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1.  Uncontrolled asthma: assessing quality of life and productivity of children and their caregivers using a cross-sectional Internet-based survey 
Background
Results of a national survey of asthmatic children that evaluated management goals established in 2004 by the National Asthma Education and Prevention Program (NAEPP) indicated that asthma symptom control fell short on nearly every goal.
Methods
An Internet-based survey was administered to adult caregivers of children aged 6-12 years with moderate to severe asthma. Asthma was categorized as uncontrolled when the caregiver reported pre-specified criteria for daytime symptoms, nighttime awakening, activity limitation, or rescue medication based on the NAEPP guidelines. Children's health-related quality of life (HRQOL) and caregivers' quality of life (QOL) were assessed using the Child Health Questionnaire Parent Form 28 (CHQ-PF28) and caregiver's work productivity using a modified Work Productivity and Activity Impairment Questionnaire. Children with uncontrolled vs. controlled asthma were compared.
Results
360 caregivers of children with uncontrolled asthma and 113 of children with controlled asthma completed the survey. Children with uncontrolled asthma had significantly lower CHQ-PF28 physical (mean 38.1 vs 49.8, uncontrolled vs controlled, respectively) and psychosocial (48.2 vs 53.8) summary measure scores. They were more likely to miss school (5.5 vs 2.2 days), arrive late or leave early (26.7 vs 7.1%), miss school-related activities (40.6 vs 6.2%), use a rescue inhaler at school (64.2 vs 31.0%), and visit the health office or school nurse (22.5 vs 8.8%). Caregivers of children with uncontrolled asthma reported significantly greater work and activity impairment and lower QOL for emotional, time-related and family activities.
Conclusions
Poorly controlled asthma symptoms impair HRQOL of children, QOL of their caregivers, and productivity of both. Proper treatment and management to improve symptom control may reduce humanistic and economic burdens on asthmatic children and their caregivers.
doi:10.1186/1477-7525-8-96
PMCID: PMC2944345  PMID: 20825674
2.  Effects of BMI, Fat Mass, and Lean Mass on Asthma in Childhood: A Mendelian Randomization Study 
PLoS Medicine  2014;11(7):e1001669.
In this study, Granell and colleagues used Mendelian randomization to investigate causal effects of BMI, fat mass, and lean mass on current asthma at age 7½ years in the Avon Longitudinal Study of Parents and Children (ALSPAC) and found that higher BMI increases the risk of asthma in mid-childhood.
Please see later in the article for the Editors' Summary
Background
Observational studies have reported associations between body mass index (BMI) and asthma, but confounding and reverse causality remain plausible explanations. We aim to investigate evidence for a causal effect of BMI on asthma using a Mendelian randomization approach.
Methods and Findings
We used Mendelian randomization to investigate causal effects of BMI, fat mass, and lean mass on current asthma at age 7½ y in the Avon Longitudinal Study of Parents and Children (ALSPAC). A weighted allele score based on 32 independent BMI-related single nucleotide polymorphisms (SNPs) was derived from external data, and associations with BMI, fat mass, lean mass, and asthma were estimated. We derived instrumental variable (IV) estimates of causal risk ratios (RRs). 4,835 children had available data on BMI-associated SNPs, asthma, and BMI. The weighted allele score was strongly associated with BMI, fat mass, and lean mass (all p-values<0.001) and with childhood asthma (RR 2.56, 95% CI 1.38–4.76 per unit score, p = 0.003). The estimated causal RR for the effect of BMI on asthma was 1.55 (95% CI 1.16–2.07) per kg/m2, p = 0.003. This effect appeared stronger for non-atopic (1.90, 95% CI 1.19–3.03) than for atopic asthma (1.37, 95% CI 0.89–2.11) though there was little evidence of heterogeneity (p = 0.31). The estimated causal RRs for the effects of fat mass and lean mass on asthma were 1.41 (95% CI 1.11–1.79) per 0.5 kg and 2.25 (95% CI 1.23–4.11) per kg, respectively. The possibility of genetic pleiotropy could not be discounted completely; however, additional IV analyses using FTO variant rs1558902 and the other BMI-related SNPs separately provided similar causal effects with wider confidence intervals. Loss of follow-up was unlikely to bias the estimated effects.
Conclusions
Higher BMI increases the risk of asthma in mid-childhood. Higher BMI may have contributed to the increase in asthma risk toward the end of the 20th century.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The global burden of asthma, a chronic (long-term) condition caused by inflammation of the airways (the tubes that carry air in and out of the lungs), has been rising steadily over the past few decades. It is estimated that, nowadays, 200–300 million adults and children worldwide are affected by asthma. Although asthma can develop at any age, it is often diagnosed in childhood—asthma is the most common chronic disease in children. In people with asthma, the airways can react very strongly to allergens such as animal fur or to irritants such as cigarette smoke, becoming narrower so that less air can enter the lungs. Exercise, cold air, and infections can also trigger asthma attacks, which can be fatal. The symptoms of asthma include wheezing, coughing, chest tightness, and shortness of breath. Asthma cannot be cured, but drugs can relieve its symptoms and prevent acute asthma attacks.
Why Was This Study Done?
We cannot halt the ongoing rise in global asthma rates without understanding the causes of asthma. Some experts think obesity may be one cause of asthma. Obesity, like asthma, is increasingly common, and observational studies (investigations that ask whether individuals exposed to a suspected risk factor for a condition develop that condition more often than unexposed individuals) in children have reported that body mass index (BMI, an indicator of body fat calculated by dividing a person's weight in kilograms by their height in meters squared) is positively associated with asthma. Observational studies cannot prove that obesity causes asthma because of “confounding.” Overweight children with asthma may share another unknown characteristic (confounder) that actually causes both obesity and asthma. Moreover, children with asthma may be less active than unaffected children, so they become overweight (reverse causality). Here, the researchers use “Mendelian randomization” to assess whether BMI has a causal effect on asthma. In Mendelian randomization, causality is inferred from associations between genetic variants that mimic the effect of a modifiable risk factor and the outcome of interest. Because gene variants are inherited randomly, they are not prone to confounding and are free from reverse causation. So, if a higher BMI leads to asthma, genetic variants associated with increased BMI should be associated with an increased risk of asthma.
What Did the Researchers Do and Find?
The researchers investigated causal effects of BMI, fat mass, and lean mass on current asthma at age 7½ years in 4,835 children enrolled in the Avon Longitudinal Study of Parents and Children (ALSPAC, a long-term health project that started in 1991). They calculated an allele score for each child based on 32 BMI-related genetic variants, and estimated associations between this score and BMI, fat mass and lean mass (both measured using a special type of X-ray scanner; in children BMI is not a good indicator of “fatness”), and asthma. They report that the allele score was strongly associated with BMI, fat mass, and lean mass, and with childhood asthma. The estimated causal relative risk (risk ratio) for the effect of BMI on asthma was 1.55 per kg/m2. That is, the relative risk of asthma increased by 55% for every extra unit of BMI. The estimated causal relative risks for the effects of fat mass and lean mass on asthma were 1.41 per 0.5 kg and 2.25 per kg, respectively.
What Do These Findings Mean?
These findings suggest that a higher BMI increases the risk of asthma in mid-childhood and that global increases in BMI toward the end of the 20th century may have contributed to the global increase in asthma that occurred at the same time. It is possible that the observed association between BMI and asthma reported in this study is underpinned by “genetic pleiotropy” (a potential limitation of all Mendelian randomization analyses). That is, some of the genetic variants included in the BMI allele score could conceivably also increase the risk of asthma. Nevertheless, these findings suggest that public health interventions designed to reduce obesity may also help to limit the global rise in asthma.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001669.
The US Centers for Disease Control and Prevention provides information on asthma and on all aspects of overweight and obesity (in English and Spanish)
The World Health Organization provides information on asthma and on obesity (in several languages)
The UK National Health Service Choices website provides information about asthma, about asthma in children, and about obesity (including real stories)
The Global Asthma Report 2011 is available
The Global Initiative for Asthma released its updated Global Strategy for Asthma Management and Prevention on World Asthma Day 2014
Information about the Avon Longitudinal Study of Parents and Children is available
MedlinePlus provides links to further information on obesity in children, on asthma, and on asthma in children (in English and Spanish
Wikipedia has a page on Mendelian randomization (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
doi:10.1371/journal.pmed.1001669
PMCID: PMC4077660  PMID: 24983943
3.  Nocturnal Asthma Symptoms and Poor Sleep Quality among Urban School Children with Asthma 
Academic pediatrics  2011;11(6):493-499.
Objective
To describe nocturnal asthma symptoms among urban children with asthma and assess the burden of sleep difficulties between children with varying levels of nocturnal symptoms.
Methods
We analyzed baseline data from 287 urban children with persistent asthma (ages 4–10) enrolled in the School-Based Asthma Therapy trial; Rochester, NY. Caregivers reported on nocturnal asthma symptoms (# nights/2 weeks with wheezing or coughing), parent quality of life (Juniper’s PACQLQ), and sleep quality using the validated Children’s Sleep Habits Questionnaire. We used bivariate and multivariate statistics to compare nocturnal asthma symptoms with sleep quality/quantity and quality of life.
Results
Most children (mean age 7.5yrs) were Black (62%); 74% had Medicaid. Forty-one percent of children had intermittent nocturnal asthma symptoms, 23% mild persistent, and 36% moderate to severe. Children’s average total sleep quality score was 51 (range 33–99) which is above the clinically significant cut-off of 41, indicating pervasive sleep disturbances among this population. Sleep scores were worse for children with more nocturnal asthma symptoms compared to those with milder symptoms on total score, as well as several subscales including night wakings, parasomnias, and sleep disordered breathing (all p<.03). Parents of children with more nocturnal asthma symptoms reported their child having fewer nights with enough sleep in the past week (p=.018) and worse parent quality of life (p<.001).
Conclusions
Nocturnal asthma symptoms are prevalent in this population, and are associated with poor sleep quality and worse parent quality of life. These findings have potential implications for understanding the disease burden of pediatric asthma.
doi:10.1016/j.acap.2011.05.006
PMCID: PMC3481184  PMID: 21816697
asthma; childhood; symptoms; sleep; quality of life; smoke
4.  Rural Children with Asthma: Impact of a Parent and Child Asthma Education Program 
The goal of this study was to determine the effectiveness of an asthma educational intervention in improving asthma knowledge, self-efficacy, and quality of life in rural families. Children 6 to 12 years of age (62% male, 56% white, and 22% Medicaid) with persistent asthma (61%) were recruited from rural elementary schools and randomized into the control standard asthma education (CON) group or an interactive educational intervention (INT) group geared toward rural families.
Parent/caregiver and child asthma knowledge, self-efficacy, and quality of life were assessed at baseline and at 10 months post enrollment. Despite high frequency of symptom reports, only 18% children reported an emergency department visit in the prior 6 months. Significant improvement in asthma knowledge was noted for INT parents and young INT children at follow-up (Parent: CON = 16.3; INT = 17.5, p < 0.001; Young children: CON = 10.8, INT = 12.45, p < 0.001). Child self-efficacy significantly increased in the INT group at follow-up; however, there was no significant difference in parent self-efficacy or parent and child quality of life at follow-up. Asthma symptom reports were significantly lower for the INT group at follow-up. For young rural children, an interactive asthma education intervention was associated with increased asthma knowledge and self-efficacy, decreased symptom reports, but not increased quality of life.
doi:10.1080/02770900500369850
PMCID: PMC2276310  PMID: 16393717
asthma education; self-efficacy; quality of life; rural; children
5.  Effect of asthma on the quality of life among children and their caregivers in the Atlanta empowerment zone 
Background and Objective
Asthma is the most common chronic pediatric disease and exacts a toll on the health-related quality of life of affected children and their primary caregivers. This investigation describes the relationship between the clinical severity of asthma among inner-city children and their quality of life and that of their primary adult caregivers.
Methods
Telephone interview data were collected from individual adult caregivers of 5-12-year-old children with asthma. Questions addressed the history, diagnosis, and management of the child's asthma, the child's family and social background, the family's socioeconomic status, the caregiver's knowledge and attitude about asthma, and the health-related quality of life of both the child and the caregiver. An asthma severity score was calculated from the caregiver's responses to questions about their child's wheezing frequency, nocturnal and early morning symptoms, and speaking during an asthma attack, as well as the impact of the disease on their child's physical activity and breathing during the prior 4-month period. A clinical asthma triage score was determined from information collected at the emergency department about the child's oxygen saturation, alertness, use of accessory respiratory muscles, extent of breathlessness, and peak expiratory flow. Spearman correlation coefficients were used to identify association between quality of life and disease severity, caretaker's asthma knowledge, and functional impact of asthma symptoms.
Results
Data from 240 of 755 eligible children were analyzed. Most children were younger than 11 years, male, black, and non-Hispanic. The children's median duration of asthma diagnosis was 86% of their life (range less than 1 to 11.3 years, median 5.0 years). Of the primary caregivers, 69% had at least completed high school, and 90% reported a total monthly household income of $1,600 or less. The maximum possible quality-of-life score and the median for caregivers were 91 and 70, respectively; for children, the same scores were 69 and 58, respectively. In addition, there was significant negative correlation of the quality-of-life scores of both the caregivers and children with the number of schooldays the children missed (r=−0.24 andr=−0.26, respectively,P<.001 for both) and the caregivers' and children's asthma severity scores (r=−0.39 andr=0−.47, respectively,P<.001 for both). The quality-of-life scores of the children and caregivers did not correlate significantly with the asthma triage scores.
Conclusions
The questionnaires captured baseline quality-of-life information about this urban population and will facilitate longitudinal monitoring. The fact that the quality-of-life scores of children with asthma correlated with those of their adult caregivers, but not with their clinical triage scores, highlights the impact of asthma on families and the importance of having a long-term comprehensive management plant that is not based on exacerbations, but that includes both the children and their primary caregivers.
doi:10.1007/BF02390538
PMCID: PMC3456120  PMID: 10856008
Asthma; Health-Related Quality of Life; Pediatrics
6.  Ancillary Benefits for Caregivers of Children with Asthma Participating in an Environmental Intervention Study to Alleviate Asthma Symptoms 
Providing care for children with asthma can be demanding and time-intensive with far-reaching effects on caregivers’ lives. Studies have documented childhood asthma symptom reductions and improved asthma-related quality of life (AQOL) with indoor allergen-reducing environmental interventions. Few such studies, however, have considered ancillary benefits to caregivers or other family members. Ancillary benefits could be derived from child health improvements and reduced caregiving burden or from factors such as improved living environments or social support that often accompanies intensive residential intervention efforts. As part of the Boston Healthy Public Housing Initiative (HPHI), a longitudinal single-cohort intervention study of asthmatic children, we examined trends in caregivers’ quality of life related to their child’s asthma (caregiver AQOL) using monthly Juniper Caregiver Asthma Quality of Life Questionnaires (AQLQ) for 32 primary caregivers to 42 asthmatic children aged 4 to 17 years. Longitudinal analyses were used to examine caregiver AQOL trends and their relationship to the child’s AQOL, then to consider additional predictors of caregiver AQOL. Caregiver AQLQ improved significantly over the course of the study with overall improvements significantly correlated with child AQOL (p = 0.005). However, caregiver AQOL improved most in the months before environmental interventions, while children’s AQOL improved most in the months following. Time trends in caregiver AQOL, controlling for child AQOL, were not explained by available social support or caregiver stress measures. Our findings suggest potential participation effects not adequately captured by standard measures. Future environmental intervention studies should more formally consider social support and participation effects for both children and caregivers
doi:10.1007/s11524-008-9341-4
PMCID: PMC2648883  PMID: 19184446
Urban childhood asthma; Quality of life; Environmental interventions; Psychological factors
7.  The Role of Parent Health Literacy Among Urban Children with Persistent Asthma 
Patient education and counseling  2009;75(3):368-375.
Health literacy (HL) affects adult asthma management, yet less is known about how parent HL affects child asthma care.
Objective
To examine associations between parent HL and measures related to child asthma.
Methods
Parents of 499 school-age urban children with persistent asthma in Rochester, New York completed home interviews. Measures: The Rapid Estimate of Adult Literacy in Medicine for parent HL; NHLBI criteria for asthma severity, and validated measures of asthma knowledge, beliefs, and experiences. Analyses: Bivariate and multivariate analyses of associations between parent HL measures related to child asthma.
Results
Response rate: 72%, mean child age: 7.0 years. Thirty-two percent had a Hispanic parent; 88% had public insurance. Thirty-three percent had a parent with limited HL. Low parent HL was independently associated with greater parent worry parent perception of greater asthma burden, and lower parent-reported quality of life. Measures of health care use (e.g., emergency care, preventive medicines) were not associated with parent HL.
Conclusions
Parents with limited HL worried more and perceived greater overall burden from the child’s asthma, even though reported health care use did not vary.
Practice Implications
Improved parent understanding and provider-parent communication about child asthma could reduce parent-perceived asthma burden, alleviate parent worry, and improve parent quality of life.
doi:10.1016/j.pec.2009.01.004
PMCID: PMC3712512  PMID: 19233588
Health Literacy; asthma; asthma care; child health; child asthma; health behavior; health beliefs; provider-patient communication; pediatric care; medical care; REALM; poverty; low-income; PACQOL; asthma burden; urban children
8.  Perceived Parent Financial Burden and Asthma Outcomes in Low-Income, Urban Children 
The purpose of this study was to describe the demographic characteristics of low-income parents who perceive financial burden in managing their child’s asthma and related associations with their children’s asthma outcomes and clinical characteristics. We hypothesized that (1) identifiable differences between parents who do and do not report burden; (2) regardless of access to care, asthma outcomes would be worse for children whose parents perceive financial burden in obtaining care for their child’s condition. Baseline data from a randomized trial evaluating the effect of a school-based asthma intervention were analyzed for this research. Eight hundred thirty-five parents were interviewed by telephone regarding their child’s asthma management. Associations between demographic and clinical factors and perception of financial burden were examined using bivariate analysis. Multivariate regression analyses were used to examine associations between perceptions of financial burden and asthma outcomes, including emergency department visits, hospitalizations, and missed school days. Perceived financial burden was evident in 10 % (n = 79) of parents. Female heads of household (χ2(3) = 7.41; p < 0.05), those at the lowest income levels (χ2(3) = 12.14; p < 0.01), and those whose child’s asthma was poorly controlled (χ2(2) = 49.42; p < 0.001) were most likely to perceive financial burden. In models controlling for level of asthma control, income, and having a usual source of asthma care, parents who perceived financial burden were more likely to have children who had at least one emergency department visit (OR = 1.95; 95 % CI = 1.15 to 3.29), hospitalization (OR = 3.99; 95 % CI = 2.03 to 7.82), or missed school days due to asthma (OR = 3.26; 95 % CI = 1.60 to 6.67) in the previous year. Our results supported our hypotheses. Among low-income parents of children with asthma, the majority do not perceive financial burden to obtaining care. However, among parents that do perceive burden, urgent care use and missed school days due to asthma for their child were significantly higher, regardless of family income and having a usual source of asthma care. Mothers and grandmothers heading families and those caring for children with uncontrolled asthma were most likely to report burden. These findings have implications for clinical practice in that health care providers may be able to take simple actions to determine patients’ financial-related perceptions, correct misconceptions, and help patients consider their full range of options to manage their child’s asthma.
doi:10.1007/s11524-012-9774-7
PMCID: PMC3675711  PMID: 23179603
Childhood asthma; Low income; Urban children; Outcomes; Barriers to care; Asthma
9.  Asthma and allergies in Jamaican children aged 2–17 years: a cross-sectional prevalence survey 
BMJ Open  2012;2(4):e001132.
Objective
To determine the prevalence and severity of asthma and allergies as well as risk factors for asthma among Jamaican children aged 2–17 years.
Design
A cross-sectional, community-based prevalence survey using the International Study of Asthma and Allergies in Childhood questionnaire. The authors selected a representative sample of 2017 children using stratified, multistage cluster sampling design using enumeration districts as primary sampling units.
Setting
Jamaica, a Caribbean island with a total population of approximately 2.6 million, geographically divided into 14 parishes.
Participants
Children aged 2–17 years, who were resident in private households. Institutionalised children such as those in boarding schools and hospitals were excluded from the survey.
Primary and secondary outcome measures
The prevalence and severity of asthma and allergy symptoms, doctor-diagnosed asthma and risk factors for asthma.
Results
Almost a fifth (19.6%) of Jamaican children aged 2–17 years had current wheeze, while 16.7% had self-reported doctor-diagnosed asthma. Both were more common among males than among females. The prevalence of rhinitis, hay fever and eczema among children was 24.5%, 25% and 17.3%, respectively. Current wheeze was more common among children with rhinitis in the last 12 months (44.3% vs 12.6%, p<0.001), hay fever (36.8% vs 13.8%, p<0.001) and eczema (34.1% vs 16.4%, p<0.001). Independent risk factors for current wheeze (ORs, 95% CI) were chest infections in the first year of life 4.83 (3.00 to 7.77), parental asthma 4.19 (2.8 to 6.08), rhinitis in the last 12 months 6.92 (5.16 to 9.29), hay fever 4.82 (3.62 to 6.41), moulds in the home 2.25 (1.16 to 4.45), cat in the home 2.44 (1.66 to 3.58) and dog in the home 1.81 (1.18 to 2.78).
Conclusions
The prevalence of asthma and allergies in Jamaican children is high. Significant risk factors for asthma include chest infections in the first year of life, a history of asthma in the family, allergies, moulds and pets in the home.
Article summary
Article focus
The prevalence of asthma and allergies in both developed and developing countries is continuing to rise.
In some Caribbean countries, asthma is a public health problem associated with high economic costs.
This study determined the prevalence of asthma, allergy symptoms and associated risk factors.
Key messages
We demonstrated that the prevalence of asthma and allergy symptoms among Jamaican children aged 2–17 years is high.
Both the prevalence and severity of asthma symptoms are comparable to that reported among children in high-income countries.
Current wheeze and doctor-diagnosed asthma were more common in males and in children with allergies.
A history of asthma in the family, chest infections in the first year of life, allergies, exposure to moulds and pets in the home were associated with significant risk for asthma.
Identifying children at high risk for asthma and controlling modifiable risk factors is important in reducing the prevalence and morbidity related to asthma.
Strengths and limitations of this study
This is the first national study on asthma and allergies in Jamaica using a nationally representative sample of children with a response rate of 80%.
We used a modified ISAAC protocol in which sampling was done by household rather than by school. Using a population-based sampling strategy; we sampled one child and one adult per household. This approach enabled us to obtain national prevalence estimates for both adults and children in one survey at a reduced cost.
Limitations of this study include the fact that the prevalence of asthma and allergies was based solely on self-reports, no objective measures were done. Also in younger children, caregivers responded to questionnaires.
doi:10.1136/bmjopen-2012-001132
PMCID: PMC3400072  PMID: 22798254
10.  Missed sleep and asthma morbidity in urban children 
Background
Children living in urban environments have many risk factors for disrupted sleep, including environmental disturbances, stressors related to ethnic minority status, and higher rates of stress and anxiety. Asthma can further disrupt sleep in children, but little research has examined the effects of missed sleep on asthma morbidity.
Objective
To examine the associations among missed sleep, asthma-related quality of life (QoL), and indicators of asthma morbidity in urban children with asthma from Latino, African American, and non-Latino white backgrounds. Given the importance of anxiety as a trigger for asthma symptoms and the link between anxiety and disrupted sleep, the associations among anxiety, asthma morbidity indicators, and missed sleep were also tested.
Methods
Parents of 147 children ages 6 to 13 years completed measures of asthma morbidity and missed sleep, parental QoL, and child behavior.
Results
Higher reports of missed sleep were related to more frequent school absences, more activity limitations, and lower QoL across the sample. The associations between missed sleep and asthma morbidity were stronger for Latino children compared with non-Latino white and African American children. For children with higher anxiety, the associations between missed sleep and asthma morbidity were stronger than for children with lower anxiety.
Conclusion
Results offer preliminary support for missed sleep as a contributor to daily functioning of children with asthma in urban neighborhoods. Missed sleep may be more relevant to Latino families. Furthermore, anxiety may serve as a link between sleep and asthma morbidity because higher anxiety may exacerbate the effects of disrupted sleep on asthma.
doi:10.1016/j.anai.2012.05.015
PMCID: PMC3426919  PMID: 22727156
11.  Partner randomized controlled trial: study protocol and coaching intervention 
BMC Pediatrics  2012;12:42.
Background
Many children with asthma live with frequent symptoms and activity limitations, and visits for urgent care are common. Many pediatricians do not regularly meet with families to monitor asthma control, identify concerns or problems with management, or provide self-management education. Effective interventions to improve asthma care such as small group training and care redesign have been difficult to disseminate into office practice.
Methods and design
This paper describes the protocol for a randomized controlled trial (RCT) to evaluate a 12-month telephone-coaching program designed to support primary care management of children with persistent asthma and subsequently to improve asthma control and disease-related quality of life and reduce urgent care events for asthma care. Randomization occurred at the practice level with eligible families within a practice having access to the coaching program or to usual care. The coaching intervention was based on the transtheoretical model of behavior change. Targeted behaviors included 1) effective use of controller medications, 2) effective use of rescue medications and 3) monitoring to ensure optimal control. Trained lay coaches provided parents with education and support for asthma care, tailoring the information provided and frequency of contact to the parent's readiness to change their child's day-to-day asthma management. Coaching calls varied in frequency from weekly to monthly. For each participating family, follow-up measurements were obtained at 12- and 24-months after enrollment in the study during a telephone interview.
The primary outcomes were the mean change in 1) the child's asthma control score, 2) the parent's quality of life score, and 3) the number of urgent care events assessed at 12 and 24 months. Secondary outcomes reflected adherence to guideline recommendations by the primary care pediatricians and included the proportion of children prescribed controller medications, having maintenance care visits at least twice a year, and an asthma action plan. Cost-effectiveness of the intervention was also measured.
Discussion
Twenty-two practices (66 physicians) were randomized (11 per treatment group), and 950 families with a child 3-12 years old with persistent asthma were enrolled. A description of the coaching intervention is presented.
Trial registration
ClinicalTrials.gov identifier NCT00860834.
doi:10.1186/1471-2431-12-42
PMCID: PMC3352109  PMID: 22469168
Asthma; Behavioral skills training; Lay coaching
12.  Secondary Outcomes of a Pilot Randomized Trial of Azithromycin Treatment for Asthma 
PLoS Clinical Trials  2006;1(2):e11.
Objectives:
The respiratory pathogen Chlamydia pneumoniae (C. pneumoniae) produces acute and chronic lung infections and is associated with asthma. Evidence for effectiveness of antichlamydial antibiotics in asthma is limited. The primary objective of this pilot study was to investigate the feasibility of performing an asthma clinical trial in practice settings where most asthma is encountered and managed. The secondary objectives were to investigate (1) whether azithromycin treatment would affect any asthma outcomes and (2) whether C. pneumoniae serology would be related to outcomes. This report presents the secondary results.
Design:
Randomized, placebo-controlled, blinded (participants, physicians, study personnel, data analysts), allocation-concealed parallel group clinical trial.
Setting:
Community-based health-care settings located in four states and one Canadian province.
Participants:
Adults with stable, persistent asthma.
Interventions:
Azithromycin (six weekly doses) or identical matching placebo, plus usual community care.
Outcome Measures:
Juniper Asthma Quality of Life Questionnaire (Juniper AQLQ), symptom, and medication changes from baseline (pretreatment) to 3 mo posttreatment (follow-up); C. pneumoniae IgG and IgA antibodies at baseline and follow-up.
Results:
Juniper AQLQ improved by 0.25 (95% confidence interval; −0.3, 0.8) units, overall asthma symptoms improved by 0.68 (0.1, 1.3) units, and rescue inhaler use decreased by 0.59 (−0.5, 1.6) daily administrations in azithromycin-treated compared to placebo-treated participants. Baseline IgA antibodies were positively associated with worsening overall asthma symptoms at follow-up (p = 0.04), but IgG was not (p = 0.63). Overall asthma symptom improvement attributable to azithromycin was 28% in high IgA participants versus 12% in low IgA participants (p for interaction = 0.27).
Conclusions:
Azithromycin did not improve Juniper AQLQ but appeared to improve overall asthma symptoms. Larger community-based trials of antichlamydial antibiotics for asthma are warranted.
Editorial Commentary
Background: Chlamydia pneumoniae is a common bacterium thought to be responsible for a substantial proportion of community-acquired pneumonia and bronchitis infections. There is some observational evidence associating chronic C. pneumoniae infection with more severe symptoms in people with asthma. However, there are very little data from clinical trials determining whether treatment with antibiotics active against C. pneumoniae has an effect on the control of asthma.
What this trial shows: In this trial, the researchers randomized 45 adults who were being treated for asthma in primary care to receive either azithromycin (an antibiotic active against C. pneumoniae) or placebo, in addition to their usual asthma care. Participants were followed up for 3 mo after completion of treatment, during which time participants recorded data relating to their overall symptoms and daily activities on a 5-point scale, and use of bronchodilators. At the start of the trial, and at 3-mo follow-up, participants also completed a quality-of-life questionnaire using a validated scale. The primary objective of this trial was to investigate the feasibility of running an asthma trial in the primary care setting, and in using IVR telephone systems to collect the outcome data, reported in [13]. In this paper, the asthma outcomes are reported. Participants receiving azithromycin did not show a significant improvement in quality of life at 3-mo follow-up as compared to participants receiving placebo. However, the investigators did see a significant improvement in the overall symptoms recorded by participants receiving azithromycin, as compared to placebo.
Strengths and limitations: The randomization methods in the trial were appropriate, as was the choice of placebo as a comparison for azithromycin. However, the number of participants in the trial was small, and it is likely that many more participants would need to be recruited to conclusively demonstrate or disprove an effect of azithromycin on asthma-related quality of life. Further, the trial used three different measures for asthma outcomes: (1) the quality-of-life questionnaire, (2) measurement of symptoms and daily activities on a 5-point scale, and (3) bronchodilator use. Only the quality-of-life questionnaire is validated, making it difficult to compare the results with those of other asthma trials.
Contribution to the evidence: This trial provides suggestive evidence that azithromycin may have benefits in the treatment of asthma, but should not on its own lead to a change in practice. The study provides a good basis for a larger randomized trial of such treatments, which would need to assess reliably the effect of these drugs not only on symptoms but also on quality of life. Information gained from this trial would help to design several aspects of future studies, e.g., their size, follow-up duration, and suitable outcome measures.
doi:10.1371/journal.pctr.0010011
PMCID: PMC1488900  PMID: 16871333
13.  444 Associations between Self-reported Adherence to Asthma Anti-inflammatory Therapy and Risk Factors for Non-adherence (NA) in Pediatric Patients 
The World Allergy Organization Journal  2012;5(Suppl 2):S158-S159.
Background
Identifying patient adherence status and reasons for non-adherence are important components of asthma management. GINA 2008 Guidelines have identified risk-factors associated with poor adherence
Methods
Three hundred sixty one parents of children with intermittent and persistent asthma (59.6% male; 64.1% Caucasian; mean age 8.07 years) completed the AsthmaPACT, a 96-item asthma survey hosted by the Asthma and Allergy Foundation of America website. The AsthmaPACT identifies risk-factors for not following treatment recommendations as well as medication use. Asthma surveys were completed from August 2009 thru June 2011.
Results
Descriptive statistics indicated that 259 of the sample reported giving their child one or more of the anti-inflammatory medication prescribed. Of these, 69 (27%) were diagnosed as NA, operationalized as whether a parent reported giving the child anti-inflammatory medication "less than prescribed by their physician." During the 4 weeks prior to completing the survey, 43.0% were having symptoms daily and 39.4% were using albuterol MDI daily. In this cross-sectional data set, items intended to relate risk factors to NA were examined using chi square (χ2). Parents who claimed that their child receive less anti-inflammatory medication than prescribed, were more likely to report: 1) symptoms from emotional states: crying χ2(df = 2) = 8.643 P = 0.013; frustration χ2(df = 2) 6.202 P = 0.045; anger χ2(df = 2) = 11.029 P = 0.0042); Parent more likely to see child as anxious or a worrier χ2(df = 2) = 6.527 P = 0.038; 2) Child's Quality of Life (QoL): is more likely to be effected at school χ2(df = 2) = 12.963 P = 0.002; and interfere with family activities χ2 (df = 2) = 8.856 P = 0.012; 3) Parent's QoL is more likely to interfere with work χ2 (df = 2) = 16.517 P < 0.001; recreational activities χ2 (df = 2) 17.759 P < 0.001 and family activities χ2 (df = 2) = 16.517 P < 0.001; 4) Parents are more likely not to agree regarding asthma management χ2 (df = 2) = 7.677 P = 0.022; not to agree with relatives/caregivers on how to manage asthma χ2 (df = 2) = 9.853 P = 0.007; lack confidence in teachers/school personnel to manage asthma at school χ2(df = 2) = 20.216 P < 0.001.
Conclusions
The AsthmaPACT provides an assessment of 1) risk-factors for non-adherence and 2) patient self-report of adherence, and is readily available as a tool to individuals with asthma who have access to the Internet. Findings in this study are consistent with GINA 2008 Guidelines regarding common risk-factors for non-adherence and specifically to the child's emotional state and QoL for both the child and parent. The AsthmaPACT might be considered for symptomatic patients to identify barriers to treatment and diagnose adherence status.
doi:10.1097/01.WOX.0000412207.83691.ef
PMCID: PMC3512985
14.  Impact of Maternal Mental Health on Pediatric Asthma Control 
Tanaffos  2013;12(4):23-27.
Background
Asthma like other chronic diseases is a stressful condition not only for children but also for their parents. Caring for a child with asthma combines the demands of parenting with the emotional and physical burdens of the child's chronic illness. Some studies have assessed the relations between parental mental health and asthma severity in children. This study aims to evaluate the mental health of mothers of asthmatic children and associations between maternal mental health and childhood levels of asthma control.
Materials and Methods
Eighty mothers with asthmatic children aged 7-12 yrs. completed a General Health Questionnaire (GHQ.28) containing questions about somatic symptoms, anxiety, social dysfunction, and severe depression. Level of asthma control in children was classified as “well controlled”,” partly controlled” and “uncontrolled” by an asthma specialist.
Results
The results showed that mothers of asthmatic children reported the depression symptoms significantly more than the community cut-off point (p<0.001); also GHQ scores were not significantly different in three levels of asthma control in children (i.e. well controlled, partly controlled and uncontrolled). The results revealed that caring for a child with asthma had an impact on the mother's mental health and depression was prevalent among mothers of asthmatic children. In addition, improving asthma control level did not promote maternal mental health.
Conclusion
Inclusion of mental health and quality of life of parents in the classification of pediatric asthma control may be helpful. Our findings suggest that the physician's awareness of maternal depression and the presence of a psychotherapist for diagnosing and treating depression in mothers of children with asthma may be important for guiding effective interventions.
PMCID: PMC4153262  PMID: 25191480
Mental health; Mother; Level of asthma control
15.  Computerised paediatric asthma quality of life questionnaires in routine care 
Archives of Disease in Childhood  2007;92(8):678-682.
Background
Asthma quality of life questionnaires are not readily incorporated into clinical care. We therefore computerised the Paediatric Asthma Quality of Life Questionnaire (standardised) (PAQLQ(S)) and the Paediatric Asthma Caregivers Quality of Life Questionnaire (PACQLQ), with a colour‐coded printed graphical report.
Objectives
To (a) assess the feasibility of the electronic questionnaires in clinical care and (b) compare the child's PAQLQ scores with the parent's score, physician's clinical score and spirometry.
Methods
Children with asthma were given a clinical severity score of 1–4 (increasing severity) and then completed the PAQLQ(S) electronically (scores 1–7 for increasing quality of life in emotional, symptoms and activity limitation domains) followed by spirometry and physician review. Parents completed the PACQLQ. Inclusion criteria required fluent Hebrew and reliable performance of spirometry. Children with additional chronic diseases were excluded.
Results
147 children with asthma aged 7–17 years completed PAQLQs and 115 accompanying parents completed PACQLQs, taking 8.3 (4.3–15) and 4.4 (1.5–12.7) min, respectively (mean (range)). Graphical reports enabled physicians to address quality of life during even brief visits. Children's (PAQLQ) and parents' (PACQLQ) total scores correlated (r = 0.61, p<0.001), although the children's median emotional score of 6.3 was higher than their parents' 5.7 (p<0.001), whereas median activity limitation score was lower than their parents': 5.0 and 6.8, respectively (p<0.001). No correlation was found with physician's clinical score or spirometry.
Conclusions
Electronic PAQLQs are easy to use, providing additional insight to spirometry and physician's assessment, in routine asthma care. Future studies must assess impact on asthma management.
doi:10.1136/adc.2006.111971
PMCID: PMC2083868  PMID: 17428818
asthma; quality of life; questionnaire; electronic; computerised
16.  The Chinese version of the Pediatric Quality of Life Inventory™ (PedsQL™) 3.0 Asthma Module: reliability and validity 
Background
Health-related quality of life (HRQOL) has been recognized as an important health outcome measurement for pediatric patients. One of the most promising instruments in measuring pediatric HRQOL emerged in recent years is the Pediatric Quality of Life Inventory (PedsQL™). The PedsQL™ 3.0 Asthma Module, one of the PedsQL™disease-specific scales, was designed to measure HRQOL dimensions specifically tailored for pediatric asthma. The present study is aimed to evaluate the psychometric properties of the Chinese version of the PedsQL™ 3.0 Asthma Module.
Methods
The PedsQL™ 3.0 Asthma Module was translated into Chinese following the PedsQL™ Measurement Model Translation Methodology. The Chinese version scale was administered to 204 children with asthma and 337 parents of children with asthma from four Triple A hospitals. The psychometric properties were then evaluated.
Results
The percentage of missing value for each item of the scale ranged from 0.00% to 8.31%. All child self-report subscales and parent proxy-report subscales approached or exceeded the minimum reliability standard of 0.70 for alpha coefficient, except 3 subscales of Young Child (aged 5-7) self-report (alphas ranging from 0.59 to 0.68). Test-retest reliability was satisfactory with intraclass correlation coefficients (ICCs) which exceeded the recommended standard of 0.80 in all subscales. Correlation coefficients between items and their hypothesized subscales were higher than those with other subscales. The PedsQL™ 3.0 Asthma Module distinguished between outpatients and inpatients. Patients with mild asthma reported higher scores than those with moderate/severe asthma in majority of subscales. The intercorrelations among the PedsQL™ 3.0 Asthma Module subscales and the PedsQL™ 4.0 Generic Core Scales were in medium to large effect size. The child self-report scores were consistent with the parent proxy-report scores.
Conclusions
The Chinese version of the PedsQL™ 3.0 Asthma Module has acceptable psychometric properties, except the internal consistency reliability for Young Child (aged 5-7) self-report. Further studies should be focused on testing responsiveness of the Chinese version scale in longitudinal studies, evaluating the reliability and validity of the scale for the patients with severe asthma or teens independently, and assessing HRQOL of children with asthma in other areas.
doi:10.1186/1477-7525-9-64
PMCID: PMC3161836  PMID: 21819618
Asthma; Children; Health-related quality of life; Reliability; Validity; PedsQL
17.  Socioeconomic, Family, and Pediatric Practice Factors Affecting the Level of Asthma Control 
Pediatrics  2009;123(3):829-835.
Background
Multiple issues bear on effective control of childhood asthma.
Objective
To identify factors related to the level of asthma control in children receiving asthma care from community pediatricians.
Patients and Methods
Data for 362 children participating in an intervention study to reduce asthma morbidity were collected by telephone administered questionnaire. Level of asthma control (“well controlled,” partially controlled,” or “poorly controlled”) was derived from measures of recent impairment (symptoms, activity limitations, albuterol use) and the number of exacerbations in a 12 month period. Data also included demographic characteristics, asthma-related quality of life, pediatric management practices, and medication usage. Univariable and multivariable analyses were used to identify factors associated with poor asthma control and to explore the relationship between control and use of daily controller medications.
Results
Asthma was “well controlled” for 24% of children, “partially controlled” for 20%, and “poorly controlled” for 56%. Medicaid insurance (p=0.016), the presence of another family member with asthma (p=0.0168), and outside the home maternal employment, (p=0.025), were significant univariable factors associated with poor asthma control. Medicaid insurance had an independent association with poor control (OR 0.49, 95% CI 0.28-0.9). Seventy-six percent of children were reported by parents as receiving a daily controller medication. Comparison of guidelines recommended controller medication with level of control indicated that a higher step level of medication would have been appropriate for 74% of these children. Significantly lower overall quality of life scores were observed in both parents and children with poor control. (ANOVA, p<0.05)
Conclusion
Despite substantial use of daily controller medication, children with asthma continue to experience poorly controlled asthma and reduced quality of life. While Medicaid insurance and aspects of family structure are significant factors associated with poorly controlled asthma, attention to medication use and quality of life indicators may further reduce morbidity.
doi:10.1542/peds.2008-0504
PMCID: PMC2723164  PMID: 19255010
Childhood asthma; asthma control; asthma outcomes
18.  Predicting moderate improvement and decline in pediatric asthma quality of life over 24-months 
Objective
Determine factors associated with 24-month change in quality of life in children with asthma and their parents during the Childhood Asthma Management Program (CAMP).
Methods
Participants from 4 CAMP clinical centers were administered the Pediatric Asthma Quality of Life questionnaire and protocol measures of asthma symptoms, lung function, and psychological measures.
Results
Multivariate logistic regression analyses determined predictors of moderate change in quality of life. Subclinical levels of depression predicted moderate improvement in child-reported quality of life. Level of depressed affect together with clinical asthma features predicted moderate decline. Improvement in parent quality of life was predicted by perception of illness burden, whereas family features and a child missing school predicted moderate decline.
Conclusions
This ancillary study provided an opportunity to examine the determinants of 24-month change in parent and child of quality of life within a subset of the CAMP participants. Moderate changes in quality of life occur in clinical studies and have both psychosocial correlates as well as illness characteristics.
doi:10.1007/s11136-010-9715-4
PMCID: PMC3555223  PMID: 20680689
Asthma; Childhood Asthma Management Program; Quality of life
19.  Negative life events and quality of life in adults with asthma 
Thorax  2006;62(2):139-146.
Background
The relationship between stress and quality of life in adults with asthma has not been well studied. Stress, quantified by negative life events, may be linked to quality of life in asthma through multiple pathways, including increase in disease severity and adverse effects on socioeconomic status (SES).
Methods
The responses to a self‐completed questionnaire assessing negative life events (NLEs) in the previous 12 months (from a 24‐item checklist) among 189 adults with asthma from a well‐characterised cohort were analysed. The relationship between the number of NLEs reported and asthma‐specific quality of life (AQOL) was measured with the Marks instrument. General linear modelling was used to test the conjoint effects of NLEs, SES and disease severity based on the Severity of Asthma Score, a validated acute and chronic disease measure.
Results
Those with annual family incomes <$60 000 reported significantly more NLEs than those with higher incomes (p = 0.03). The number of NLEs did not differ significantly between those with forced expiratory volume in 1 s <80% predicted and those with >80% predicted, nor among those with lower compared with higher Severity of Asthma Score. The frequency of NLEs was associated with poorer (higher numerical score) AQOL (p = 0.002). When studied together in the same model, combinations of income level and asthma severity (greater or lesser Severity of Asthma Score; p<0.001) and number of NLEs (p = 0.03) were both significantly associated with AQOL.
Conclusion
NLEs are associated with quality of life among adults with asthma, especially among those of lower SES. Clinicians should be aware of this relationship, especially in vulnerable patient subsets.
doi:10.1136/thx.2006.065730
PMCID: PMC2111249  PMID: 16928721
20.  The Effects of Combining Web-Based eHealth With Telephone Nurse Case Management for Pediatric Asthma Control: A Randomized Controlled Trial 
Background
Asthma is the most common pediatric illness in the United States, burdening low-income and minority families disproportionately and contributing to high health care costs. Clinic-based asthma education and telephone case management have had mixed results on asthma control, as have eHealth programs and online games.
Objectives
To test the effects of (1) CHESS+CM, a system for parents and children ages 4–12 years with poorly controlled asthma, on asthma control and medication adherence, and (2) competence, self-efficacy, and social support as mediators. CHESS+CM included a fully automated eHealth component (Comprehensive Health Enhancement Support System [CHESS]) plus monthly nurse case management (CM) via phone. CHESS, based on self-determination theory, was designed to improve competence, social support, and intrinsic motivation of parents and children.
Methods
We identified eligible parent–child dyads from files of managed care organizations in Madison and Milwaukee, Wisconsin, USA, sent them recruitment letters, and randomly assigned them (unblinded) to a control group of treatment as usual plus asthma information or to CHESS+CM. Asthma control was measured by the Asthma Control Questionnaire (ACQ) and self-reported symptom-free days. Medication adherence was a composite of pharmacy refill data and medication taking. Social support, information competence, and self-efficacy were self-assessed in questionnaires. All data were collected at 0, 3, 6, 9, and 12 months. Asthma diaries kept during a 3-week run-in period before randomization provided baseline data.
Results
Of 305 parent–child dyads enrolled, 301 were randomly assigned, 153 to the control group and 148 to CHESS+CM. Most parents were female (283/301, 94%), African American (150/301, 49.8%), and had a low income as indicated by child’s Medicaid status (154/301, 51.2%); 146 (48.5%) were single and 96 of 301 (31.9%) had a high school education or less. Completion rates were 127 of 153 control group dyads (83.0%) and 132 of 148 CHESS+CM group dyads (89.2%). CHESS+CM group children had significantly better asthma control on the ACQ (d = –0.31, 95% confidence limits [CL] –0.56, –0.06, P = .011), but not as measured by symptom-free days (d = 0.18, 95% CL –0.88, 1.60, P = 1.00). The composite adherence scores did not differ significantly between groups (d = 1.48%, 95% CL –8.15, 11.11, P = .76). Social support was a significant mediator for CHESS+CM’s effect on asthma control (alpha = .200, P = .01; beta = .210, P = .03). Self-efficacy was not significant (alpha = .080, P = .14; beta = .476, P = .01); neither was information competence (alpha = .079, P = .09; beta = .063, P = .64).
Conclusions
Integrating telephone case management with eHealth benefited pediatric asthma control, though not medication adherence. Improved methods of measuring medication adherence are needed. Social support appears to be more effective than information in improving pediatric asthma control.
Trial Registration
Clinicaltrials.gov NCT00214383; http://clinicaltrials.gov/ct2/show/NCT00214383 (Archived by WebCite at http://www.webcitation.org/68OVwqMPz)
doi:10.2196/jmir.1964
PMCID: PMC3409549  PMID: 22835804
Asthma; asthma information; childhood disease; case management; patient education; eHealth; social support
21.  Preterm Birth and Childhood Wheezing Disorders: A Systematic Review and Meta-Analysis 
PLoS Medicine  2014;11(1):e1001596.
In a systematic review and meta-analysis, Jasper Been and colleagues investigate the association between preterm birth and the development of wheezing disorders in childhood.
Please see later in the article for the Editors' Summary
Background
Accumulating evidence implicates early life factors in the aetiology of non-communicable diseases, including asthma/wheezing disorders. We undertook a systematic review investigating risks of asthma/wheezing disorders in children born preterm, including the increasing numbers who, as a result of advances in neonatal care, now survive very preterm birth.
Methods and Findings
Two reviewers independently searched seven online databases for contemporaneous (1 January 1995–23 September 2013) epidemiological studies investigating the association between preterm birth and asthma/wheezing disorders. Additional studies were identified through reference and citation searches, and contacting international experts. Quality appraisal was undertaken using the Effective Public Health Practice Project instrument. We pooled unadjusted and adjusted effect estimates using random-effects meta-analysis, investigated “dose–response” associations, and undertook subgroup, sensitivity, and meta-regression analyses to assess the robustness of associations.
We identified 42 eligible studies from six continents. Twelve were excluded for population overlap, leaving 30 unique studies involving 1,543,639 children. Preterm birth was associated with an increased risk of wheezing disorders in unadjusted (13.7% versus 8.3%; odds ratio [OR] 1.71, 95% CI 1.57–1.87; 26 studies including 1,500,916 children) and adjusted analyses (OR 1.46, 95% CI 1.29–1.65; 17 studies including 874,710 children). The risk was particularly high among children born very preterm (<32 wk gestation; unadjusted: OR 3.00, 95% CI 2.61–3.44; adjusted: OR 2.81, 95% CI 2.55–3.12). Findings were most pronounced for studies with low risk of bias and were consistent across sensitivity analyses. The estimated population-attributable risk of preterm birth for childhood wheezing disorders was ≥3.1%.
Key limitations related to the paucity of data from low- and middle-income countries, and risk of residual confounding.
Conclusions
There is compelling evidence that preterm birth—particularly very preterm birth—increases the risk of asthma. Given the projected global increases in children surviving preterm births, research now needs to focus on understanding underlying mechanisms, and then to translate these insights into the development of preventive interventions.
Review Registration
PROSPERO CRD42013004965
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Most pregnancies last around 40 weeks, but worldwide, more than 11% of babies are born before 37 weeks of gestation (the period during which a baby develops in its mother's womb). Preterm birth is a major cause of infant death—more than 1 million babies die annually from preterm birth complications—and the number of preterm births is increasing globally. Multiple pregnancies, infections, and chronic (long-term) maternal conditions such as diabetes can all cause premature birth, but the cause of many preterm births is unknown. The most obvious immediate complication that is associated with preterm birth is respiratory distress syndrome. This breathing problem, which is more common in early preterm babies than in near-term babies, occurs because the lungs of premature babies are structurally immature and lack pulmonary surfactant, a unique mixture of lipids and proteins that coats the inner lining of the lungs and helps to prevent the collapse of the small air sacs in the lungs that absorb oxygen from the air. Consequently, preterm babies often need help with their breathing and oxygen supplementation.
Why Was This Study Done?
Improvements in the management of prematurity mean that more preterm babies survive today than in the past. However, accumulating evidence suggests that early life events are involved in the subsequent development of non-communicable diseases (non-infectious chronic diseases). Given the increasing burden of preterm birth, a better understanding of the long-term effects of preterm birth is essential. Here, the researchers investigate the risks of asthma and wheezing disorders in children who are born preterm by undertaking a systematic review (a study that uses predefined criteria to identify all the research on a given topic) and a meta-analysis (a statistical method for combining the results of several studies). Asthma is a chronic condition that is caused by inflammation of the airways. In people with asthma, the airways can react very strongly to allergens such as animal fur and to irritants such as cigarette smoke. Exercise, cold air, and infections can also trigger asthma attacks, which can sometimes be fatal. The symptoms of asthma include wheezing (a high-pitched whistling sound during breathing), coughing, chest tightness, and shortness of breath. Asthma cannot be cured, but drugs can relieve its symptoms and prevent acute asthma attacks.
What Did the Researchers Do and Find?
The researchers identified 30 studies undertaken between 1995 and the present (a time span chosen to allow for recent changes in the management of prematurity) that investigated the association between preterm birth and asthma/wheezing disorders in more than 1.5 million children. Across the studies, 13.7% of preterm babies developed asthma/wheezing disorders during childhood, compared to only 8.3% of babies born at term. Thus, the risk of preterm babies developing asthma or a wheezing disorder during childhood was 1.71 times higher than the risk of term babies developing these conditions (an unadjusted odds ratio [OR] of 1.71). In analyses that allowed for confounding factors—other factors that affect the risk of developing asthma/wheezing disorders such as maternal smoking—the risk of preterm babies developing asthma or a wheezing disorder during childhood was 1.46 times higher than that of babies born at term (an adjusted OR of 1.46). Notably, compared to children born at term, children born very early (before 32 weeks of gestation) had about three times the risk of developing asthma/wheezing disorders in unadjusted and adjusted analyses. Finally, the population-attributable risk of preterm birth for childhood wheezing disorders was more than 3.1%. That is, if no preterm births had occurred, there would have been more than a 3.1% reduction in childhood wheezing disorders.
What Do These Findings Mean?
These findings strongly suggest that preterm birth increases the risk of asthma and wheezing disorders during childhood and that the risk of asthma/wheezing disorders increases as the degree of prematurity increases. The accuracy of these findings may be affected, however, by residual confounding. That is, preterm children may share other, unknown characteristics that increase their risk of developing asthma/wheezing disorders. Moreover, the generalizability of these findings is limited by the lack of data from low- and middle-income countries. However, given the projected global increases in children surviving preterm births, these findings highlight the need to undertake research into the mechanisms underlying the association between preterm birth and asthma/wheezing disorders and the need to develop appropriate preventative and therapeutic measures.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001596.
The March of Dimes, a nonprofit organization for pregnancy and baby health, provides information on preterm birth (in English and Spanish)
Nemours, another nonprofit organization for child health, also provides information (in English and Spanish) on premature babies and on asthma (including personal stories)
The UK National Health Service Choices website provides information about premature labor and birth and a real story about having a preterm baby; it provides information about asthma in children (including real stories)
The MedlinePlus Encyclopedia has pages on preterm birth, asthma, asthma in children, and wheezing (in English and Spanish); MedlinePlus provides links to further information on premature birth, asthma, and asthma in children (in English and Spanish)
doi:10.1371/journal.pmed.1001596
PMCID: PMC3904844  PMID: 24492409
22.  Development of a core outcome set for clinical trials in childhood asthma: a survey of clinicians, parents, and young people 
Trials  2012;13:103.
Background
In clinical trials in childhood asthma, outcomes reflecting short-term disease activity are frequently measured, whilst functional status, quality of life (QoL), and long-term treatment effects are rarely assessed. There is also non-uniformity across studies in the selection and measurement of outcomes within these domains. The development of a core outcome set has the potential to reduce heterogeneity between trials, lead to research that is more likely to have measured relevant outcomes, and enhance the value of evidence synthesis by reducing the risk of outcome reporting bias and ensuring that all trials contribute usable information.
Methods
Paediatricians and specialist nurses, identified through the British Paediatric Respiratory Society, completed a two-round Delphi survey. Separate cohorts of parents of children younger than 18 years, recruited in clinics, participated in each round. Young people with asthma, aged at least 13 years, participated in the first round. Outcomes were identified separately for preschool and school-aged children.
We identified outcomes considered important in routine clinical assessment by clinicians and parents/young people. In round 1, 46 clinicians suggested outcomes they considered important when deciding whether to adjust a child’s asthma therapy regime, and 49 parents/young people were asked, using open questions, how they judged whether their child’s (for young people, their own) asthma therapy was appropriate. Two researchers independently classified responses into appropriate, corresponding outcomes.
In round 2, 43 clinicians and 50 parents scored, from 0–4, the importance of each outcome suggested by at least 10 % of round 1 responders and selected the three most important.
Results
The most important outcomes, when making shared decisions about regular therapies for school-aged and preschool children with asthma, were daytime and nocturnal symptoms, exacerbations, QoL, and mortality. Results from parents and clinicians were generally concordant, but parents placed more emphasis on long-term treatment effects.
Conclusions
We have developed a methodology to identify outcomes of most relevance to clinicians, parents, and young people when evaluating regularly administered therapies for asthma. Daytime and nocturnal symptoms, exacerbations, QoL, and mortality are particularly important outcomes that should be measured and reported in all clinical trials of regular therapies for children with asthma.
doi:10.1186/1745-6215-13-103
PMCID: PMC3433381  PMID: 22747787
Asthma; Core outcome set; Delphi; Children; Paediatrics
23.  Parental education and guided self-management of asthma and wheezing in the pre-school child: a randomised controlled trial 
Thorax  2002;57(1):39-44.
Background: The effects on morbidity were examined of providing an educational intervention and a written guided self-management plan to the parents of pre-school children following a recent attendance at hospital for asthma or wheeze.
Methods: A prospective, randomised, partially blinded, controlled trial was designed at two secondary care centres. Over a 13 month period 200 children aged 18 months to 5 years at the time of admission to a children's ward or attendance at an accident and emergency department or children's (emergency) assessment unit (A&E/CAU) with a primary diagnosis of acute severe asthma or wheezing were recruited. 101 children were randomised into the control group and received usual care and 99 were assigned to the intervention group and received: (1) a pre-school asthma booklet; (2) a written guided self-management plan; and (3) two 20 minute structured educational sessions between a specialist respiratory nurse and the parent(s) and child. Subjects were assessed at 3, 6, and 12 months. The main outcomes were GP consultation rates, hospital re-admissions, and attendances at A&E/CAU. Secondary outcomes included disability score, caregivers' quality of life, and parental knowledge of asthma.
Results: There were no statistically significant differences between the two groups during the 12 month follow up period for any of the main or secondary outcome measures.
Conclusions: These results do not support the hypothesis that the introduction of an educational package and a written guided self-management plan to the parents of pre-school children with asthma who had recently attended hospital for troublesome asthma or wheeze reduces morbidity over the subsequent 12 months.
doi:10.1136/thorax.57.1.39
PMCID: PMC1746177  PMID: 11809988
24.  A children’s asthma education program: Roaring Adventures of Puff (RAP), improves quality of life 
BACKGROUND:
It is postulated that children with asthma who receive an interactive, comprehensive education program would improve their quality of life, asthma management and asthma control compared with children receiving usual care.
OBJECTIVE:
To assess the feasibility and impact of ‘Roaring Adventures of Puff’ (RAP), a six-week childhood asthma education program administered by health professionals in schools.
METHODS:
Thirty-four schools from three health regions in Alberta were randomly assigned to receive either the RAP asthma program (intervention group) or usual care (control group). Baseline measurements from parent and child were taken before the intervention, and at six and 12 months.
RESULTS:
The intervention group had more smoke exposure at baseline. Participants lost to follow-up had more asthma symptoms. Improvements were significantly greater in the RAP intervention group from baseline to six months than in the control group in terms of parent’s perceived understanding and ability to cope with and control asthma, and overall quality of life (P<0.05). On follow-up, doctor visits were reduced in the control group.
CONCLUSION:
A multilevel, comprehensive, school-based asthma program is feasible, and modestly improved asthma management and quality of life outcomes. An interactive group education program offered to children with asthma at their school has merit as a practical, cost-effective, peer-supportive approach to improve health outcomes.
PMCID: PMC2866218  PMID: 20422062
Asthma education; Childhood asthma; Program evaluation; Quality of life; School-based program
25.  Validity of two common asthma-specific quality of life questionnaires: Juniper mini asthma quality of life questionnaire and Sydney asthma quality of life questionnaire 
Background
This study explored the psychometric properties (internal consistency, construct validity, discriminative ability) of the Juniper Mini Asthma Quality of Life Questionnaire (Mini AQLQ-J) and the Sydney Asthma Quality of Life Questionnaire (AQLQ-S).
Methods
One hundred fourty-six adults (18–45 years) with asthma requiring regular inhaled corticosteroids were recruited to a trial of written emotional disclosure. Correlational analyses were performed to understand the relationship of the two measures with each other, with symptoms, lung function, asthma control, asthma bother and generic quality of life. Median quality of life scores were compared according to gender, health care usage and levels of asthma severity.
Results
AQLQ-J and AQLQ-S total scores correlated strongly with each other (rho = −0.80) and moderately with the EuroQol Current Health Status Scale (AQLQ-J: rho = 0.35; AQLQ-S: rho = −0.40). Domain score correlations between AQLQ-J and AQLQ-S were mostly moderate (0.50 < rho < 0.80).
Both QoL measures were significantly correlated with symptom score. Correlations with the symptom score asthma module (AQLQ-J: rho = −0.69; AQLQ-S: rho = 0.50) were stronger compared with the total symptom score and the symptom score rhinitis module (AQLQ-J: rho = −0.41; AQLQ-S: rho =0.31).
Neither QoL measure was significantly correlated with FEV1, % predicted at the total or the domain level.
Total scores of both measures were significantly correlated with subjective asthma control (AQLQ-J: rho = 0.68; AQLQ-S: rho = −0.61) and asthma bother (AQLQ-J: rho = −0.73; AQLQ-M: rho = 0.73).
Total AQLQ-J score and total AQLQ-S score were significantly associated with perceived asthma severity (AQLQ-J: p=0.004, AQLQ-S: p=0.002) and having visited a GP in the past four months (AQLQ-J: p=0.003, AQLQ-S: p=0.002).
Conclusions
This study provides further evidence for the validity of the AQLQ-J and the AQLQ-S in a British population of adult patients with asthma managed in primary care. Correlations with lung function parameters were weak or absent. Correlations with generic quality of life were moderate, those with asthma symptoms, asthma control and asthma bother were strong. Both measures are able to discriminate between levels of asthma severity and health care usage.
doi:10.1186/1477-7525-10-97
PMCID: PMC3478207  PMID: 22906054

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