AAAAI: Pediatric Asthma Highlights

Allergies & Asthma

With the cancellation of the American Academy of Allergy, Asthma, and Immunology’s annual meeting on account of the COVID-19 outbreak, MedPage Today is reviewing some of the research abstracts that were scheduled for presentation. Here are some highlights of those focusing on asthma in children and adolescents.

Parents’ Stress, Kids’ Breathing Trouble

When minority parents are under stress, especially in low-income urban families, children with asthma exhibit more breathing symptoms, researchers reported in abstract #358.

When all three types of parental stress — depression, stress of their environment, and stress caused by discrimination — were considered, there appeared to be an impact on their children’s asthma symptoms, especially cough and nighttime symptoms, reported Erin Rodriguez, PhD, of the University of Texas at Austin.

Rodriguez said that of those stressors, parental depression appeared to be the most influential.

“Parental depressive symptoms may be a more important risk factor for asthma symptoms in low-income urban children with asthma than contextual stress or discrimination stress,” she reported. “Parental stress is linked with children’s asthma symptoms, but the independent associations of co-occurring types of stress with asthma is less understood.”

She and colleagues enrolled 102 children with asthma, ages 5 to 17, to participate in an observational study on asthma and housing mobility. Parents/guardians reported their own depressive symptoms on the Personal Health Questionnaire-8 (PHQ-8), contextual stress such as that caused by parenting or issues in the neighborhood, and discrimination stress such as stress experienced at work. The caregivers also recorded children’s asthma symptoms, including days of cough, wheezing, and nighttime waking in the previous 2 weeks.

All the participants were black or African American, 99% were on public health insurance, and 53% were male. Children had 6.2 asthma symptom days during the 2-week period. The caregivers’ average PHQ-8 score was 13.9, indicating an elevated risk for depression, Rodriguez reported. Parental depressive symptoms were associated with childhood cough and nocturnal symptoms; there were trends toward a link between depressive symptoms and overall children’s asthma symptoms, and in symptoms limiting the ability to speak among the children. Rodriguez did not observe a link between stressors and slowed activity, exercise-related symptoms, or the use of asthma rescue medication.

Rhinitis Adds to Asthma Morbidity

In abstract #364, researchers reported that asthma patients who also exhibited symptoms of allergic rhinitis were more likely to be treated in the emergency department, to miss school, and to use rescue medication than children with asthma who were not affected by allergic rhinitis.

“Allergic rhinitis is prevalent in high-risk adolescents with persistent asthma and is associated with significant asthma morbidity and undertreatment,” reported Jessica Stern, MD, of the University of Rochester Medical Center in New York.

She and colleagues enrolled 387 adolescents with persistent asthma into the study. The children, ages 12-16, were from the Rochester City School District and participated in the School Based Asthma Care for Teens trial in 2016-2017. History of allergic rhinitis and asthma outcomes were assessed via clinical history and spirometry. Participants’ mean age was 13. About 55% of the student population was black and 32% were Hispanic; 85% were on Medicaid.

“Allergic rhinitis is a known comorbidity in asthmatic adolescents that may exacerbate symptoms,” Stern noted in her abstract. “School-based programs have demonstrated that preventive asthma therapy administered under school nurse supervision reduces morbidity. However a subgroup of adolescents continue to have difficult to control asthma despite monitored preventive treatment. Using the unified airway paradigm, we hypothesized that this cohort of adolescents would have significant burden of allergic rhinitis, and allergic rhinitis would be associated with worse asthma outcomes.”

Her group found that 77% of participants reported a history of allergic rhinitis. Those with allergic rhinitis were more than twice as likely to be seen in the emergency department for asthma compared with those without (adjusted OR 2.64, 95% CI 1.29-5.44). Additionally, adolescents with allergic rhinitis were more likely to use rescue medication and miss school due to asthma compared with those without allergic rhinitis. “Importantly, only 52% of adolescents with allergic rhinitis reported taking allergy medication,” Stern noted.

Delayed Diagnosis of Asthma

Children who were immediately diagnosed with asthma after an initial visit with a physician had more asthma-specific events in the first year after diagnosis than children whose diagnosis was delayed, but after 5 years the groups had similar outcomes, researchers reported (abstract #346).

The research team, under the direction of Young Juhn, MD, of the Mayo Clinic in Rochester, Minnesota, examined the records of 1,398 eligible subjects — 60% of whom were male and 79% white who were part of the Olmsted County (Minnesota) Birth Cohort. Children were stratified into two groups: 808 who were diagnosed with asthma within 4 weeks of their index visit and 590 with a delayed diagnosis (after a median of 452 days). Eligibility for inclusion in the study required 5 years of follow-up.

Compared with those with a timely diagnosis, the delayed diagnosis group had lower odds of an asthma-specific emergency department visit and/or hospitalization during the first year after the index visit, the research team reported. About 26% of the timely diagnosed children met the event criteria compared with 23% of those with a delayed diagnosis after the first year (OR 0.66, 95% CI 0.50-0.89). But they reported that by the end of 5 years, there was no difference between the groups, as 37% of those with a timely diagnosis met the endpoint criteria compared with 39% of those with delayed diagnosis (OR 0.90, 95% CI 0.70-1.17).

“A delayed diagnosis of asthma is common,” the researchers wrote in their abstract. “Longer-term studies are needed to capture its long-term impact given increasing tendency of poor outcomes in delayed asthma diagnosis group.”

Insulin Linked to Asthma Risk

High serum insulin levels in childhood were associated with increased risk of asthma — a risk that was independent of obesity, researchers suggested (abstract #350).

Their analysis used records from the Tucson Children’s Respiratory Study covering non-fasting insulin levels from participants at age 6 who had body mass index measurements at age 6 and then were later assessed for asthma. The registry used in the study had had continuous follow-up for 36 years.

Among those in the highest quartile of insulin levels at age 6, risk of developing asthma was doubled from age 8 to 36 (OR 2.04, 95% CI 1.31-3.2, P=0.002), reported Tara Carr, MD, of the University of Arizona in Tucson.

“Asthma and obesity are major, interconnected public health challenges that usually have their origins in childhood, and for which the relationship is strengthened among those with insulin resistance,” Carr stated. “We hypothesized that high insulin in early life confers increased risk for asthma independent of obesity.”

Adjustment for markers of metabolic syndrome — leptin, C-reactive protein, and interleukin-6 — did not alter the association between high childhood insulin levels and future asthma diagnosis, Carr and colleagues reported. But high insulin was not associated with current asthma at age 6.

Primary Care Physicians Order More Steroids

Asthma patients were more likely to get steroid prescriptions from primary care physicians than from specialists, researchers reported (abstract #359).

In claims data from Symphony Health for October 2016 to October 2018, Fernando Holguin, MD, of the University of Colorado Hospital in Aurora, determined that 2,970,605 adult patients met the criteria for the study, and that primary care physicians prescribed oral corticosteroids to about 42% of the patients. Allergists, on the other hand, prescribed steroids to 32% of patients, and pulmonologists prescribed the medications to about 30% of their asthma patients.

The primary care physicians also prescribed steroids for longer periods of time — an average of 271 days, versus 219 days for allergists and 230 days for pulmonologists. Holguin also noted that patients in specialists’ care had more severe cases of asthma, as determined by higher GINA (Global Initiative for Asthma) scores.

“These findings highlight important differences across health care providers in terms of oral corticosteroid use,” Holguin stated in the abstract. “While primary care physicians are the largest prescribers of oral corticosteroids, a higher proportion of patients with more severe disease who are more likely to receive chronic oral corticosteroid treatment are managed by specialists. Alternative therapies to replace frequent corticosteroid use should be considered.”

Last Updated March 18, 2020

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