Randall Sterkel

Socioeconomic, Family, and Pediatric Practice Factors That Affect Level of Asthma Control

BACKGROUND. Multiple issues play a role in the effective control of childhood asthma. OBJECTIVE. To identify factors related to the level of asthma control in children receiving asthma care from community pediatricians. PATIENTS AND METHODS. Data for 362 children participating in an intervention study to reduce asthma morbidity were collected by a telephone-administered questionnaire. Level of asthma control (well controlled, partially controlled, or poorly controlled) was derived from measures of recent impairment (symptoms, activity limitations, albuterol use) and the number of exacerbations in a 12-month period. Data also included demographic characteristics, asthma-related quality of life, pediatric management practices, and medication usage. Univariable and multivariable analyses were used to identify factors associated with poor asthma control and to explore the relationship between control and use of daily controller medications. RESULTS. Asthma was well controlled for 24% of children, partially controlled for 20%, and poorly controlled for 56%. Medicaid insurance, the presence of another family member with asthma, and maternal employment outside the home were significant univariable factors associated with poor asthma control. Medicaid insurance had an independent association with poor control. Seventy-six percent of children were reported by parents as receiving a daily controller medication. Comparison of guideline recommended controller medication with current level of asthma control indicated that a higher step level of medication would have been appropriate for 74% of these children. Significantly lower overall quality-of-life scores were observed in both parents and children with poor control. CONCLUSIONS. Despite substantial use of daily controller medication, children with asthma continue to experience poorly controlled asthma and reduced quality of life. Although Medicaid insurance and aspects of family structure are significant factors associated with poorly controlled asthma, attention to medication use and quality-of-life indicators may further reduce morbidity.

Telephone Coaching for Parents of Children With Asthma: Impact and Lessons Learned

OBJECTIVE To determine whether an asthma coaching program can improve parent and child asthma-related quality of life (QOL) and reduce urgent care events. DESIGN Randomized controlled trial of usual care vs usual care with coaching. Comparisons were made between groups using mixed models. SETTING A Midwest city. PARTICIPANTS A community-based sample of 362 families with a child aged 5 to 12 years with persistent asthma. INTERVENTION A 12-month structured telephone coaching program in which trained coaches provided education and support to parents for 4 key asthma management behaviors. MAIN OUTCOME MEASURES Parental and child QOL measured with a validated, interview-administered, 7-point instrument and urgent care events in a year (unscheduled office visits, after-hours calls, emergency department visits, or hospitalizations) determined by record audit. RESULTS Parental asthma-related QOL scores improved by an average of 0.67 units (95% confidence interval [CI], 0.49 to 0.84) in the intervention group and 0.28 units (95% CI, 0.10 to 0.46) in the control group. The difference between study groups was statistically significant (difference, 0.38; 95% CI, 0.14 to 0.63). No between-group difference was found in the change in the childs QOL (difference, -0.17; 95% CI, -0.47 to 0.12) or in the mean number of urgent care events per year (difference, 1.15; 95% CI, 0.82 to 1.61). The proportion of children with very poorly controlled asthma in the intervention group decreased compared with the control group (difference, 0.34; 95% CI, 0.21 to 0.48). CONCLUSIONS A telephone coaching program can improve parental QOL and can be implemented without additional physician training or practice redesign.

Physician and parent response to the FDA advisory about use of over-the-counter cough and cold medications.

OBJECTIVE The aim of this study was to assess the likely impact of the US Food and Drug Administration (FDA) advisory not to use over-the-counter (OTC) cough and cold products for children aged <2 years on care provided by pediatricians and parents. METHODS A mailed survey was completed by 105 community pediatricians (53% response rate), and 1265 parents with children aged <12 years completed a self-administered survey while waiting for an office visit. RESULTS All physicians were aware of the advisory; 75% agreed with it. Fifty-nine percent did not recommend OTC cough and cold products for children aged <2 years before the advisory, and 35% were less likely to do so afterward. Seventy-three percent of parents were aware of the advisory, 70% believed these products relieved symptoms, 68% did not believe they were dangerous, and 74% had them at home. After the advisory, 21% of parents were more likely to request an antibiotic from the doctor. Among the parents, 225 only had children aged <2 years and 695 only had children aged 2 to 11 years; of these parental groups, 53% and 10% of parents, respectively, did not use these products before the advisory, an additional 33% and 28%, respectively, were less likely to do so afterward, and 15% and 61%, respectively, would continue use them. CONCLUSIONS Pediatricians must be prepared for requests from parents for antibiotics and other remedies for symptom relief for their children with colds. As no effective alternatives are available, maybe nontreatment should be promoted.

What are parents worried about? Health problems and health concerns for children

Patient-centered care requires pediatricians to address parents’ health concerns, but their willingness to solicit parental concerns may be limited by uncertainty about which topics will be raised. The authors conducted surveys of parents to identify current health-related issues of concern. Methods Participants rated 30 items as health problems for children in their community (large, medium, small, or no problem) and volunteered concerns for their own children. Results A total of 1119 parents completed the survey. Allergies (69%), lack of exercise (68%), asthma (65%), attention deficit hyperactivity disorder (65%), Internet safety (63%), obesity (59%), smoking (58%), and bullying (57%) were identified as important problems (large or medium) with variation among demographic subgroups. Concerns for their own children included healthy nutrition; obesity; lack of exercise, healthy growth and development; safety and injury prevention; and mental health issues. Conclusion Parents’ health concerns for children are varied and may differ from those routinely addressed during well-child care.

Opportunities to Reduce Children’s Excessive Consumption of Calories From Beverages

Objective. To describe children’s consumption of sugar-sweetened beverages (SSBs) and 100% fruit juice (FJ), and identify factors that may reduce excessive consumption. Design. A total of 830 parents of young children completed a 36-item questionnaire at the pediatricians’ office. Results. Children consumed soda (62.2%), other SSBs (61.6%), and FJ (88.2%): 26.9% exceeded the American Academy of Pediatrics’ recommended daily FJ intake. 157 (18.9%) children consumed excessive calories (>200 kcal/d) from beverages (median = 292.2 kcal/d, range 203.8-2177.0 kcal/d). Risk factors for excessive calorie consumption from beverages were exceeding recommendations for FJ (odds ratio [OR] = 119.7, 95% confidence interval [CI] = 52.2-274.7), being 7 to 12 years old (OR = 4.3, 95%CI = 1.9-9.9), and having Medicaid insurance (OR = 2.6, 95%CI = 1.1-6.0). Parents would likely reduce beverage consumption if recommended by the physician (65.6%). Conclusions. About 1 in 5 children consumes excessive calories from soda, other SSBs and FJ, with FJ the major contributor.

The Comparative Effectiveness of Prednisolone and Dexamethasone for Children With Croup A Community-Based Randomized Trial

Background. Although common practice, evidence to support treatment of croup with prednisolone is scant. Methods. We conducted a community-based randomized trial to compare the effectiveness of prednisolone (2 mg/kg/d for 3 days, n = 41) versus 1 dose of dexamethasone (0.6 mg/kg) and 2 doses of placebo (n = 46). Participants were children 1 to 8 years old with croup symptoms ≤48 hours, categorized as mild (42%) or moderate (58%). Results. There were no differences for those treated with dexamethasone or prednisolone for additional health care for croup (2% vs 7%, P = .34), duration of croup symptoms (2.8 vs 2.2 days, P = .63), nonbarky cough (6.1 vs 5.9 days, P = .81), nights with disturbed sleep for the parent (0.68 vs 1.21 nights, P = .55), and days with stress (1.39 vs 1.56 days, P = .51). Conclusion. There were no detected differences in outcomes between the 2 croup treatments for either child or parent.

Providing Depression Care in the Medical Home: What Can We Learn From Attention-Deficit/ Hyperactivity Disorder?

Although many primary care providers (PCPs) are reluctant to manage adolescent depression,1 they commonly provide care for children with attention deficit hyperactivity disorder (ADHD).1, 2 We sought to describe differences in care for these common diseases in order to identify opportunities to improve depression care.

Using Parental Perceptions of Childhood Allergic Rhinitis to Inform Primary Care Management

Objective. To describe parents’ experience with their child’s allergic rhinitis (AR) to inform management by the primary care provider (PCP). Study Design. Two hundred parents with a child 7 to 15 years old with AR symptoms within the past 12 months completed a paper survey. Results. The child’s AR was identified as a significant problem in spring (89.3%), fall (63.4%), summer (50.3%), and winter (21.4%); 51.3% had persistent disease. AR symptoms most commonly interfered with the child’s outdoor activities and sleeping, and frequently bothered the parent and other family members. Most parents (88.3%) wanted to know what their child was allergic to and had many concerns about treatment options. A total of 62.9% had sought AR care from the PCP in the past 12 months. Conclusions. Many families experience significant morbidity from their child’s AR and turn to their PCP for help. We identified opportunities for the PCP to reduce AR morbidity.