Personal Health : Kids and Asthma : Often Undertreated, the Ailment Should Get Much More Aggressive Care, Experts Advise
If Johnny can’t breathe, it’s time for Johnny, his parents and his doctor to get educated.
That’s because childhood asthma--once regarded as a problem that could be ignored because most youngsters would “grow out of it”--now is viewed as a chronic problem that can and should be controlled with regular medication.
The change in view occurred within the last 15 years and has had profound effects on patients and their families. Just ask Susan Cerini, a La Canada Flintridge mother who watched her son, Nick, deteriorate from mild wheezing at age 1 1/2 to a frightening period of severe asthma episodes when he was 8.
“We did not get one good night’s sleep with him for, gosh, probably six or eight months. He was up every night with these terrible asthma attacks. This kid just could not breathe,” Cerini says. “I’m not a real nervous person, but I came so close to calling the paramedics one night because we just couldn’t get it under control.”
That was when she decided that no matter what doctors had told her, there had to be a better way to deal with Nick’s asthma.
Nick’s was a classic case of undertreatment, said Dr. Warren Richards, the new physician Cerini consulted a year ago. Until he saw Richards at Childrens Hospital of Los Angeles, Nick’s treatment consisted primarily of allergy shots and the traditional preventive drug, theophylline, which can ease asthma but is losing favor as the asthma drug of first choice. In Nick’s case, it wasn’t working well enough.
Widespread Approach
Richards, instead, adopted an approach that has become widespread among asthma specialists familiar with the latest research on the disease. Unfortunately, the specialists say, many pediatricians and family practitioners, as well as some allergists, are unfamiliar with these methods.
In an attempt to remedy this, a panel of doctors convened by the National Heart, Lung and Blood Institute met in Washington last week to begin developing asthma treatment recommendations for use in educating physicians nationwide. They hope the guidelines will help lower asthma hospitalizations as well as deaths, which totaled 122 children and 3,833 adults in the United States in 1986.
The recommendations will not be issued before next summer, but the panel’s chairman indicated they will follow a course similar to that adopted by Richards in treating Nick:
--Richards enlisted Nick’s involvement and cooperation in combatting his illness. Studies have shown this is essential to ensure that children take their medicine regularly and learn to recognize early warning signs of an asthma attack.
--He started the boy on a regular schedule of an inhaled corticosteroid spray to reverse bronchial inflammation, which doctors now know goes on in an asthmatic even during periods when no shortness of breath is felt. Used in this form, corticosteroids have fewer of the serious side effects associated with regular use of oral or injected steroids.
Feeding on Itself
Without suppression, the inflammation would feed on itself over time and eventually lead to severe attacks, doctors say. Another drug that is increasingly used to prevent the inflammation is cromolyn sodium (Intal).
--He stepped up Nick’s use of bronchodilators, medications to open the airways. Besides continuing theophylline pills, he added an adrenaline-like bronchodilator spray. Nick inhales this daily through a “spacer” regulating device. (Without this accordion-like device, the spray often is improperly inhaled and so is ineffective.)
It’s also important that Nick now knows to increase the frequency of his bronchodilator at the first, minor signs of an asthma attack, before playing or taking part in other activities that might cause him problems.
“First, I try to settle down,” Nick says of the times he feels an approaching asthma episode. “Then, if that doesn’t work I tell my mom that I’m going to take a puff.”
Inhaling the bronchodilator opens his airways and has allowed 10-year-old Nick to run, bike, play baseball, golf and swim without the awful sensation that used to scare him so much, the feeling of “breathing through a straw.”
If all else fails, he calls his doctor for permission to take an oral cortisone to stop his lung spasms. He also can use a home aerosol machine (a nebulizer) to deliver a higher dose of bronchodilator to his lungs.
Such care has helped Nick stay away from where asthmatic children often end up: in hospital emergency rooms. There, asthma accounts for 2% to 3% of all visits, when continuous preventive therapy would have controlled the problem at home, doctors say.
‘Permitted to Suffer’
But even if they never see a hospital, for some youngsters, uncontrolled asthma can mean a tortured, abnormal childhood of physical limitations, feeling different and sometimes, depression, Richards said: “There are some children that I think it’s scandalous that they have been permitted to suffer so much discomfort and incapacitation for so long without somebody having done something about it, especially in view that some of these medications are so effective.”
Indeed, his study, published in the July 1 issue of the journal, Pediatrics, concluded that many asthmatic children seen in the Childrens Hospital emergency room are there because their asthma therapy was inadequate or nonexistent.
Hospitalized Children
He looked at 100 asthma cases seen from February to June, 1988, and found that, of children repeatedly hospitalized for severe asthma and whose doctors were not allergists, a third had no continuous-use medication prescribed for their condition.
With 92% of children cared for by pediatricians or family practitioners, their parents never had been told the well-established fact that allergies were a possible trigger of asthma; more than half the children seeing these physicians never had received inhaled, adrenaline-like drugs considered key to halting asthmatic episodes.
A separate questionnaire given to 45 pediatricians and family physicians indicated they often didn’t ask questions Richards considers crucial in assessing asthma’s severity. Although 68% asked if a child’s physical activities were hampered, only 36% asked if asthma was preventing their sleeping or attending school; 4% asked about the child’s general comfort level.
But ineffective asthma treatment isn’t just a problem among non-specialists, said Dr. Albert Sheffer, clinical professor of medicine at Harvard Medical School and head of the federal panel advising doctors on how to treat asthma. “It’s not whether you’re an allergist or a pulmonary doctor, it’s whether you take care of asthma. So it doesn’t make any difference what the specialty is.”
Sheffer’s panel met last week to work on its first draft of recommendations for the National Heart, Lung and Blood Institute. The effort is part of the National Asthma Education Program, launched in March by the institute and a coalition of medical and patient groups.
He said the panel hopes the education program--modeled after successful federal efforts with high blood pressure and cholesterol--not only will educate physicians but will result in better-informed, more activist asthma patients.
The panel, for example, will recommend that physicians monitor asthma patients’ lung function by having them blow into a peak-flow meter, a plastic tube that measures how much air is exhaled, indicating whether therapy is effective. The group also wants patients to take their own peak-flow measurements every morning as routinely as they brush their teeth.
“We’re going public with peak flow meters. We’re going to try to have them available free,” Sheffer said. “We’re wondering whether when we publish this thing the physicians are going to assume the initiative and get peak flow meters or whether the patients are going to come in there and say ‘Gee, doctor, I’ve got a peak flow meter, what does 300 mean?’ ”
Sheffer said the panel’s recommendations will be based on two key premises: that patients need to be well-informed about their disease and that asthma must be treated as a chronic inflammatory condition, not as a succession of unrelated lung spasms.
If a child has asthma attacks more often than every month or two, he needs a continuous treatment regimen, said Dr. Robert B. Mellins, a pediatric lung specialist and professor at Columbia University who chaired the June, 1988, workshop that was the impetus to establish the National Asthma Education Program.
Just as important as treatment, Mellins said, is the need to educate the child and his parents about asthma so they can share responsibility with the doctor for bringing it under control: “It’s not just enough to write some prescriptions and disappear. It takes time, and the better educated and informed the patient is, the more successful treatment is likely to be.”
One of the most common chronic diseases in children, asthma often is associated with allergies to pollen, dust, animal dander, molds or foods. Like allergies, it tends to be inherited from parents. But once the asthma cycle begins, attacks can follow other triggers, including Santa Ana winds, colds, emotional stress, paint vapors, air pollution and cigarette smoke.
During an asthma episode, smooth muscle tightens spasmodically within the bronchi, the major airways in the lungs. The bronchi swell, mucus begins to fill them and the victim wheezes, feels chest tightness and gasps for oxygen.
Severe Second Phase
Even after initial symptoms fade, the inflammatory response in the lungs proceeds and is followed by a more severe second phase hours later. The inflammation worsens with repeated episodes and makes the lungs increasingly sensitive to irritants.
There are an estimated 9.7 million asthmatics in the United States, 3 million of them under 18. No one is sure why, but between 1970 and 1985, the incidence of asthma in the United States increased 22%, with the largest increases in blacks, and in people younger than 18 or older than 65. Deaths from asthma nearly doubled from 1979 to 1987.
From 1979 to 1984, the asthma death rates for blacks between 10 and 19 years old were three to nine times that for whites. Black children were twice as likely to need hospitalization for asthma. Boys continue to be more likely to be affected than girls.
Uncontrolled, asthma can cause serious, adult problems. Lung specialists cite the case of Richard R. Green, the New York City schools chief who had had asthma since childhood and died during a May asthma attack. Access to regular medical care wasn’t an issue for Green, as it is for some of the black population, which is greatly affected by asthma. Yet at age 52, Green died from a condition that lung specialists say only rarely should be fatal.
‘Out of Control’
“If you listen to some tapes of him . . . you can hear on the tape that he was short of breath,” Mellins said. “I have no personal information about his case, so I can only tell what a layperson could tell with his naked ear, but you could tell from those that he was out of control at least some of the time.”
Lung specialists say adults benefit from the same treatment regimen that children do: cromolyn sodium and inhaled corticosteroids regularly to combat inflammation; allergy shots to moderate allergic reactions; and bronchodilators to keep the airways open.
Parents of small children should discuss with their doctors the possibility of keeping injectable adrenaline, also called epinephrine, on hand at home in case of an extreme asthma attack that does not respond to an inhaled dose of the drug, said Dr. R. Michael Sly, chairman of allergy and immunology at Children’s National Medical Center in Washington.
“There have been instances in which fatalities have occurred for lack of the capacity to adminster epinephrine by injection,” said Sly, who has studied asthma deaths nationwide. He said this is a particular hazard in communities where ambulances are staffed by technicians who are not as highly trained as paramedics and don’t have or cannot administer the drug.
When Your Child Needs More Treatment Although asthmas and allergies cannot be cured, in most cases their symptoms can be controlled, doctors say. So most of the time a child with asthmas or allergies will be able to: * Engage in normal physical activites * Sleep restfully * Attend school regularly * Be unhampered at school by his or her condition * Experience no side effects from medicine * Rarely experience asthmas flareups. The flareups are can be controlled at home If this is not the case for your child, he or she needs more intensive treatment with anti-asthmas drugs, according to Dr. Warren Richards, head of the division of allergy/clinical immunology at Childrens Hospital of Los Angeles. What Doctors Should Ask Here are questions parents of asthmas and allergy sufferers should expect their child’s doctor to ask: * How satisfied are you that you can control your child’s asthmas and allergy symptoms? * How often has asthmas (wheezing, shortness of breath or chest tightness) interfered with your child’s physical activities since the last visit to the doctor? * How often has asthma and/or allergies (such as nose congestion, itching and sniffling) interfered with your child’s sleep? * Asthma and allergy medications occasionally cause some uncomfortable, though not serious, side effects. Has your child been experiencing: * Nervousness * Drowsiness * Nausea * Difficulty concentrating at school * Difficulty sleeping * Irritability * Headaches * Shaking * How many days of school has your child missed because of asthma or allergies since your last visit to the doctor? * Are asthmatic or allergy symptoms or side effects of medications interfering with your child’s school performance? * How frequently has your child been having asthma flareups? A flareup is an attack in which a child experiences significant discomfort that lasts for more than an hour. * How many times since your child’s last regular doctor’s visit has he or she had to visit a doctor’s office or hospital emergency room because of a flareup? * Since his or her last scheduled visit to a doctor, how many times has your child been hospitalized for asthma? SOURCE: Dr. Warren Richards, head of the division of allergy/ clinical immunology at Childrens Hospital of Los Angeles.
