clinic Closure Visit (at 6–12 months)

For subsequent clinic visits, the clinician and the clinical case manager follow the same protocols as in the second visit. When the results of the clinic visit show that the child’s asthma is under control and the family is practicing good asthma self-management, the clinician and the clinical case manager determine that, from a medical standpoint, the child can be returned to primary care. Indications of good asthma control are defined in the program as:

  • minimal (if any) chronic symptoms, including nocturnal symptoms less frequently than twice a month
  • infrequent exacerbations
  • minimal need for bronchodilators (less than two times a week)
  • no limitations on activities, including exercise
  • peak expiratory flow is consistently greater than or equal to 80% (optimally 90%) of personal best
  • minimal, if any, adverse effects from asthma medicines

Families demonstrate good self-management skills when they understand

  • personal asthma triggers and how to avoid them
  • correct inhaler and spacer techniques
  • how to measure peak flow
  • how to use medications correctly
  • how to recognize an asthma flare-up
  • how to adjust medications during an asthma flare-up
  • have systems in place to effectively manage asthma, for example, Asthma Action Plan posted and use of medication/equipment boxes.

Criteria for closure of care management by the asthma clinic also includes a social evaluation that considers the following questions.

  • Does the child have insurance coverage?
  • Does the family have a primary care provider?
  • Does the family have an Asthma Action Plan, prescribed medications, and equipment on hand?

When the criteria are met and the answers to the social questions are affirmative, the decision is made to return the child to primary care, and the family is so informed. The clinical case manager coordinates the transition from asthma clinic care back to enhanced primary care. If either the health criteria or the social criteria are not met, the child continues care in the asthma clinic until such time as these criteria are met.

Flow Chart 3 depicts the operation of the four levels of care in the program. Children with the greatest need receive the greatest amount of clinical, environmental, and social care. The flow chart also demonstrates the sequencing of interventions between clinical visits, home visits, and clinical assessment phone calls. The interventions continue until the child’s asthma is shown to be under control, the family demonstrates good self-management skills, and the family has acquired primary care, health insurance, and access to asthma medications and prevention supplies.

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Childhood asthma

On this page, when to see a doctor, risk factors, complications.

In childhood asthma, the lungs and airways become easily inflamed when exposed to certain triggers. Such triggers include inhaling pollen or catching a cold or other respiratory infection. Childhood asthma can cause irritating daily symptoms that interfere with play, sports, school and sleep. In some children, unmanaged asthma can cause dangerous asthma attacks.

Childhood asthma isn't a different disease from asthma in adults, but children face unique challenges. The condition is a leading cause of emergency department visits, hospitalizations and missed school days.

Unfortunately, childhood asthma can't be cured, and symptoms can continue into adulthood. But with the right treatment, you and your child can keep symptoms under control and prevent damage to growing lungs.

Common childhood asthma symptoms include:

  • A whistling or wheezing sound when breathing out.
  • Shortness of breath.
  • Chest congestion or tightness.
  • Has a viral infection.
  • Is sleeping.
  • Is exercising.
  • Is in the cold air.

Childhood asthma also might cause:

  • Trouble sleeping due to shortness of breath, coughing or wheezing.
  • Bouts of coughing or wheezing that get worse with a cold or the flu.
  • Delayed recovery or bronchitis after a respiratory infection.
  • Trouble breathing that hampers play or exercise.
  • Fatigue, which can be due to poor sleep.

Asthma symptoms vary from child to child and might get worse or better over time. Your child might have only one symptom, such as a lingering cough or chest congestion.

It can be difficult to tell whether your child's symptoms are caused by asthma. Wheezing and other asthma-like symptoms can be caused by infectious bronchitis or another respiratory problem.

Take your child to see a health care provider if you suspect that your child has asthma. Early treatment will help control symptoms and possibly prevent asthma attacks.

Make an appointment with your child's provider if you notice:

  • Coughing that is constant, is intermittent or seems linked to physical activity.
  • Wheezing or whistling sounds when your child breathes out.
  • Shortness of breath or rapid breathing.
  • Complaints of chest tightness.
  • Repeated episodes of suspected bronchitis or pneumonia.

Children who have asthma may say things such as, "My chest feels funny" or "I'm always coughing." Listen for coughing in children, which might not wake them, when they are asleep. Crying, laughing, yelling, or strong emotional reactions and stress also might trigger coughing or wheezing.

If your child is diagnosed with asthma, creating an asthma plan can help you and other caregivers monitor symptoms and know what to do if an asthma attack occurs.

When to seek emergency treatment

In severe cases, you might see your child's chest and sides pulling inward when breathing is difficult. Your child might have an increased heartbeat, sweating and chest pain. Seek emergency care if your child:

  • Has to stop in midsentence to take a breath.
  • Is using abdominal muscles to breathe.
  • Has widened nostrils when breathing in.
  • Is trying so hard to breathe that the abdomen is sucked under the ribs during a breath.

Even if your child hasn't been diagnosed with asthma, seek medical attention immediately if you notice troubled breathing. Although episodes of asthma vary in severity, asthma attacks can start with coughing, which progresses to wheezing and labored breathing.

Childhood asthma causes aren't fully understood. Some factors thought to be involved include having:

  • A tendency to develop allergies that runs in the family.
  • Parents with asthma.
  • Some types of airway infections at a very young age.
  • Exposure to environmental factors, such as cigarette smoke or other air pollution.

Increased immune system sensitivity causes the lungs and airways to swell and produce mucus when exposed to certain triggers. Reaction to a trigger can be delayed, making it more difficult to identify the trigger. Triggers vary from child to child and can include:

  • Viral infections such as the common cold.
  • Exposure to air pollutants, such as tobacco smoke.
  • Allergies to dust mites, pet dander, pollen or mold.
  • Physical activity.
  • Weather changes or cold air.

Sometimes, asthma symptoms occur with no apparent triggers.

Factors that might increase your child's chance of developing asthma include:

  • Exposure to tobacco smoke, including before birth.
  • Previous allergic reactions, including skin reactions, food allergies or hay fever, also called allergic rhinitis.
  • A family history of asthma or allergies.
  • Living in an area with high pollution.
  • Respiratory conditions, such as a chronic runny or stuffy nose, inflamed sinuses, or pneumonia.
  • Gastroesophageal reflux disease (GERD)
  • Being male.
  • Being Black or Puerto Rican.

Asthma can cause a number of complications, including:

  • Severe asthma attacks that require emergency treatment or hospital care.
  • Permanent decline in lung function.
  • Missed school days or falling behind in schoolwork.
  • Poor sleep and fatigue.
  • Symptoms that interfere with play, sports or other activities.

Careful planning and avoiding asthma triggers are the best ways to prevent asthma attacks.

  • Limit exposure to asthma triggers. Help your child avoid the allergens and irritants that trigger asthma symptoms.
  • Don't allow smoking around your child. Exposure to tobacco smoke during infancy is a strong risk factor for childhood asthma, as well as a common trigger of asthma attacks.
  • Encourage your child to be active. As long as your child's asthma is well controlled, regular physical activity can help the lungs work more efficiently.

See your child's health care provider when necessary. Check in regularly. Don't ignore signs that your child's asthma might not be under control, such as needing to use a quick-relief inhaler too often.

Asthma changes over time. Consulting your child's provider can help you make needed treatment adjustments to control symptoms.

  • Help your child maintain a healthy weight. Being overweight can worsen asthma symptoms, and it puts your child at risk of other health problems.
  • Keep heartburn under control. Acid reflux or severe heartburn might worsen your child's asthma symptoms. To control acid reflux, your child may need prescription medicines or medicines you can buy off the shelf.

Apr 05, 2023

  • Asthma in children. American College of Allergy, Asthma & Immunology. https://acaai.org/asthma/asthma-101/who-gets-asthma/children/. Accessed Feb. 13, 2023.
  • Childhood asthma. American Academy of Allergy, Asthma & Immunology. https://www.aaaai.org/Tools-for-the-Public/Conditions-Library/Asthma/childhood-asthma. Accessed Feb. 13, 2023.
  • Gupta A, et al. What is new in the management of childhood asthma? Indian Journal of Pediatrics. 2018; doi:10.1007/s12098-018-2705-1.
  • Asthma. Centers for Disease Control and Prevention. https://www.cdc.gov/asthma/. Accessed Feb. 13, 2023.
  • Asthma. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/asthma. Accessed Feb. 13, 2023.
  • Sawicki G, et al. Asthma in children younger than 12 years: Initial evaluation and diagnosis. https://www.uptodate.com/contents/search. Accessed Feb. 13, 2023.
  • Litonjua AA, et al. Natural history of asthma. https://www.uptodate.com/contents/search. Accessed Feb. 13, 2023.
  • Arakawa H, et al. Japanese guidelines for childhood asthma 2017. Allergology International. 2017; doi:10.1016/j.alit.2016.11.003.
  • So you have asthma. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health-topics/asthma. Accessed Feb. 13, 2023.
  • Martin RJ. Complementary, alternative, and integrative therapies for asthma. https://www.uptodate.com/contents/search. Accessed Feb. 13, 2023.
  • Natural medicines in the clinical management of asthma. Natural Medicines. https://naturalmedicines.therapeuticresearch.com. Accessed Feb. 13, 2023.
  • Diseases & Conditions
  • Childhood asthma symptoms & causes

News from Mayo Clinic

case study for asthma in a child

More Information

  • Asthma in children under 5
  • Treating asthma in children ages 5 to 11

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  • Open access
  • Published: 17 February 2024

Evaluation of Healthy Eating Index and Children's Diet Inflammatory Index according to asthma severity group

  • Nevra Koç   ORCID: orcid.org/0000-0002-4358-4443 1 ,
  • Nursena Ersoy 2 ,
  • Hülya Yardimci 3 ,
  • İlknur Külhaş Çelik 4 &
  • Ersoy Civelek 5  

BMC Pediatrics volume  24 , Article number:  127 ( 2024 ) Cite this article

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Metrics details

Diet may contribute to better asthma control in children by impacting the immune and inflammatory pathophysiology. Therefore, this study aimed to investigate differences in nutrient intake, Children’s Dietary Inflammatory Index (C-DII), and dietary quality according to asthma severity.

Materials and methods

Asthma severity, dietary inflammatory status, and diet quality were assessed in a sample of 202 children with asthma (55.6% males, aged 5–18 years) attending a pediatric allergy outpatient clinic. Asthma severity was evaluated according to the Global Initiative for Asthma criteria and categorized as mild, moderate, or severe. The Children’s Dietary Inflammatory Index (C-DII) and Healthy Eating Index (HEI-2010) were calculated based on information collected by the 24-h dietary recall method. Dietary quality was categorized as poor, moderate, or good diet according to HEI-2010.

The mean age of the participants was 9.6 ± 3.2 years. Children with severe asthma were younger on average ( p  < 0.05). Children with mild asthma had significantly higher fiber and iron intake than those with moderate asthma ( p  < 0.05). C-DII values did not differ significantly according to asthma severity ( p  > 0.05). Dietary quality was evaluated as moderate in 89.1% of the participants and also showed no difference based on asthma severity.

Conclusions

These findings suggest that inflammatory status and diet quality may not affect asthma severity in children, highlighting the influence of various genetic and environmental factors on the association between diet and asthma severity. More comprehensive and longitudinal studies are needed to investigate the mechanisms linking diet and asthma.

Peer Review reports

Introduction

Asthma is a common chronic disease in children [ 1 ]. In the International Study of Asthma and Allergies in Childhood (ISAAC) III, the global frequency of wheezing in the last 12 months was found to be 11.8% in the 6–7 years age group and 13.8% in the 13–14 age group [ 2 ]. Among children in Turkey, the lifetime prevalence of wheezing has been reported as 10.2–31.4%, the prevalence of wheezing in the last year as 3.1–15.8%, and the prevalence of physician-diagnosed asthma as 0.7–21.2% [ 3 ]. Factors such as low socioeconomic status, various pollutants, low awareness, and underdiagnosis may lead to differences in the prevalence of asthma. However, asthma management is recognized as a global public health problem [ 4 ].

The recent changes in dietary patterns worldwide may contribute to the increasing prevalence of asthma through systemic inflammation [ 5 ]. Although studies on particular foods and food groups are conducted in nutrition research, the effect of consuming foods in combination has also attracted attention [ 6 ]. As a result, the link between food quality and asthma is significant because it reflects the interaction of nutrients, their bioavailability, and the overall diet. Other than diet quality, there could be a number of confounding factors in this association [ 7 ]. For instance, Li et al. (2017) showed that better diet quality in adults, regardless of BMI, reduced asthma symptoms in never-smokers [ 8 ]. Similarly, Baptista Menezes et al. (2022) determined that diet quality had a greater impact on asthma symptoms than other individual components [ 9 ]. The European Academy of Allergy and Clinical Immunology (EAACI) stated that diet quality in childhood is associated with a decrease in asthma symptoms [ 10 ]. However, studies on this topic are limited.

The Mediterranean diet shows a protective effect against asthma risk or asthma symptoms, whereas the Western-style diet, characterized by low dietary quality, increases the risk of asthma [ 11 , 12 ]. The Western-style diet is high in fat and low in fiber, vitamins/minerals, and antioxidants [ 13 , 14 ]. Low antioxidant content reduces response capacity to oxidative stress; a high-fat diet can lead to respiratory hyperreactivity through proinflammatory cytokines; and a low-fiber diet can worsen allergic airway inflammation [ 15 ]. In addition, the Dietary Inflammatory Index (DII), developed to determine the inflammatory potential of the diet, has been associated with increased systemic inflammation and poorer lung function [ 16 ]. An antioxidant-rich diet with high dietary quality in asthma patients may reduce the severity of asthma through its anti-inflammatory potential [ 17 ].

When designing this study, we hypothesized that DII would be higher and dietary quality lower in pediatric patients with more severe asthma. The objectives of this study were to determine the nutrient intake, Children’s Dietary Inflammatory Index (C-DII) values, and dietary quality of children with asthma and evaluate differences in these variables according to asthma severity.

Study population and sample selection

This study was conducted with 202 participants aged 5–18 years who presented to the pediatric allergy outpatient clinic of the Ministry of Health Ankara Children’s Hematology and Oncology Training and Research Hospital. Before starting the study, ethical approval was obtained from the Ethics Committee for Non-Invasive Scientific Research (no: 2017/50). All study procedures were carried out September 2017 and November 2018 in accordance with the Declaration of Helsinki.. Patients with asthma who were diagnosed at least a year ago, used inhalers, were followed up on in this hospital, and were able to respond to the questionnaire personally or obtain a response from their companions were included in the study. Exclusion criteria were being diagnosed with asthma less than 1 year ago, being younger than 5 or older than 18, and inability to communicate with the patient or a parent/guardian. All children in the study participated voluntarily and met the inclusion criteria. Informed consent was obtained from all subjects and their parent/legal guardian(s).

Study design

The study data were collected from the patients and parents using a paper-based questionnaire completed by face-to-face interview under the supervision of a dietician and doctor. The questionnaire consisted of sociodemographic characteristics, anthropometric measurements (weight and height), and one-day dietary intake record based on the 24-h recall method. The following sociodemographic information about the children was obtained: date and mode of birth, birth weight, duration of exclusive breastfeeding, and total duration of breastfeeding. Dietary intake, children’s Healthy Eating Index (HEI-2010) and C-DII values were calculated based on the diet data collected by 24-h recall.

Asthma was diagnosed according to the Global Initiative for Asthma (GINA) criteria by a specialist in pediatric allergy and immunology. Asthma severity was classified according to medication requirement as mild (steps 1 and 2), moderate (steps 3–4), or severe (step 5) as recommended in the current GINA guideline [ 18 ].

Anthropometric measurements

Height (cm) and body weight (kg) were measured and recorded in an anthropometric data form. Anthropometric measurements were obtained from all participants in the morning on an empty stomach, without shoes and outer garments. If the children did not have an empty stomach on the day of study recruitment, they were invited back on another day for measurement. Weight was measured using SECA brand scale. Height was measured with a portable stadiometer while the children were standing against a wall, feet flat, and the head held with the Frankfort horizontal plane (line between inferior orbital margin and supratragal notch) parallel to the ground. Body mass index (BMI) percentiles for age and sex were calculated from the children’s weight and height data using the World Health Organization’s Anthroplus program [ 19 ]. BMI values below the 15th percentile were interpreted as underweight, between the 15th and 85th percentiles as normal, between the 85th and 97th percentiles as overweight, and above the 97th percentile as obese [ 20 ].

Assessment of dietary intake

One-day intake records were obtained using the 24-h dietary recall method. The day of recording was taken on the days that families stated that this was the day their children typically consumed food. The researcher conducting the interview asked for detailed information about the foods consumed at meals and their amounts, using a food photograph catalog. Food amounts were quantified as number and units of measure, and the corresponding nutrient content per portion was determined using this data and a standard recipe book. The average energy and macro/micronutrient content in the food consumed was calculated using the Turkish Nutrition Information System (BeBiS) version 7.0.

Healthy Eating Index (HEI-2010)

Dietary quality was assessed using the HEI-2010 based on the children’s 24-h food intake records. The HEI-2010 includes a total of 12 groups. The first 9 groups (total fruit, whole fruit, total vegetables, greens and beans, whole grains, dairy, total protein foods, seafood and plant proteins, fatty acids) assess dietary adequacy and the last 3 groups (refined grains, sodium, and empty calories [i.e., energy from solid fats, alcohol, and added sugars]) assess foods that should be consumed in moderation. Each of the adequacy groups has its own standard and scores increase with greater consumption. In the moderate intake groups, lower consumption increases the score. The HEI-2010 is evaluated out of 100 points. Dietary quality is classified as poor if the total HEI-2010 score is below 51, moderate if between 51–80, and good if above 80 [ 21 ].

Children’s diet inflammatory index

The C-DII has been validated in pediatric populations [ 22 ]. C-DII values were calculated according to 1-day food intake records obtained using the 24-h recall method. The calculation has 25 nutrient parameters, including vitamin A, thiamine, riboflavin, niacin, vitamin B 6 , folic acid, vitamin B 12 , vitamin D, vitamin C, vitamin E, beta carotene, energy, carbohydrates, fiber, total fat, saturated fat, monounsaturated fats, polyunsaturated fats, cholesterol, protein, alcohol, iron (Fe), magnesium (Mg), selenium (Se), and zinc (Zn). However, alcohol was not included in the calculation as none of the children in the study sample consumed alcohol. Z-scores were determined by subtracting the standard mean of the children’s consumption from each child’s reported consumption and dividing this value by the global standard deviation. These z-scores were then converted to a scale of -1 (maximal anti-inflammatory) to + 1 (maximal pro-inflammatory) to minimize the right-leaning effect. Finally, this score was multiplied by the nutrient parameter effect score. The overall C-DII score for each child was determined by summing the C-DII scores specific to all of the nutritional parameters. Higher C-DII indicates higher proinflammatory status.

Statistical analyses

The data were analyzed using IBM SPSS Statistics version 25 package software. Normally distributed data were given as mean and standard deviation, and non-normally distributed data were given as median and range (minimum—maximum values). Nominal data were expressed as number and percentage. In the analysis of continuous variables, ANOVA was used to compare means between more than two parametric groups and the Kruskal–Wallis test was used to compare median values between more than two non-parametric groups. Categorical variables were analyzed using the chi-square test. If the variables were found to be significant in these tests, a post-hoc comparison was performed using Tukey HSD and Bonferroni-corrected Dunn test, respectively.

The sociodemographic and clinical characteristics of the participants are shown in Table  1 . Of the participants, 55.6% were male and the mean age was 9.6 ± 3.2 years. Mode of delivery was vaginal for 53.0% of the participants, and 79.2% had normal birth weight. The mean total duration of breastfeeding was 16.2 ± 10.9 months and the duration of exclusive breastfeeding was 5.3 ± 2.5 months. According to their current weight, 55.9% of the participants were at a normal weight and 37.7% were overweight or obese.

The comparison of the participants’ nutrient intake according to asthma severity is shown in Table  2 . Children with mild asthma had significantly higher fiber and iron intake than those with moderate asthma ( p  < 0.05).

Comparisons of the children’s demographic information, dietary quality, and diet inflammatory status according to asthma severity are shown in Table  3 . Children with mild asthma severity were older on average than those with severe asthma severity ( p  < 0.05). Children with severe asthma had longer total breastfeeding duration compared to those with moderate asthma ( p  < 0.05). Furthermore, when forced expiratory volume in the first second (FEV 1 ) was classified as low (< 70% of predicted) and high (> 70% of predicted), there was no statistically significant difference between children in the low and high FEV 1 groups in terms of HEI-2010 ( p  = 0.409) or C-DII ( p  = 0.141).

In this study, although C-DII values were higher in children with severe asthma compared to those with mild asthma, dietary inflammatory status and quality did not differ according to asthma severity. The majority of children with asthma had moderate dietary quality.

Asthma severity is an important indicator for evaluating asthma care and management [ 23 ].The decrease in asthma severity with age observed in our study may have related to the high frequency of infections, a known trigger of asthma, in young children. In addition, we noted a longer total breastfeeding duration among children with severe asthma. Breast milk is rich in bioactive components such as oligosaccharides, cytokines, enzymes, and immune cells. This could impact the maturation of the infant’s gut microbiota and immune system, which may be involved in the development of asthma [ 24 ]. However, these bioactive factors are affected by factors such as ethnicity, diet, body composition, smoking, medical history, and geographical location [ 25 ]. Furthermore, a variety of factors such as drug use, passive smoking, disease, and stress have an impact on the gut flora [ 26 ]. These differences may explain the higher total breastfeeding time in children with severe asthma compared to those with mild asthma. In addition, the possible introduction of complementary foods later in children with high asthma severity may have contributed, though this was not questioned in our study.

Children who are obese have a higher risk of asthma. Obesity may reduce respiratory capacity, leading to shortness of breath and respiratory tract hypersensitivity [ 27 ]. In addition, higher BMI is associated with increased leptin levels. Leptin may aid in the prediction of asthma severity [ 28 ]. However, in this study, there was no difference in children’s BMI category according to level of asthma severity. Adipose tissue, which increases with body weight, can affect inflammatory processes. However, inflammatory processes are influenced by various hormones and systems. The lack of difference in this study may be due to the complexity of the inflammatory process and the fact that the majority of the participants were pubescent adolescents with normal weight.

Dietary patterns have important impacts on metabolic processes and immune health through the gut microbiota [ 29 ]. It has been previously reported that adherence to the Mediterranean diet and longer breastfeeding time reduce the incidence of asthma in children [ 30 ]. Another study showed that children with asthma had fewer attacks and associated complications after adherence to the Mediterranean diet [ 31 ]. Similarly, various studies stated that adherence to the Mediterranean diet was negatively associated with asthma symptoms in children [ 32 , 33 ]. In addition, children who consume refined and processed foods were found to have higher levels of inflammatory markers compared to children who eat an abundance of fruits and vegetables [ 34 , 35 ].

Limited consumption of refined flour and sugar in the Mediterranean diet lowers the glycemic index. It prevents hyperinsulinemia, which promotes the formation of pro-inflammatory eicosanoids [ 36 ]. In addition, decreased consumption of unhealthy fats limits inflammation, while omega-3 and omega-6 fatty acids reduce inflammatory cytokines and supports the differentiation of T helper cells [ 37 ]. The Mediterranean diet is also rich in vitamins, minerals, fiber, and antioxidants. Thus, it supports the immune response, blocks the bronchial inflammatory response, and contributes to the symbiotic gut flora, thereby inducing oral tolerance. These features of the Mediterranean diet, which has high dietary quality, may be associated with asthma severity [ 38 ]. However, in contrast to these results, there there are no differences in diet quality between categories of asthma severity in the present study. The disparities in our study’s findings could be attributed to children’s typically poor dietary quality.

Only the children’s fiber and iron intake differed according to asthma severity ( p  < 0.05). Fiber may support immune health through metabolic modulation of gut microbiota [ 10 ]. This may explain the lower intake of fiber in children with moderate asthma compared to children with mild asthma. Dietary iron, which has pro-inflammatory activities, is a significant component of the dietary inflammatory score [ 39 ]. However, iron intake was higher in the mild asthma group in this study. This emphasizes the importance of the inflammatory status of the diet as a whole, despite the inflammatory qualities of certain foods. In addition, the majority of children were found to have moderate dietary quality.. These results show that children’s eating habits do not meet nutritional requirements. Determining causality in follow-up studies evaluating asthma severity and dietary quality may yield more accurate results. Parents in particular can be educated on the characteristics of the Mediterranean diet and the health benefits it will provide.

When dietary inflammatory status and asthma severity were examined, no significant differences were detected between the groups. It has been shown that asthma symptoms increase with greater inflammatory potential of the diet in children aged 5 to 14 years [ 40 ]. A higher DII score, which is an indicator of a proinflammatory diet, may be associated with more severe symptoms due to increased systemic inflammation [ 16 ]. However, C-DII scores of the children in our study did not differ according to asthma severity. This may be due to the generally high dietary inflammatory potential and predominantly moderate asthma among the children sampled.

Limitations

Although this study provides important data on the relationship between asthma severity and dietary quality and inflammatory status, there are several limitations. Firstly, because of the cross-sectional design, the results may not be generalizable to the general population. Secondly, both HEI and C-DII may be affected by seasonality. Additionally, since the 24-h recall method was used, short-term food intake was focused on. However, taking it on days when it is similar to their daily intake is a strength of the study. In addition, determining the children’s time of diagnosis and whether have a family history of asthma may yield more definitive results. Finally, studies conducted in larger population groups are needed to confirm our findings. Despite these limitations, the study brings new perspectives to the current literature.

Nutrition may contribute to better asthma control in children by affecting the immune and inflammatory pathophysiology. However, in the present study, diet quality and inflammatory status did not differ by asthma severity. This relationship remains unclear because of the lack of longitudinal studies and adequate dietary control.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to privacy or ethical restrictions, but are available from the corresponding author on reasonable request.

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Department of Nutrition and Dietetics, Gülhane Health Sciences of Faculty, Sağlık Bilimleri University, İstanbul, Turkey

Ankara University, Institute of Health Sciences, Ankara, Turkey

Nursena Ersoy

Department of Nutrition and Dietetics, Faculty of Health Sciences, Ankara University, Ankara, Turkey

Hülya Yardimci

Division of Pediatric Allergy Immunology, Faculty of Medicine, Selcuk University, Konya, Turkey

İlknur Külhaş Çelik

Division of Pediatric Allergy Immunology, Sağlık Bilimleri University, Ankara City Hospital, Ankara, Turkey

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K.N. and E.N. and C.E. designed the study,K.N. and KCI collected dataK.N., E.N. and Y.H. and KCI performed the statistical analyses,K.N. and E.N. wrote the manuscript.All authors read and approved the manuscript.

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Koç, N., Ersoy, N., Yardimci, H. et al. Evaluation of Healthy Eating Index and Children's Diet Inflammatory Index according to asthma severity group. BMC Pediatr 24 , 127 (2024). https://doi.org/10.1186/s12887-023-04507-y

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  • Asthma severity
  • Healthy eating index
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BMC Pediatrics

ISSN: 1471-2431

case study for asthma in a child

Rhinovirus infection of airway epithelial cells uncovers the non-ciliated subset as a likely driver of genetic susceptibility to childhood-onset asthma

  • PMID: 38370648
  • PMCID: PMC10871459
  • DOI: 10.1101/2024.02.02.24302068

Asthma is a complex disease caused by genetic and environmental factors. Epidemiological studies have shown that in children, wheezing during rhinovirus infection (a cause of the common cold) is associated with asthma development during childhood. This has led scientists to hypothesize there could be a causal relationship between rhinovirus infection and asthma or that RV-induced wheezing identifies individuals at increased risk for asthma development. However, not all children who wheeze when they have a cold develop asthma. Genome-wide association studies (GWAS) have identified hundreds of genetic variants contributing to asthma susceptibility, with the vast majority of likely causal variants being non-coding. Integrative analyses with transcriptomic and epigenomic datasets have indicated that T cells drive asthma risk, which has been supported by mouse studies. However, the datasets ascertained in these integrative analyses lack airway epithelial cells. Furthermore, large-scale transcriptomic T cell studies have not identified the regulatory effects of most non-coding risk variants in asthma GWAS, indicating there could be additional cell types harboring these "missing regulatory effects". Given that airway epithelial cells are the first line of defense against rhinovirus, we hypothesized they could be mediators of genetic susceptibility to asthma. Here we integrate GWAS data with transcriptomic datasets of airway epithelial cells subject to stimuli that could induce activation states relevant to asthma. We demonstrate that epithelial cultures infected with rhinovirus significantly upregulate childhood-onset asthma-associated genes. We show that this upregulation occurs specifically in non-ciliated epithelial cells. This enrichment for genes in asthma risk loci, or 'asthma heritability enrichment' is also significant for epithelial genes upregulated with influenza infection, but not with SARS-CoV-2 infection or cytokine activation. Additionally, cells from patients with asthma showed a stronger heritability enrichment compared to cells from healthy individuals. Overall, our results suggest that rhinovirus infection is an environmental factor that interacts with genetic risk factors through non-ciliated airway epithelial cells to drive childhood-onset asthma.

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People

Asthma Medication May Help Children With Severe Allergies Safely Eat Nuts and Other Foods

A new study shows that Xolair, commonly used to treat asthma and hives, may allow children with allergies to eat foods that commonly cause reactions

An existing injectable drug that’s used to treat asthma and chronic hives may provide preventative protection for children with severe food allergies — and potentially make it possible for them to eat peanuts, eggs, and other foods that commonly cause reactions.

Omalizumab — known as Xolair — “significantly increased“ the quantity of food that children and adolescents with food allergies “could consume without an allergic reaction,” according to the results of a study sponsored and funded by the National Institutes of Health ’s allergy wing, the National Institute of Allergy and Infectious Diseases (NIAID).

The study followed 165 children, ages 1 to 17, and three adults, ages 18 to 55 years, who were all allergic to peanuts and at least two other foods. 

“Study participants who received Omalizumab injections could consume higher doses of peanut, egg, milk and cashew without allergic reactions than participants who received placebo injections,” the study said.

Xolair comes in pre-filled syringes , which patients can self-inject into their stomach or upper thighs — or they can have the injection administered in their arm by a caregiver.

According to the CDC , nearly 6% of U.S. adults and children have a food allergy. People of color are more likely to be affected, per a study released this past June.

An allergic reaction is when the immune system reacts abnormally to a foreign substance. FARE , an advocacy organization for people with food allergies, states that more than 170 foods have been reported to cause allergic reactions.

Related: Mom Shows How Scary a Child's Allergic Reaction Can Be: 'We Didn't Realize How Severe It Was'

Symptoms of an allergic reaction to food can range from an itchy mouth to anaphylaxis, which, according to the Mayo Clinic , is a “severe, life-threatening allergic reaction” where the body goes into shock, and the airways narrow in response.

According to FARE, about 200,000 people seek emergency medical care due to food allergies every year.

A preventative medication such as Xolair could save lives—especially since takeout and prepackaged foods have caused fatal reactions in people who unknowingly consume food containing an ingredient such as nuts.

One teen with food allergies died within an hour and a half after eating a cookie that contained peanut butter chips. Another man died after eating a take-out taco that was made with peanut butter.

People with food allergies often carry an EpiPen or similar device to provide a lifesaving dose of epinephrine—a chemical that opens up the airways during an allergic reaction.

Related: 13-Year-Old Girl Dies of 'Severe Allergic Reaction' After Accidentally Eating an Unsafe Dessert

Dr. Larry Tsai, global head of respiratory, allergy and infectious disease product development at Genentech, which manufactures Xolair, suffers from food allergies and has a child with food allergies, as well.

He told NBC in an email , “I know firsthand how challenging it is to cope with this condition and to live in continued fear of an accidental exposure.”

Xolair is now under review by the FDA to be prescribed for food allergies.

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Getty Images; Genentech USA, Inc. and Novartis Pharmaceuticals Corporation Xolair may help kids with allergies safely eat foods like peanut butter.

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Impact of Nurse-Led Asthma Intervention on Child Health Outcomes: A Scoping Review

Zainab al kindi.

1 School of Nursing and Midwifery, Trinity College Dublin, Ireland

2 College of Nursing, Sultan Qaboos University, Muscat, Oman

Catherine McCabe

Margaret mccann.

Given the leading role school nurses occupy within the school setting, they are often the most suited health care professionals to lead asthma programs. However, most school-based asthma programs have been conducted by researchers outside the school setting. Thus, we aim to determine what is currently known about the type of school nurse-led asthma intervention programs and their impact on children’s asthma-related outcomes. This article describes published literature on school nurse-led asthma intervention programs for the school-aged population using Arksey and O’Malley’s scoping review framework. A search strategy was developed and implemented in six electronic databases from 1980 to 2020. Results showed that school nurse-led asthma programs were predominantly educational interventions. Yet given the positive outcomes of school nurse-led asthma interventions reported across the articles reviewed, it is important to emphasize the leadership role school nurses assume in asthma programs, to promote more positive asthma-related outcomes in school children.

Asthma is the most common chronic condition among children, with more than a million children in the United Kingdom ( Asthma UK, 2020 ) and more than 6 million children in the United States living with asthma ( Zahran et al., 2018 ). Despite health care advancement, asthma prevalence and exacerbation rates continue to persist among children ( Global Initiative for Asthma [GINA], 2019 ). Children with asthma are at risk of disability, emotional problems, and poor academic outcomes ( Cicutto et al., 2013 ; Nurmagambetov et al., 2018 ). For chronic conditions such as asthma, management is achieved through medical intervention combined with self-care. As asthma is a lifelong disease, there is a demand to prioritize self-management strategies to promote positive outcomes and prevent asthma exacerbation ( Isik et al., 2020 ).

The National Association of School Nurses (NASN) defines school nursing as a specialized public health nursing field that protects and promotes student health, enables normal development, and promotes academic success ( NASN, 2016 ). In the school setting, school nurses are key players in asthma management. This is because they spend more time in contact with children in comparison to all other health care professionals, allowing them to develop a thorough knowledge of each child’s condition and promote self-management strategies. Additionally, their advocacy role in children’s care places them in an ideal position to identify high-risk children with asthma, plan for interventions, and evaluate programs’ effectiveness. The GINA guidelines support the implementation of effective asthma management programs for school-aged children. These programs include preventive asthma care that supports and guides school nurses’ effort to deliver asthma interventions for school communities. Consequently, school nurses focus on preventive care rather than caring for children when they are experiencing an asthma exacerbation ( Halterman et al., 2018 ).

The impact of asthma intervention programs on children’s health outcomes using various interventions has been consistently reported in the literature ( Grover et al., 2016 ; Horner et al., 2016 ; Kintner et al., 2015 ; Payrovee et al., 2014 ; Suwannakeeree et al., 2016 ). These interventions were delivered by research teams and required additional resources, that is, manpower and materials that could affect the sustainability of the intervention in a real-world setting. Nonetheless, several researchers found a significant improvement in school children’s quality of life (QoL; Payrovee et al., 2014 ), asthma management and risk reduction behavior ( Kintner et al., 2015 ), and in self-management behavior, asthma control, and asthma knowledge ( Suwannakeeree et al., 2016 ) following asthma intervention programs. Furthermore, other studies investigating similar interventions found fewer emergency room (ER) visits, less hospital admissions, better medication compliance, enhanced QoL, and improved asthma management self-efficacy ( Grover et al., 2016 ; Horner et al., 2016 ).

Implementing school nurse-led asthma intervention programs outside of the hospital setting enables students with asthma to learn about their condition, develop asthma self-management skills, and reduce school absence and missed class time ( Isik et al., 2020 ; Yoder, 2019 ). However, school-based asthma interventions are often conducted by researchers outside the school setting ( Isik et al., 2019 ). Thus, school nurses need to be emphasized as leaders of asthma programs in a school setting and should instead conduct these interventions. To our knowledge, the literature regarding school nurse-led asthma interventions has not been systematically reviewed or synthesized. Although Isik et al. (2019) explored the effectiveness of school and community-based educational intervention programs for school-aged children and their parents, none of the studies included school nurse-led intervention programs. The current review differed because it included school-based programs that were led by the school nurse. Therefore, the objective of this scoping review was to examine and map out what is currently known about the impact that school nurse-led asthma intervention programs have on child health outcomes by including solely school-based programs that were led by school nurses. This scoping review did not include any of the studies in the review done by Isik et al. (2019) .

Scoping reviews aim to identify and map the existing evidence in a specific area of research. Furthermore, they have a broader question and aim to identify research gaps in existing literature ( Arksey & O’Malley, 2005 ). As such, a scoping review methodology was used in this article to answer the following question: What is the impact of school nurse-led asthma education programs on child health outcomes? Furthermore, the review had the following objectives:

  • Describe the types of school nurse-led asthma intervention programs that have been reported for the school-aged population, their impact on children’s asthma-related outcomes, and the role of school nurses in each program.
  • Identify the research gaps in existing literature concerning aspects of school nurse-led asthma intervention programs, particularly educational interventions.

Inclusion/Exclusion Criteria

The population, exposure, and outcomes framework was employed to guide the selection of included studies and can be seen in Table 1 ( Bettany-Saltikov, 2012 ).

PEO Framework.

Note . Exclusion criteria: Studies with asthma interventions who were not school nurse-led and studies outside the school setting were excluded. Case management and infection prevention studies were also excluded. PEO = population, exposure, and outcomes; ER = emergency room.

Search Strategy

Six electronic databases were searched: Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsychINFO, MEDLINE, Educational Resources Information Centre (ERIC), EMBASE, and Applied Social Sciences Index and Abstracts (ASSIA). The search was limited to articles published in the English language. The reference lists of the retrieved articles were examined but the manual search did not uncover additional eligible studies. The search was carried out between June and August 2020.

Search terms related to “asthma,” “school,” and “nurses” were adapted to maximize results from each database. These terms were combined with the Boolean operator (AND). The search strategy was designed in the CINAHL database and translated to other databases (see Table 2 ).

Search Strategy Index Terms Used in Databases.

Study Selection and Data Extraction Process

The literature review search was conducted in consultation with the university librarian. Figure 1 shows the process of study selection according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. As shown, the initial database screening, which was conducted by one of the authors, resulted in 2,117 papers; 647 duplicates were removed leaving 1,470 to screen. A three-step process was followed to assess the inclusion/exclusion of articles. In the first step, screening of the title and abstracts was performed by one author using Covidence software extraction 2.0 (Covidence GmbH, Australia). Following a review of titles and abstracts, 19 papers went forward for full-text review. On the second step, the other two authors independently reviewed the full text of the 19 articles to determine alignment with the inclusion criteria. Of these, 12 studies were excluded because they focused on school nurse case management ( N = 5) and were not a school nurse-led intervention ( N = 7). Overall, seven studies were included in the review. There were no disagreements between the evaluators when selecting and extracting the data. The third step was to review the bibliography of the identified articles; no additional articles were identified.

An external file that holds a picture, illustration, etc.
Object name is 10.1177_10598405211003303-fig1.jpg

Preferred Reporting Items for Systematic Review and Meta-Analyses flowchart.

Data from the included studies were extracted into an evidence table that included author, year, country, aim, design, population/sample, nature of the intervention, outcome assessed, results, and measurement tools (see Table 3 ).

Characteristics of the Included Studies.

Note . SN = school nurse; NA = not applicable; ER = emergency room. a Refer to level of evidence in Table 4 .

The purpose of this review was to identify the current evidence on the impact of school nurse-led asthma intervention programs. The school nurse’s role in the included studies varied between providing educational interventions for asthmatic children ( D. M. Carpenter et al., 2016 ; Isik et al., 2020 ; Persaud et al., 1996 ; Simoneau et al., 2020 ), supervising the administration of preventive asthma medication ( Harrington et al., 2018 ; Trivedi et al., 2018 ), and running a school asthma clinic ( Salisbury et al., 2002 ).

Study Characteristics

All included studies ( N = 7) discussed an asthma program led by a school nurse ( D. M. Carpenter et al., 2016 ; Harrington et al., 2018 ; Isik et al., 2020 ; Persaud et al., 1996 ; Salisbury et al., 2002 ; Simoneau et al., 2020 ; Trivedi et al., 2018 ). Furthermore, all reported at least one of the asthma health-related outcomes. The seven studies combined represented a total of 946 school-aged children and 15 school nurses. The sample size ranged from 25 to 490. The target population of the included studies was children alone ( D. M. Carpenter et al., 2016 ; Harrington et al., 2018 ; Isik et al., 2020 ; Salisbury et al., 2002 ; Trivedi et al., 2018 ), children with their parents ( Persaud et al., 1996 ), or children and school nurses (Simoneau et al., 2020). Notably, none of the studies included in this review indicated the qualification of the school nurses who led the interventions.

The intervention programs led by school nurses were conducted in the school setting. Six studies were conducted in the United States and one in the United Kingdom ( Salisbury et al., 2002 ). The research study designs used in the included studies were randomized controlled trials (RCTs; N = 4; Harrington et al., 2018 ; Isik et al., 2020 ; Persaud et al., 1996 ; Salisbury et al., 2002 ) or quasi-experimental designs ( N = 3; D. M. Carpenter et al., 2016 ; Simoneau et al., 2020 ; Trivedi et al., 2018 ). Table 4 shows the evidence level ( Melnyk & Fineout-Overholt, 2015 ). The discussion of studies in this review is grouped into the following categories: (1) school nurse asthma education intervention, (2) school nurse supervised asthma therapy, (3) school nurse asthma clinic, and (4) asthma health-related outcomes.

Melnyk Levels of Evidence.

School Nurse Asthma Education Intervention

Four studies evaluated school nurse-led asthma education programs with two being RCTs ( Isik et al., 2020 ; Persaud et al., 1996 ) and two quasi-experimental studies ( D. M. Carpenter et al., 2016 ; Simoneau et al., 2020 ). The format of the education programs varied to include structured educational sessions ( Isik et al., 2020 ; Persaud et al., 1996 ; Simoneau et al., 2020 ) and a tailored video program ( D. M. Carpenter et al., 2016 ). The asthma education session led by school nurses was delivered to a group of participants in a face-to-face setting (group format) in two studies ( D. M. Carpenter et al., 2016 ; Isik et al., 2020 ; Simoneau et al., 2020 ) and a one-on-one session (individual format) in two studies ( Persaud et al., 1996 ; Simoneau et al., 2020 ).

The participating school nurses in Persaud et al.’s (1996) study attended a 4-hr training session to improve their knowledge and skills before they delivered the education session to children. They received a theoretical session covering asthma pathophysiology, management strategy, and medication use. School nurses also received a practical demonstration on peak flow monitoring, inhaled medication, and the use of spacer devices. They were also introduced to the following educational strategies: how to communicate with the child, conduct interviews and role-plays, and provide positive reinforcement. Following the 4-hr training session, school nurses provided a weekly one-on-one, 20-min session for each child for 8 weeks. Children were taught asthma self-management principles and peak flow monitoring. Before the education sessions and following the consent process, children were randomly assigned to the intervention group ( N = 18) and the control group ( N = 18). Both groups had a preintervention appointment where they received a physical examination and pulmonary function test by a pediatrician. However, the intervention group received education sessions by the school nurse, while the control group received no education. There were two data collection points, at baseline and immediately following the 8-week session.

Similarly, D. M. Carpenter et al. (2016) provided a validated training program to school nurses before these school nurses delivered the education sessions to school children. However, D. M. Carpenter et al.’s (2016) study focused on the inhaler technique. School nurses watched a demonstration video on inhaler use by three children. Then, they viewed 18 incorrect inhaler techniques and used a certified respiratory therapist checklist to score each technique; thereafter, they received feedback on each video. After the training, school nurses recruited a convenience sample of seven asthmatic children (four elementary, two middle school, and one high school). Children demonstrated their inhaler technique and school nurses evaluated the demonstration using a checklist score. The children’s demonstrations were video-recorded and entered into a tailored video software program. Children then viewed a correct inhaler technique by one of the video characters of their choice (there were six characters with different genders and ethnicities). The children then watched their 1–2-min tailored video with systematic feedback on each step demonstrated. In addition, children were praised for each correct step with positive statements. One month later, school nurses asked children to demonstrate the inhaler technique and evaluated them by using the same validated checklist to score their technique. This was the only follow-up point after the intervention.

Simoneau and colleagues (2020) investigated the effectiveness of a five-element school nurse-led asthma management program in providing asthma care and reducing school absenteeism. In this study, the school nurse-led asthma intervention extended beyond a structured education program. Researchers trained 28 school nurses on five program elements (asthma risk assessment, control, education, medication, and communication) with the medical care provider. Once trained, school nurses conducted the five-element program in their school setting. They continued to enroll students throughout the two academic years (2015–2016 to 2016–2017). An area of concern in this study is that school nurses could choose elements to deliver based on a needs assessment of each student with asthma. This led to the limited implementation of specific elements such as communication with primary care providers where school nurses communicate concerns or ask questions to the child’s primary care provider. The most utilized element was the inhaler technique task. There were 102 students with asthma who completed two inhaler technique assessments over the 2 academic years: one at baseline and one at the end of the academic year.

Isik et al. (2020) investigated the effectiveness of a theoretically based school nurse-led asthma intervention on symptoms, asthma self-management with peak flow meter (PFM) usage, daily activities, and school absenteeism among elementary school children aged 7–12 years. Participants were randomly assigned to receive a school nurse-led asthma intervention (treatment N = 37) or usual care (control N = 36). The intervention group received a school nurse-led asthma group session over 6 weeks. Topics covered were (1) pathophysiology, (2) PFM, (3) symptom identification and asthma action plans, (4) medication and delivery devices, (5) triggers identification and prevention as well as breathing exercises, and (6) individualized discussion and self-management strategies. To improve class interaction, researchers utilized hands-on practice, problem-based learning, case studies, storytelling, role-plays, and class discussions. The treatment group received a PFM with a personal peak flowchart and a spacer. The control group received usual care, which refers to receiving their medication according to the action plan prescribed by the child’s doctor. Data collection took place three times: at baseline, 6 weeks, and 12 weeks.

School Nurse-Supervised Asthma Therapy

Two studies examined school nurse-supervised asthma therapy ( Harrington et al., 2018 ; Trivedi et al., 2018 ). In an RCT, Harrington et al. (2018) assessed school nurses’ administration of asthma therapy to students with persistent asthma ( N = 21) and its impact on asthma-related health outcomes. The school nurse administered a daily dose of the inhaled corticosteroids (ICS) every morning at school to those assigned to the intervention group ( n = 18). The clinician prescribed administration of ICS at home every evening of a school day, and every morning and evening during holidays. Parents did home medication administration. For the control group ( n = 25), the ICS doses were prescribed to be administered daily by parents at home every morning and evening for the 2-month study period. There were two data collection points: at baseline and 60 days after enrolment. Structured telephone follow-up interviews were conducted with parents to assess ICS doses and parental reported asthma symptoms and disability during the study period.

Similarly, Trivedi et al. (2018) investigated the outcome of health care utilization after a school nurse-supervised asthma intervention that included daily directly observed ICS medication administration. The difference in this study is that the school nurse administered both the morning (at 8:00 a.m.) and evening doses (at 2:00 p.m.) at school. There were 84 enrolled children with asthma. As part of the program, school nurses provided training to participants on the correct inhaler and spacer techniques, but there was no reporting on how often instructions were given or how often these skills were followed up on. There was a retrospective assessment of asthma-related ER visits, asthma-related hospital admissions, and school absenteeism 1 year before enrolment and 1 year after enrolment.

School Nurse Asthma Clinic

Salisbury et al. (2002) conducted an RCT of a nurse-run asthma clinic in four secondary schools. Asthmatic adolescents at these schools were randomly assigned to receive a review of their asthma status at school (school clinic group) or in general practice (GP; practice care group). The nurse-run asthma clinic took place weekly in each of the four schools. The school clinic group received the same care as the practice care group; however, the discussion was tailored to the needs and interests of adolescents. Follow-up was done at the school asthma clinic 1 month and 6 months after the initial assessment. Students in the control group were invited by their practice to attend an asthma review that could be provided by a practice nurse or a doctor, according to the usual practice.

Asthma-Related Health Outcomes

The focus of this scoping review is to discuss the available evidence in relation to the impact of school nurse-led asthma programs on children’s health-related outcomes. The measurement of different outcomes varied and was complex due to the incomplete data reported by some papers. The outcomes reported included: medication use, inhaler technique, and PFM use, symptoms, school absence, QoL, health care utilization, and asthma knowledge.

Medication use

Three studies evaluated medication usage among asthmatics in a school setting after a school nurse-led asthma program ( Harrington et al., 2018 ; Salisbury et al., 2002 ; Trivedi et al., 2018 ). Trivedi et al. (2018) found a significant decline in the number of asthma rescue medication (beta agonist) refills between the pre-and postintervention periods ( p < .001). Harrington et al. (2018) reported similar significant findings as the intervention group received 91.7% of the expected morning dose of ICS at school by the school nurse (that is more than the hypothesized percentage of 80%). Contrastingly, Salisbury et al. (2002) reported no significant differences in the number of adolescents prescribed ICS ( p = .89) or daily ICS use ( p = .60) following the implementation of a school nurse-led asthma program.

Inhaler technique and PFM use

Two studies assessed the inhaler technique among students with asthma ( D. M. Carpenter et al., 2016 ; Salisbury et al., 2002 ). D. M. Carpenter et al. (2016) evaluated a school nurse-led tailored video intervention to improve inhaler techniques among asthmatic children. The number of correct steps increased significantly from baseline after watching the video ( p = .03). Carpenter and colleagues reported that the steps children most commonly missed were exhaling normally before taking a deep breath, shaking their inhaler four to six times, and holding their breath for 10 s after inhaling the medicine. In this study, children significantly sustained inhaler technique at the 1-month follow-up. Likewise, adolescents with asthma in the intervention group demonstrated higher inhaler scores ( p < .001) than their peers randomized to the control group in the study by Salisbury et al. (2002) .

There was a lack of PFM assessment in the included studies with only two studies highlighting this outcome ( Persaud et al., 1996 ; Salisbury et al., 2002 ). Persaud et al. (1996) did not assess changes in PFM reading; however, they reported that knowing the baseline PFM reading facilitated decision making by school nurses on when to seek medical help or when to advise the child to use an inhaler. Salisbury et al. (2002) assessed PFM readings before and after the intervention, reporting no differences in PFM reading ( p = .36) between the groups.

Two studies assessed the impact of school nurse-led asthma programs on symptom frequency ( Isik et al., 2020 ; Salisbury et al., 2002 ). While Salisbury et al. (2002) reported no differences in the level of symptoms ( p = .42) for the intervention group (adolescents) attending a school nurse asthma clinic, Isik et al. (2020) reported a statically significant difference in asthma symptoms among the treatment group after a theoretically based school nurse-led asthma intervention ( p < .001).

School absence

The outcome of school absenteeism was measured using school records or self-reported data in six of the included studies ( Harrington et al., 2018 ; Isik et al., 2020 ; Persaud et al., 1996 ; Salisbury et al., 2002 ; Simoneau et al., 2020 ; Trivedi et al., 2018 ). Overall, these studies reported a reduction in the number of missed school days among school-aged children after the school nurse-led intervention. Persaud et al. (1996) reported that 5 months following an asthma education program delivered by school nurses, there was a decline in the number of missed school days, but there was no significant difference between the intervention and the control group (6.4 and 7.6 days, respectively). The same result was supported by Salisbury et al. (2002) and Trivedi et al. (2018) who also reported a nonsignificant decline in asthma-related school absence between students in the treatment and control group.

Simoneau et al. (2020) reported that students with asthma who engaged in a school nurse-led asthma program (easy breathing for schools) had a 25% reduction in their absenteeism rate compared to students without asthma who did not engage. This translated into three to four gained school days annually. Similarly, Isik et al. (2020) reported that school absence decline was not statically significantly different between groups ( p = .179), yet the treatment group missed fewer school days.

In our review, three studies examined QoL as an outcome ( Harrington et al., 2018 ; Persaud et al., 1996 ; Salisbury et al., 2002 ). Salisbury et al. (2002) assessed the differences in QoL among asthmatic adolescents assigned to the school clinic or GP care. There was no significant difference in the QoL score among the groups ( p = .63).

The study by Persaud et al. (1996) assessed child health locus of control using an instrument that measured children’s perception of the extent to which their health was primarily affected by their action versus outside forces. This study also assessed children’s feelings about themselves using an asthma attitude survey. While differences existed between the intervention and control group, these were not significant and would require a larger sample to approach significance.

Harrington et al. (2018) assessed multiple measures of QoL in terms of functional limitation, family adjustment, and medical interference. There were significantly less functional limitations ( p = .04), required adjustment to family life ( p = .03), and sleep loss due to asthma ( p = .04) after the school nurse-supervised asthma therapy. Overall, there was a statistically significant difference in QoL in the treatment group compared to the control group ( p < .001).

Health care utilization

The impact of school nurse-led asthma programs on health care use includes ER visits, unscheduled visits to physicians, and/or hospitalization. Out of the seven included studies, three studies explored the impact of a nurse-led asthma program on the number of ER visits ( Harrington et al., 2018 ; Persaud et al., 1996 ; Trivedi et al., 2018 ). Persaud et al. (1996) reported that the percentage of students who attended the ER due to an exacerbation of their asthma was significantly higher in the control group (50% N = 9) than the intervention group (22%, p ≤ .05). When the age of onset was controlled, however, the association between the number of ER visits per child and the educational intervention was not statistically significant.

Trivedi et al. (2018) also found a significant reduction in asthma-related health care utilization in a recent study. The authors reported a decrease in asthma-related ER visits and asthma-related hospitalization over a 1-year follow-up period after enrolment in a school nurse supervised asthma therapy. The ER visits declined 37.5% from the preintervention mean of 0.8 to a postintervention mean of 0.3 visits ( p < .001). Asthma-related hospital admission showed a significant decline as well from a preintervention mean of 0.3 admissions to a postintervention mean of 0 admissions ( p < .001). Contrastingly, Harrington et al. (2018) reported no difference in unscheduled ER visits or hospitalization as the school nurse-supervised asthma therapy was administered over 60 days.

Asthma knowledge among children and their parents

Only two studies in this review assessed the knowledge of children after an asthma program was delivered by a school nurse ( Persaud et al., 1996 ; Salisbury et al., 2002 ). Persaud et al. (1996) found that there was no statistically significant difference in the knowledge score among children ( p = .9) and their parents ( p = .54) after program implementation. This was the only study that addressed parent’s knowledge alongside children’s knowledge. In contrast, Salisbury et al. (2002) found that asthmatic students attending school clinics (treatment group) had a greater knowledge of asthma compared to students in the practice care group (control group; p = .001).

As has been illustrated, nurses play a leading role in the school setting, placing them in an optimal position to lead programs in asthma management. However, most school-based asthma programs were conducted by researchers outside the school setting; thus, highlighting a gap in the literature. We, therefore, aimed to determine what is currently known about the type of school nurse-led asthma intervention programs and their impact on children’s asthma-related outcomes by conducting a scoping review.

Types of School Nurse-Led Intervention Programs and Their Outcomes

Our scoping review found that school nurse-led asthma programs had a positive impact on children’s asthma health-related outcomes, which include medication use, reduction in school absenteeism, reduction in health care utilization, improved asthma knowledge, and QoL. The review findings are consistent with previous non-nurse-led intervention studies, which found that school-based asthma programs improved health outcomes and prevented complications ( Horner et al., 2016 ; Rasberry et al., 2014 ; Suwannakeeree et al., 2016 ). However, not all of the interventions contributed to significant results. Indeed, there was a mix of statistically significant and nonsignificant findings. For example, only one study reported a significant reduction in asthma symptoms following the intervention ( Isik et al., 2020 ), and one study found a significant difference in QoL postintervention ( Harrington et al., 2018 ).

The review highlighted a positive impact on medication adherence and, therefore, symptom frequency among children. This positive impact was not significantly prominent among adolescents in Salisbury et al.’s (2002) study. This could be due to adolescents’ reluctance to go to the GP as recommended by the school nurse who advised participants who needed drug changes or delivery devices to contact their GP. The results in this study corroborate Persaud et al.’s (1996) findings of younger children being more vulnerable to visit the ER due to their asthmatic symptoms and are more likely to benefit from school nurse-led asthma programs; thus, indicating the significance of preventive health earlier in life. Ismaila et al. (2013) who systematically reviewed asthma burden in Canada emphasized this trend. They reported that rates of health care utilization outcomes (ER visits, hospitalization, and physician visits) are higher among children with asthma <18 years old.

The frequency and accuracy of medication administration through medication delivery devices to either prevent symptoms or for quick episode relief are important indicators of asthma management. The review reported a weakening of inhaler technique skills as early as 1 month after receiving education on best practice inhaler technique skills. This illustrates how improper inhaler technique is a major problem among asthmatic children ( Román-Rodríguez et al., 2019 ). Suwannakeeree et al. (2016) made this point and noticed that the rate of ICS use among children with asthma at 6 months after the intervention was fewer than at 3 months after the intervention. While GINA guidelines recommended that inhaler technique should be assessed at every visit, this is challenging. One way of improving the inhaler technique is through systematic-standardized teaching by health care providers ( Simoneau et al., 2020 ). As seen in this review, the studies varied regarding the number of follow-ups conducted, that is, some studies collected data in two separate occasions (one follow-up), while other collected data in three separate occasions (two follow-ups). School nurses are in the best position to conduct periodic skill assessment to prevent skill deterioration and promote the sustainability of learning.

As asthma is strongly linked to school absenteeism, studies supported school nurses’ role in reducing school absence among students with chronic conditions ( Johnson et al., 2019 ; Moricca et al., 2013 ; Rodriguez et al., 2013 ). The American Academy of Pediatrics Council recommended establishing a relationship with school nurses to improve chronic condition management ( Council on School Health, 2016 ). This is because school nurses play a proactive role in preventing school absence among younger children with asthma. In line with this, our review stressed the essential role the school nurse plays in preventing school absence among students with asthma. Despite reporting nonsignificant findings due to the small sample size, short assessment period, and variation in absence recording, the five included studies that investigated school absence reported a trend in the declining number of missed school days after the school nurse-led intervention, regardless of the intervention type. Furthermore, an important point to consider when assessing the asthma burden on school absence is the consideration of students’ and parents’ reports, as well as school health records ( Johnson et al., 2019 ).

Addressing asthma knowledge among children and their parents is an important determining factor of asthma management. Our results demonstrated that educating parents and children was a major component of school nurse-led asthma interventions. The National Heart, Lung, and Blood Institute highlights the importance of involving children and their parents in asthma management ( National Institutes of Health, 2012 ; van Bragt et al., 2015 ). However, in this review, only two studies examined asthma knowledge outcomes, one among children only and one among children and their parents. Despite being nonsignificant, the parent knowledge score showed an improvement ( Persaud et al., 1996 ). Several school-based non-nurse-led asthma education programs addressed asthma knowledge among children and their parents ( Grover et al., 2016 ; Horner et al., 2016 ; Kintner et al., 2015 ; Payrovee et al., 2014 ; Suwannakeeree et al., 2016 ). These studies showed improved knowledge scores postintervention. Agusala et al. (2018) recommended involving parents in asthma programs and indicated that parents reported increased knowledge in managing asthma symptoms and triggers. It is, therefore, clear that parents’ education was also associated with a reduction in health care utilization ( Agusala et al., 2018 ). It is important to note that asthma knowledge can be improved through educational programs; however, knowledge improvement does not necessarily reflect an improvement in care practice.

It could be argued from our review that the consistency and sustainability of the intervention is a challenge. Trivedi et al. (2018) reported that relying on the school infrastructure and the existing school nurse service promoted the sustainability and reproducibility of the intervention. However, it should be noted that school nursing services are not available across the globe. This requires asthma intervention programs to be developed for school personnel such as schoolteachers. A systematic review by Coelho et al. (2016) emphasized such a trend by highlighting that asthma educational activities should include the whole school community. Hence, students, teachers, and school staff can recognize disease symptoms and management strategies ( Coelho et al., 2016 ). While schoolteachers play an essential role in implementing school policies, the literature showed that their asthma knowledge was suboptimal ( Lucas et al., 2012 ; Rodríguez Fernández-Oliva et al., 2010 ). To address such issues, some asthma education programs were developed for teachers in England, Italy, and the United States ( Brooten et al., 2008 ; Goei et al., 2010 ; McWhirter et al., 2008 ). Also, a review by Al Aloola et al. (2014) discussed this point and reported that relying on nonhealth care personnel, such schoolteachers, to deliver asthma interventions may seem more sustainable; however, teachers’ limited time and training on asthma education could represent a challenge ( Al Aloola et al., 2014 ). Similarly, Suwannakeeree et al. (2016) included five teachers in an asthma training program and supported that enhanced asthma knowledge among teachers provided them with an awareness of the child’s condition and enabled them to support children to manage their asthma symptoms.

Our review highlighted supervised asthma medication administration in school settings as a form of a school nurse-led asthma intervention. Salazar et al. (2018) emphasized that school-supervised asthma therapy improves asthma outcomes. Although successfully implemented, they suggested that medication administration by school nurses causes an uncompensated workload for school nurses ( Salazar et al., 2018 ). Schools with limited nursing services can establish a system to maintain the administration of preventive asthma medications as seen in Halterman et al.’s (2018) study, where an asthma care coordinator who received additional asthma training was appointed to assist the school nurse in communicating with the physician, families, and school. This role promotes a therapeutic relationship between the school nurse and schoolchildren; thus, facilitating ongoing monitoring and education. An additional strategy that may help to reduce school nurse workload while implementing such programs is the electronic linkage between the hospital health record and school electronic health record, so that the school nurse is aware of any change in the treatment plan.

School-Based Intervention Versus Nurse-Led Intervention

Many studies described school-based interventions targeting children, and these interventions showed improvement in asthma outcomes ( Cicutto et al., 2013 ; Grover et al., 2016 ; Payrovee et al., 2014 ; Perry et al., 2018 ; Szefler et al., 2018 ). However, these programs are sometimes short-term, delivered by research teams, or require additional resources such as manpower or materials that could affect the sustainability of the intervention. Asthma intervention programs should be developed in schools to sensitize the school and community to self-management practice in the long run ( Coelho et al., 2016 ). To enable practice sustainability and maintain asthma self-management skills, school nurses need to be involved in planning, implementing, evaluating, and leading the intervention ( L. Carpenter et al., 2013 ; Isik et al., 2020 ). School nurses are leaders in the development of programs, policies, and procedures provided to students in the school system ( NASN, 2016 ). Therefore, at the policy development and implementation level, school nurses act as change agents to promote the concept of self-management of chronic conditions such as asthma. Accordingly, school nurse-led programs are of particular importance to achieve sustainable evidence-based practice nursing care by creating a linkage between schools, hospitals, and home ( L. Carpenter et al., 2013 ). As studies in this review did not elaborate on school nurses’ extent of involvement in intervention design, further research is needed to compare child health outcomes when asthma interventions are developed by school nurses versus implemented or led by school nurses.

School Nurses’ Training Needs

The NASN framework for 21st Century School Nursing Practice includes leadership as one of the domains. Through school nurse-led interventions, school nurses contribute to the health and well-being of the students ( Hoekstra et al., 2016 ) as well as to their academic development ( Yoder, 2019 ). For school nurses to lead asthma interventions, there is a demand to assess their training needs to strengthen their competency. Ongoing education for school nurses based on a theoretical framework is recommended. Yet there is a dearth of qualitative studies that identify the training needs of school nurses in competency-based education programs ( Shin & Roh, 2020 ).

In summary, different school nurse-led asthma interventions carried out in schools can improve child health outcomes. Training of school nurses specifically support positive practice sustainability at a reduced cost ( L. Carpenter et al., 2013 )

Overall, this scoping review found that school nurse-led asthma intervention programs had a positive impact on children’s asthma-related outcomes. Several limitations identified in this review should be considered when planning a school nurse-led asthma program in the future. First, the included studies did not explore the effect a school nurse-led asthma program had on several other outcomes such as the number of exacerbations and asthma severity. Second, the dearth of evaluation strategies of school nurse-led programs requires investigation. It is not possible to draw a firm conclusion on the impact of a school nurse-led asthma program without an in-depth evaluation of such outcomes and a longer follow-up period of each outcome. Third, the wide variations in sample size, measurement tools, and the nature of school nurse-led asthma programs in the studies reviewed require a more rigorous type of research designed to better illustrate how nurse-led asthma programs are beneficial in reducing asthma-related outcomes. Most interventions included in our review were short-term, individual programs that lasted 1 year or consisted of four or less sessions. This reduced the impact of school nurse-led interventions or limited the opportunity to reinforce the instructions. Finally, the sustainability of interventions is influenced by the degree to which school nursing services are available, as the partnership between the clinical system (clinical setting) and the public system (school setting) promotes long-term asthma outcomes sustainability. Thus, the school nurse, as a member of an interprofessional team, can act as a linkage between the health sector and the educational sector. This provides an important insight that should be further explored in future research. Taken together, the findings highlighted in this review provide important practical implications in terms of ensuring the effectiveness of school nurse-led intervention programs addressing asthma among school-aged children. Thus, these insights can guide the future development and implementation of such programs, led by nurses, which will ensure positive asthma-related outcomes.

Author Biographies

Zainab AL Kindi , RN, MSN, PhD, is a candidate at School of Nursing and Midwifery, Trinity College Dublin, Ireland.

Catherine McCabe , RN, MSN, PhD, is an associate professor at School of Nursing and Midwifery, Trinity College Dublin, Ireland.

Margaret McCann , RN, MSN, PhD, is an assistant professor at School of Nursing and Midwifery, Trinity College Dublin, Ireland.

Author Contributions: Zainab Al kindi contributed to the conception and design of the paper, analysis, and interpretation of the data, drafting and revising the final version of the manuscript to be published, and agreed to be accountable for all aspects of the work. Catherine McCabe contributed to the conception and design of the paper, analysis, and interpretation of the data, drafting and revising the final version of the manuscript to be published, and agreed to be accountable for all aspects of the work. Margaret McCann contributed to the conception and design of the paper, analysis, and interpretation of the data, drafting and revising the final version of the manuscript to be published, and agreed to be accountable for all aspects of the work.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD: Zainab Al Kindi, RN, MSN, PhD https://orcid.org/0000-0002-7028-4606

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Shinshu University undertakes study into link between prenatal exposure to organic fluorine compounds and child asthma symptoms at 4 years of age

A research team led by Professor Tetsuo Nomiyama and Assistant Professor Kohei Hasegawa of the Japan Environment and Children's Study (JECS) Koshin Unit Center at Shinshu University examined the association between maternal blood levels of organic fluorine compounds (per- and polyfluoroalkyl substances [PFAS]) during pregnancy and the prevalence of child wheezing and asthma symptoms at 4 years of age in approximately 18,000 mother-child pairs in the JECS. On December 12, 2023, the research team announced no apparent association. The study results were published in Environmental Research .

case study for asthma in a child

The JECS is a nationwide large-scale birth cohort survey study of child health and environment. It has been performed longitudinally on approximately 100,000 mother-child pairs across Japan by the Ministry of the Environment since 2010.

One risk factor for asthma, which is among the most common diseases in children, involves the exposure to chemicals during gestation and early life. Organic fluorine compounds (PFAS) affect the immune system.

Among approximately 100,000 mother-child pairs participating in the JECS, data of approximately 25,000 pairs whose maternal blood levels of PFAS during pregnancy had been measured were compiled in the present study. Of them, it used data from 17,856 pairs that contains a complete set of data required for the analysis.

Data on the prevalence of child wheezing and asthma symptoms at 4 years of age were obtained from the questionnaire. Six types of PFAS were analyzed.

A logistic regression analysis was performed to examine the association between maternal blood PFAS levels during pregnancy and the prevalence of child wheezing and asthma symptoms. It considered the effect of factors potentially related to the prevalence of child asthma symptoms (maternal age, body mass index, asthma history, education, smoking history, household income, and parity).

No definite association was found between maternal blood PFAS levels during pregnancy and the prevalence of child wheezing and asthma symptoms, nor were there apparent differences in the associations by child sex or maternal asthma history. Regional heterogeneity was observed in the associations. Further research is needed to investigate the long-term impacts of PFAS exposure during gestation.

Journal Information Publication: Environmental Research Title: Associations between prenatal exposure to per- and polyfluoroalkyl substances and wheezing and asthma symptoms in 4-year-old children: The Japan Environment and Children's Study DOI: 10.1016/j.envres.2023.117499

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This article has been translated by JST with permission from The Science News Ltd. ( https://sci-news.co.jp/ ). Unauthorized reproduction of the article and photographs is prohibited.

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    Abstract. Aim: In this cross-sectional descriptive study, we aimed to determine the clinical characteristics of children admitted to a tertiary hospital with asthma exacerbations in a city in southern Turkey where aeroallergens are common and to determine how these characteristics affect the severity of exacerbations. Methods: Data from a cross-sectional analysis of children with asthma ...

  24. Evaluation of Healthy Eating Index and Children's Diet Inflammatory

    Asthma is a common chronic disease in children [].In the International Study of Asthma and Allergies in Childhood (ISAAC) III, the global frequency of wheezing in the last 12 months was found to be 11.8% in the 6-7 years age group and 13.8% in the 13-14 age group [].Among children in Turkey, the lifetime prevalence of wheezing has been reported as 10.2-31.4%, the prevalence of wheezing ...

  25. Pediatric severe asthma: a case series report and perspectives on anti

    Case presentation All children had been initially referred because of asthma not responding to long-term treatment with high-dose inhaled steroids, long-acting β 2 -agonists and leukotriene receptor antagonists. Definitive diagnosis was severe asthma.

  26. Rhinovirus infection of airway epithelial cells uncovers the non

    Asthma is a complex disease caused by genetic and environmental factors. Epidemiological studies have shown that in children, wheezing during rhinovirus infection (a cause of the common cold) is associated with asthma development during childhood. This has led scientists to hypothesize there could b …

  27. Asthma Medication May Help Children With Severe Allergies Safely ...

    The study followed 165 children, ages 1 to 17, and three adults, ages 18 to 55 years, who were all allergic to peanuts and at least two other foods.

  28. Impact of Nurse-Led Asthma Intervention on Child Health Outcomes: A

    Asthma is the most common chronic condition among children, with more than a million children in the United Kingdom (Asthma UK, 2020) and more than 6 million children in the United States living with asthma (Zahran et al., 2018).Despite health care advancement, asthma prevalence and exacerbation rates continue to persist among children (Global Initiative for Asthma [GINA], 2019).

  29. Shinshu University undertakes study into link between prenatal exposure

    The JECS is a nationwide large-scale birth cohort survey study of child health and environment. It has been performed longitudinally on approximately 100,000 mother-child pairs across Japan by the Ministry of the Environment since 2010. ... It considered the effect of factors potentially related to the prevalence of child asthma symptoms ...