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Sunday, March 25, 2012

Myths, obstacles and snafus - why children with asthma don't always receive the right care

Asthma affects about one in twelve children, making it the most common chronic disease in pediatrics.  Much more is known than ever before about the genes and molecules that make it happen, and expert guidelines provide a roadmap to care.  Newer agents and delivery systems promise improved efficacy and safety.  As such, we ought to be really good at diagnosing and treating it.   And yet, serious gaps remain.  Here's why.

First, asthma is a "sneaky" condition.  It would be great if every child with asthma, and only those with asthma, came to the doctor with cough, chest tightness, and wheezing.  Mission accomplished.  Good job everyone.  Next case. But that's not the reality.  According to studies, half of all children have one wheezing episodes by 36 months of age, but only a fifth of them will turn out to have asthma.  Further, young children don't complain of chest discomfort; they just get cranky.  On the other hand, recurrent cough and wheeze at any age requires an explanation, and as a matter of fact, a "cough history" is one of our most important tools for sorting out the thorny problem of diagnosis.

When I say that asthma is "sneaky," I also mean that the symptoms can increase so gradually that parents can easily overlook the fact that something is amiss.  One of my favorite diagnostic encounters was with a wonderful parent from whom I was getting some historical information.  In connection with her four year old son, whom I was seeing for the first time with shortness of breath, I asked "does Johnny have trouble with coughing?"  Her answer was incredibly helpful: "No, just his normal cough."  You see, this boy's symptoms had emerged so insidiously that it became this family's new "normal."

Here's another reason.  Neither pediatricians nor parents like to see children taking any more medication than necessary.  Ok, I know this is a generalization.  But when it comes to chronic medication, we're squeamish.  Which is really dysfunctional, since we ought to be more concerned about unnecessary antibiotics, decongestants, antihistamines and other commonly prescribed medications where over-prescribing exposes children to risks that exceed the benefits. (See my previous posts on inappropriate antibiotic use!)   When it comes to asthma, evidence-based guidelines highlight the role of airway inflammation and the central role of every-day inhalation of anti-inflammatory medications for all children with "persistent" asthma.

Finally, we need to take asthma seriously.  For children with the most severe forms, this is easily done - when a child gets very sick from asthma it's impossible NOT to see that this condition requires diligent, ongoing care.  My concern here is with children with mild and moderate asthma who suffer unnecessary loss of sleep, discomfort, missed school, exercise intolerance, restricted play and the like.  They, too, are at risk for more severe exacerbations leading to an ED visit or hospitalization.  But aside from this, they are suffering needlessly.  These children and their families need good primary asthma care, including a partnership between the care provider, child and parent.  They need to know what causes asthma, what avoidable triggers (like tobacco smoke) make it worse, how to use their medications properly, how to self-monitor and when to seek assistance.  They need periodic asthma "check ups" to adjust medications and review control.

Fortunately, more and more pediatricians are getting involved in quality improvement work around conditions like asthma that ensure that the care we provide is standardized against the best science, and also individualized to meet the need of every child.

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