Pediatric Primary Care Case Studies (64 page)

•   Whether steroids were ever prescribed and, if so, last course and for how long

•   Precipitating factors

•   General medical history, including medications and immunizations

James has had four or five similar episodes over the past 2 years that resulted in unscheduled visits to his former pediatrician’s office. Each time, James was sent home with a prescription for an albuterol inhaler to be used as needed. According to Mom, he has a lot of “colds” year round, and they seem to last for a long time. During these episodes, James often wakes up at night coughing. His daycare providers have noticed that he will often start to cough while playing and has to stop his activity to “catch his breath.”

James was born at 39 weeks gestational age via a normal spontaneous vaginal delivery. He has no significant medical illnesses other than the wheezing. He has never been prescribed steroids nor hospitalized overnight. He takes no medications other than the albuterol as described, has no known drug allergies, and his immunizations are up to date by record review. He has no complaints of vomiting, heartburn, or hoarseness, and actively engages in vigorous running games with his playmates when “his asthma” is not acting up.

James lives with his parents and an older sister. There is a history of secondhand smoke exposure—Mom smokes in the house. They have one dog, two cats, and a hamster (all house pets).

Dad was diagnosed with asthma as a child but “grew out of it.” He still has environmental allergies to dust and pollens and takes an over-the-counter antihistamine as needed.

Wheezing and Asthma in the Child

Many aspects of current and past history as well as physical examination can help the clinician distinguish between transient wheezing and asthma in the young child and confirm asthma in the older child. Although many parents confuse wheezing with upper airway congestion or noisy breathing, a history of previous healthcare provider–diagnosed wheezing is helpful to confirm true wheeze. Most wheezing and coughing in children occurs in association with viral illnesses, but wheezing or coughing apart from obvious infection, such as with exercise, activity, exposure to allergens, or exposure to environmental tobacco smoke, suggests more persistent disease. Additionally, coughing that has responded to bronchodilator therapy is consistent with an asthma cough. Frequent nocturnal coughing may be associated with more severe asthma.

Past medical history, including birth history, prematurity, and history of oxygen requirement or mechanical ventilation, documents important factors that can help differentiate other conditions seen in pediatric patients with recurrent respiratory symptoms. This is especially relevant because often non-atopic infants can have bronchopulmonary dysplasia and airway hyperresponsiveness similar to asthma with a different underlying pathophysiology. Determining the severity of previous respiratory episodes, including urgent or emergent care, hospitalization, and hypoxia, helps the clinician quantify symptom control and potentially predict subsequent episodes. Previous response to therapy, including bronchodilators and steroids (both inhaled and systemic), can also help confirm a diagnosis of asthma. Finally, a prior history of other allergic conditions increases the risk for developing asthma.

The evaluation of a child with recurrent respiratory symptoms should include a thorough review of the family medical history and environmental exposures. A history of healthcare provider–diagnosed asthma in a parent is an important risk factor for persistent wheezing in children. Reviewing the family history for the presence of other atopic disease, such as allergic rhinitis, food allergy, and eczema, can help to establish an atopic genetic background for the patient.

An environmental history should document the presence of potential allergens in the home, including pets and cockroaches; the use of allergen covers for mattresses and pillows; the frequency of cleaning bed linens; and the presence of carpets, upholstered furniture, and stuffed animals. Other potential sources of irritation in the home include tobacco smoke, fireplaces, home heating systems, and home cooling systems. As mentioned earlier, children sensitized to certain allergens are more likely to have asthma.

Overview of Asthma

Asthma is the leading serious chronic illness of children in the United States and the most common chronic disease of childhood. Asthma can be difficult to identify in many cases because of its complexity and heterogeneity; therefore, clinicians need to understand the pathophysiology and natural history of the disease along with the diversity of patient response in order to make an early diagnosis and develop an appropriate management strategy (Centers for Disease Control and Prevention [CDC], 2006a, 2006b).

Epidemiology of Asthma

The following are some pediatric asthma statistics:

•   In 2006, an estimated 6.8 million children under age 18 (almost 1.2 million under age 5) were diagnosed with asthma (CDC, 2006b).

•   The highest current prevalence rate was seen in those 5–17 years of age (106.3 per 1,000 population), with rates decreasing with age. Overall, the rate in those under 18 years (92.8 per 1,000) was much greater than those over 18 years (72.4 per 1,000) (CDC, 2006b).

•   Approximately 12.8 million school days are missed annually due to asthma (CDC, 2006a)

•   Asthma has the following impact annually on the medical community (CDC, 2006a):

   12.7 million physician visits

   1.9 million asthma-related emergency room visits

   5,000 deaths

•   Asthma has the following annual financial impact:

   Direct healthcare costs of more than $11.5 billion

   Indirect healthcare costs of $4.6 billion

   Prescription drug costs of $5 billion

The statistics on pediatric asthma are quite alarming. More than 9 million U.S. children have been diagnosed with asthma. The prevalence of asthma has increased 75% over the past two decades, and in children under the age of 5 years, asthma rates have increased more than 160%. This has resulted in more than 12 million missed school days annually and a tremendous financial burden in healthcare-related costs (more than $20 billion annually) (CDC, 2006a, 2006b).

The morbidity related to asthma is staggering. People with asthma miss more days at work or school than the average American. Asthma patients and their families spend on average $1,000 per year on medications. The annual cost of asthma in 1998 was estimated to be $11.3 billion, with hospitalizations accounting for most of these costs. The costs associated with asthma continue to increase (Asthma and Allergy Foundation, 2000).

Racial differences in the prevalence of asthma have been demonstrated in the data collected by the National Center for Health Statistics (2002). There continue to be racial and ethnic differences in asthma prevalence and healthcare use and mortality. In 2004, the lifetime prevalence of asthma in persons younger than 14 years of age was highest in the black population with a prevalence of 12.5% in comparison with 7.1% in Hispanics and 7.5% in whites.

An analysis of data from the National Health and Nutrition Examination Survey III (NHANES; CDC, 2002) showed low education status, female sex, current or past smoking history, pet ownership, atopy, and obesity all to be associated with an increased prevalence of asthma. The effect of socioeconomic status on asthma prevalence was further illustrated by this study. There was a statistically significant difference in the prevalence of asthma noted in non-Hispanic black children from families with income less than half the federal poverty level. This difference remained significant even in comparison with non-Hispanic white children from very poor families. The difference in prevalence rates can be postulated to be caused by environmental exposures that are unique to children from poor families that increase the risk of developing bronchial hyperreactivity and asthma. This difference in environmental exposures can be related to the percentage of disadvantaged black children who live in urban areas rather than rural areas. The population at highest risk for asthma is African American children from poor urban neighborhoods (Simon et al., 2003; Smith et al., 2005).