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	Pediatric asthma patients realize improved health and reduced corticosteroid use when they receive integrated care that considers personal, familial, and environmental risk factors, according to the 

 published in the October 17, 2017, issue of 

	Rather than just physical factors, lead author Alyssa A. Oland, PhD, assistant professor of psychiatry at the University of Colorado School of Medicine, and colleagues found that a number of factors-lifestyle, social and psychological-affect outcomes in children with asthma. Asthma is the most common childhood illness and disproportionately affects low-income, minority children who live in urban areas, typically because children living in low-income households are more likely to experience less parental support and involvement, and to feel more of a lack of control over their environment, the authors wrote.

	“Recent research has underscored the importance of multidisciplinary, collaborative, integrated care for pediatric asthma patients with promising results. Such a comprehensive approach is ideal for addressing the multitude of complex, inter-related psychosocial and wellness/lifestyle factors that play a role in childhood asthma,” the authors wrote.

	Children from economically disadvantaged households may also experience less access to care and poorer quality of care. For example, it is estimated that 41% of children aged 2 to 17 years do not receive needed mental health services.

	“As such, low-income, urban minority children have increased barriers to proper asthma management, including increased exposure to environmental triggers and reduced access to appropriate treatment,” the authors wrote.

	However, it is not just income that impacts asthma morbidity and mortality rates. A variety of other risk factors include: treatment non-adherence, exposure to environmental triggers, exposure to chronic stress, child psychological problems, parental stress, family functioning, obesity, physical inactivity, and unhealthy diets, according to the study. “These risk factors often have complex interactions and inter-relationships. Comprehensive studies that explore the inter-relationships of these factors in accounting for asthma morbidity and mortality are needed and would help to inform clinical intervention.”

	While there are now a range of psychosocial interventions for children with asthma, such as educational programs, behavioral interventions, cognitive-behavioral therapy, family interventions, and/or community-based interventions, research on the efficacy of psychosocial interventions is “limited, inconclusive, and plagued by concerns regarding methodological issues,” according to the authors.

	Despite these problems, “Preliminary evidence suggests that psychosocial interventions can improve the quality of life and medical outcomes for children with asthma. Interventions that combine education with psychosocial interventions, such as behavioral, cognitive-behavioral, and/or family interventions show particular promise,” they wrote.

	Self-management training and education are also well-established and essential parts of treatment for asthma patients. Studies have shown that children with asthma taking part in these programs have improved adherence, improved asthma symptoms, reduced energy room visits, fewer school absences, and other positive benefits.

	“Similarly, education combined with family therapy resulted in benefits for children and for parents, resulting in reduced airway inflammation, improved physical health, and improved mental health,” the authors wrote.

	Integrated care programs have demonstrated significant improvements in asthma symptoms, perceived competence in asthma management, reduced corticosteroid use, and improved quality of life for caregivers and children, according to the study.

Articles

A new study reveals interesting findings about improving the health of pediatric asthma patients and integrated care programs.

Integrated care can benefit pediatric asthmatics

	While breastfeeding has been thought to decrease children’s risk of developing allergies and asthma, a 

	In the largest study of its kind, researchers with Uppsala University in Uppsala, Sweden, found that breastfeeding might increase the risk of developing hay fever and eczema. Plus, they said, breastfeeding does not have any clear effect on the risk of developing asthma, according to the article published in the 

Journal of Allergy and Clinical Immunology.

	Individuals’ risk of having asthma and allergies depends on their genes, environment and lifestyle factors, wrote Weronica Ek, lead author and researcher at Uppsala University’s Department of Immunology, Genetics and Pathology.

	However, studies on breastfeeding have shown inconsistent results. “Many studies have found breastfeeding to have a protective effect against asthma and allergy, while other studies have reported increased risk,” according to an Uppsala University 

	Meanwhile, the large Uppsala University study examined self-reported data from more than 330,000 middle-aged individuals in the United Kingdom.

	They found that increased socioeconomic status lowers the risk of asthma, while it increases the risk of developing hay fever. “These results are in line with the ‘hygiene hypothesis’, which states that growing up in a cleaner environment increases the risk of being diagnosed with allergies due to a lack of early childhood exposure to microorganisms, among other things,” Uppsala University said.

	The study also showed that a high body mass index (BMI) increases the risk for asthma, hay fever and eczema. However, the risk for developing all of the conditions decreases in individuals with higher birth weight.

	The researchers noted certain limitations to the study, including the fact that it is an observational study, which does not allow for clinical recommendations to be made. “In such studies, there may always be underlying factors that the researchers do not have information about, which are the true causes of the observed effects.”

	For example, mothers who have hay fever, asthma or eczema themselves may have been advised to breastfeed or not to breastfeed, which may affect the study’s findings.

	“It is well established that breastfeeding has a positive effect on the health of the baby. Even though we do not see a protective effect of breastfeeding on the risk of developing asthma or allergies, these results should not be used to recommend or discourage breastfeeding, since the present study only investigates the effect of breastfeeding on allergies and asthma,” Uppsala University said.

	“However, we hope that our study can give a more correct picture of the health benefits of breastfeeding,” Ek added.

While breastfeeding has been  thought to decrease children’s risk of developing allergies and asthma, a new study counters that belief.

Does breastfeeding protect children against asthma?

	Asthma healthcare providers should consider other treatments for severe asthma besides the regular use of oral corticosteroids and conduct testing to better diagnose asthma severity, according to a new article.

	"We felt strongly that, before regular use of oral corticosteroids, because of the numerous complications with their chronic use, that other medical interventions should be considered related to the patient's asthma phenotype," says Bradley Chipps, MD, an allergist, president of the American College of Asthma, Allergy  and Immunology (ACAAI), and coauthor of the 

	Regular or high doses of oral corticosteroids should not be the first point of treatment-for multiple reasons, Chipps says. “We use doses that are too high. There is very little evidence that doses over 60 mg to 80 mg a day are effective, and there is a very poor understanding of the downside of using two or more doses per year. That definitely leads to a greater risk of hip fractures, bruising, and elevated blood sugar.”

	It is very important for clinicians to fine-tune their asthma management strategies and “make sure we use the least toxic drugs to control asthma, and get the right drug to the right patient,” Chipps said.

Recommendation: Perform asthma phenotyping sooner

	To determine the best methods for diagnosing asthma and the use of various treatment options, including brachial thermoplasty, a roundtable meeting of seven asthma experts reviewed select literature. “Participants acknowledged that the body of evidence needed to develop strong guidelines for the use of newer biologic therapies or bronchial thermoplasty is limited,” the authors wrote. “However, guiding principles for practicing clinicians could be derived from available clinical trial evidence, experience in practice, and clinical logic.”

	The panel concluded that asthma phenotyping-determining the clinical characteristics of asthma-should be carried out at diagnosis, and not after the patient’s condition is severe. “Our hope is to prevent potentially poor outcomes before asthma symptoms worsen,” they wrote.

	Bronchial thermoplasty, which delivers therapeutic radio frequency energy to the airway wall, was presented as one alternative treatment option for severe asthma. A five-year follow-up of patients in trials using bronchial thermoplasty showed a sustained decrease in exacerbations, decreased health care resource usage, and no further decline in lung function, the authors wrote.

	“Overall, bronchial thermoplasty has proved an effective therapeutic option (in addition to macrolide antibiotics and OCS, which can be considered under certain circumstances) for patients with a non-TH2 type inflammation asthma phenotype,” the authors wrote. “Furthermore, bronchial thermoplasty has shown similar efficacy in patients with other asthma phenotypes and airway smooth muscle hypertrophy.”

	The panel also said that clinicians need a better definition of severe asthma, and agreed to the following definition: “asthma that, despite patient adherence, requires high-dose ICS plus LABA and/or additional controller medication or requires oral corticosteroids to prevent it from becoming uncontrolled or that remains uncontrolled despite this therapy.”

Allergist Bradley Chipps, MD, shares research on how to fine-tune asthma management strategies.

Two asthma treatment recommendations for health organizations

	A landmark study shows how clinicians may be able to identify whether asthma will develop in patients as young as one-year-old.

	Children at one-year-old who have eczema or atopic dermatitis (AD) and are sensitized to an allergen are seven times more likely than other infants to develop asthma, and significantly more likely to have a food allergy by age three, according to a study published in the 

The Journal of Allergy and Clinical Immunology

	“These findings may prompt pediatricians to undertake skin testing early in life in children with apparent skin allergies..to determine if the child is in fact sensitized to food allergens as it is these children who are at higher risk of going on to develop asthma and so more preventative or treatment measures may be indicated,” Malcolm Sears, MD, founding director of the CHILD Study, a professor of medicine at McMaster University in Hamilton, Ontario, and a researcher at the Firestone Institute for Respiratory Health at St. Joseph’s Healthcare Hamilton, told 

	Using data from more than 2,300 children from across Canada participating in the CHILD Study, A team of Canadian researchers evaluated the presence of AD and allergic sensitization at age one. When the children were three years of age, the researchers performed a clinical assessment to determine the presence of asthma, allergic rhinitis, food allergy and AD.

	The combined effect of AD and allergic sensitization was found to be greater than the sum of their individual effects, both on the risk of asthma and on reported food allergy.

	“Much of what happens to us later in life is related to the exposures we encounter in early childhood,” Sears said in a statement.

	It has long been known that infants with eczema or AD are more likely to develop asthma and allergic rhinitis in later childhood. However, predicting precisely which children with AD will go on to develop these conditions has been difficult.

	“Over the years, the clinical community has struggled to explain the atopic march,” Sears 

. “These findings help us to understand the interactive effects of AD and early allergic sensitization on the risk of asthma and food allergy, and show that in combination they pose a significant risk for future allergic disease.”

	The findings are useful to help predict which children may develop asthma and allergies, according to the study’s lead author, Maxwell Tran, a BHSc graduate from McMaster University and AllerGen trainee who is now studying medicine at the University of Toronto. “There are certain genetic variants that we know are risk factors for allergy, but genotyping is not widely used in clinical practice, so this research offers healthcare professionals an alternative method of identifying at-risk children.”

	Meanwhile, the CHILD researchers found that having AD alone, without sensitization to an allergen, did not significantly increase children’s risk of developing asthma.

A Canadian study reveals how clinicians may be able to identify whether asthma will develop in patients as young as age one.

Author | Christine Blank

Articles

Integrated care can benefit pediatric asthmatics

Does breastfeeding protect children against asthma?

Two asthma treatment recommendations for health organizations

Landmark study identifies asthma in infants