Good Asthma Control Trumps Triggers in Kids With Asthma

Pam Harrison

October 08, 2018

SAN ANTONIO — When asthma is optimally controlled, children do not suffer from exacerbations or loss of disease control after exposure to triggers such as pets in the home, new research suggests.

"Regardless of whether the children had a pet at home, they all improved significantly as a result of optimal asthma control," said Shahid Sheikh, MD, from Nationwide Children's Hospital in Columbus, Ohio.

In fact, "if asthma is diagnosed in the right way and patients are on the right medication, other environmental triggers, such as the presence of a pet in the home, or even exposure to second-hand smoke, are not independent indicators for uncontrolled asthma," he told Medscape Medical News.

Sheikh presented results from a prospective study of 471 children with uncontrolled asthma who were referred for treatment to the Nationwide Children's Hospital here at CHEST 2018.

The study participants were 2 to 17 years of age, and the majority had been diagnosed with either mild or moderate persistent asthma. More than half of them reported having a cat or dog at home, and on-quarter reported exposure to second-hand tobacco smoke.

They were treated in accordance with the most recent EPR-3 guidelines from the National Asthma Education and Prevention.

In the year before Sheikh and his colleagues began their study, there were 216 admissions to the hospital for uncontrolled asthma.

Then, in the first year of the 4-year study there were 64 hospital admissions, in the second year there were 13, in the third year there were 11, and in the fourth year there were 12.

There was also a 90% decrease in the number of emergency department, urgent care, and unscheduled primary care visits in the year after referral for treatment.

Before referral for treatment, children missed 10 to 15 days of school each year, but after 6 months of treatment, they were missing only 1 or 2 days of school.

There were also significant reductions in night-time cough, exercise limitations, and the use of rescue albuterol (Ventolin) 3 to 6 months after referral (P < .001).

All of these improvements persisted throughout the 4-year follow-up period.

Level of Severity

Before referral to the hospital for uncontrolled asthma, the level of asthma severity had been incorrectly diagnosed for many — if not most — of the children, and many were not on the right medications.

In addition, "some of them might have been on the right medications but their parents were not giving them their medications, so there were major adherence issues," Sheikh reported.

And emergency department or urgent care visits were used for the treatment of acute asthma flare-ups to a much greater extent by some minority groups, such as black children, than by white children, he explained.

When children at risk for poorer asthma control were on the right medications — and their parents were on board with the administration of those medications — the level of asthma control was as good as it was for children at lower risk for exacerbations, he noted.

A key component in the optimal management of children with asthma is a good relationship between the provider and the parents, so that the parents can become active members of the asthma management team.

"There are always variations. For example, if a child has an acute bronchospasm or a severe allergic response to a cat or a dog, it's always better if those triggers are not in their environment," Sheikh emphasized. "Having said that, for the vast majority of patients, these secondary issues are not really significant as long as their asthma is controlled with the right medications."

"Asthma guidelines need to be followed," Sheikh and his colleagues conclude.

It is a very challenging situation that families are in, having to decide between a beloved pet and potentially worsening their child's asthma control.

Pet exposure is a common trigger for children with asthma, said Christopher Carroll, MD, from the Connecticut Children's Medical Center in Hartford.

"It is a very challenging situation that families are in, having to decide between a beloved pet and potentially worsening a child's asthma control," he told Medscape Medical News.

"The real benefit of a study like this is that it shows that with good adherence to asthma control, you can improve a child's asthma symptoms and risk of asthma hospitalizations and you might not need to get rid of that pet," he added.

A twice-daily regimen of asthma medications is difficult for many parents, Carroll acknowledged.

"I'm a pediatrician, I'm a pediatric asthma researcher, and I have a child with asthma, and I can tell you that remembering to give your child's twice-a-day asthma medication is very challenging, even for someone who understands the importance of giving asthma medication twice a day," he told Medscape Medical News.

However, the finding that good asthma control can neutralize the potential triggering effects of pet exposure is a very encouraging message.

And "the added benefit of allowing a child to keep a dog or cat in the home" could be motivation for adherence, he pointed out.

However, Carroll added, he is not "thrilled with the cigarette-smoke exposure aspect" of the trial.

"I don't know how they assessed smoking status other than asking them," he said, "and parents lie about smoking."

"I frequently have to take care of children with asthma who are admitted to the hospital and you can smell the smoke on their parents," he told Medscape Medical News. When you ask them if they smoke, "they say no."

"Keep on smoking" is not the message we want to put out there, he said.

Sheikh and Carroll have disclosed no relevant financial relationships.

CHEST 2018: American College of Chest Physicians Annual Meeting: Abstract 13465. To be presented October 10, 2018.

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