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Background Allergic sensitization is associated with increased child asthma morbidity and decreased pulmonary function. Nocturnal symptoms and/or awakenings typically are measured by self-report from diary data, whereas objective assessments of sleep in child asthma studies are lacking. Objective To investigate the association between increased allergic sensitization (number of positive allergy test results measured by skin prick test or specific immunoglobulin E) and sleep outcomes (sleep efficiency, sleep duration, and mean number of awakenings measured by actigraphy) in urban schoolchildren with persistent asthma. Methods One hundred ninety-six children with persistent asthma (7–9 years old) attending public school in 1 of 4 large urban school districts completed allergy testing during a study clinic visit. Forced expiratory volume in 1 second was monitored at home using a handheld spirometer. Sleep outcomes were measured with a wrist Actiwatch during a 1-month period in the fall and winter seasons. Results Number of positive allergy test results significantly predicted mean sleep efficiency ( P = .02), such that children with more positive test results experienced less efficient sleep. Number of positive allergy test results significantly predicted mean number of night awakenings ( P = .05), such that children with more positive allergy test results experienced more night awakenings. Variability in forced expiratory volume in 1 second was a significant moderator in the association between number of positive allergy test results and variability in sleep efficiency ( P = .04). Racial and ethnic differences in allergic sensitization and sleep outcomes were found between African Americans and Latinos. Conclusion More positive allergy test results were associated with poorer sleep outcomes measured objectively in this sample of urban children. Implications for environmental control interventions and asthma treatments in different racial and ethnic groups are discussed.

In this study, we examine the association of asthma (asthma symptoms, asthma control, lung function) and sleep problems in a group of urban children. The role of allergic rhinitis (AR), a comorbid condition of asthma, on children's sleep problems is also examined. Finally, we investigate whether sleep hygiene moderates the association between asthma and sleep problems, and whether there are differences in these associations based on ethnic background.Non-Latino White, Latino, and African American urban children with asthma (n = 195) ages 7-9 (47% female) and their primary caregivers participated in a baseline visit involving interview-based questionnaires on demographics, asthma and rhinitis control, and caregiver report of children's sleep problems and sleep hygiene. Children and their caregivers participated in a clinical evaluation of asthma and AR, followed by a month monitoring period of children's asthma using objective and subjective methods.Total sleep problem scores were higher in children of the sample who were from African American and Latino backgrounds, compared to non-Latino white children. Poor asthma control was predictive of higher levels of sleep problems in the entire sample. Poorer AR control also was related to more sleep problems, over and above children's asthma in the sample. This association was more robust in non-Latino white children. Poor sleep hygiene heightened the association between poor asthma control and sleep problems in the entire sample and in African American children.Multidisciplinary interventions integrating the co-management of asthma, AR, and the effects of both illnesses on children's sleep, need to be developed and tailored to children and their families' ethnic background.

Objective To assess sleep hygiene and the sleep environment of urban children with and without asthma, and examine the associations among urban stressors, sleep hygiene, and sleep outcomes. Methods Urban children, 7-9 years old, with (N = 216) and without (N = 130) asthma from African American, Latino, or non-Latino White backgrounds were included. Level of neighborhood risk was used to describe urban stress. Parent-reported sleep hygiene and daytime sleepiness data were collected using questionnaires. Sleep duration and efficiency were assessed via actigraphy. Results Higher neighborhood risk, not asthma status, was associated with poorer sleep hygiene. Controlling for neighborhood risk, sleep hygiene was related to daytime sleepiness. Asthma status, not sleep hygiene, was related to sleep efficiency. In children with asthma, poorer sleep hygiene was associated with shorter sleep duration. Conclusion Considering urban stressors when treating pediatric populations is important, as factors related to urban stress may influence sleep hygiene practices and sleep outcomes.

Allergic rhinitis (AR) is a risk factor for the development of asthma, and if poorly controlled, it may exacerbate asthma. We sought to describe AR symptoms and treatment in a larger study about asthma, sleep, and school performance. We examined the proportion (1) who met criteria for AR in an urban sample of school children with persistent asthma symptoms, (2) whose caregivers stated that they were not told of their child's allergies, (3) who had AR but were not treated or were undertreated for the disease, as well as (4) caregivers and healthcare providers' perceptions of the child's allergy status compared with study assessment, and (5) associations between self-report of asthma and AR control over a 4-week monitoring period. One hundred sixty-six children with persistent asthma participated in a clinical evaluation of asthma and rhinitis, including allergy testing. Self-report of asthma control and rhinitis control using the Childhood Asthma Control Test (C-ACT) and Rhinitis Control Assessment Test (RCAT) were measured 1 month after the study clinic session. Persistent rhinitis symptoms were reported by 72% of participants; 54% of rhinitis symptoms were moderate in severity, though only 33% of the sample received adequate treatment. AR was newly diagnosed for 53% during the clinic evaluation. Only 15% reported using intranasal steroids. Participants with poorly controlled AR had poorer asthma control compared with those with well-controlled AR. This sample of urban school-aged children with persistent asthma had underdiagnosed and undertreated AR. Healthcare providers and caregivers in urban settings need additional education about the role of allergies in asthma, recognition of AR symptoms, and AR's essential function in the comanagement of asthma. Barriers to linkages with allergy specialists need to be identified.

While the pediatric psychology literature underscores the importance of illness related aspects of the home environment for optimal family asthma management, little is known about the contribution of more global aspects of the home environment (e.g., family routines/schedule, quality of stimulation provided to child) to asthma management in ethnic minority and urban families. The goals of this study were to: 1) explore ethnic/racial group differences in global and specific dimensions of home environment quality among Latino, non-Latino white (NLW), and African American urban children with asthma; and 2) examine associations between the quality and quantity of support and stimulation within the home environment, as measured by the HOME Inventory, and family asthma management in this sample. Urban, low-income children (N=131) between the ages of 6 and 13 with asthma and a primary caregiver participated in a multi-modal assessment including an in home observation and semi structured interviews to assess aspects of home environment quality and family asthma management practices. While controlling for poverty, no ethnic group differences were found in the global home environment; however, there were significant differences in specific dimensions (e.g. Family Participation in Developmentally Stimulating Experiences, and Aspects of the Physical Environment) of home environment quality. Across the whole sample, home environment quality predicted family asthma management. When examining this association for specific ethnic groups, this finding did not hold for the Latino subsample. The results highlight the need to consider ethnic group differences in non-illness specific aspects of the home environment when addressing families’ asthma management strategies.

Atopic diseases, such as asthma and allergic rhinitis, are common conditions that can influence sleep and subsequent daytime functioning. Children and patients with allergic conditions from ethnic minority groups might be particularly vulnerable to poor sleep and compromised daytime functioning because of the prevalence of these illnesses in these groups and the high level of morbidity. Research over the past 10 years has shed light on the pathophysiologic mechanisms (eg, inflammatory mediators) involved in many atopic diseases that can underlie sleep disruptions as a consequence of the presence of nocturnal symptoms. Associations between nocturnal symptoms and sleep and poorer quality of life as a result of missed sleep have been demonstrated across studies. Patients with severe illness and poor control appear to bear the most burden in terms of sleep impairment. Sleep-disordered breathing is also more common in patients with allergic diseases. Upper and lower airway resistance can increase the risk for sleep-disordered breathing events. In patients with allergic rhinitis, nasal congestion is a risk factor for apnea and snoring. Finally, consistent and appropriate use of medications can minimize nocturnal asthma or allergic symptoms that might disrupt sleep. Despite these advances, there is much room for improvement in this area. A summary of the sleep and allergic disease literature is reviewed, with methodological, conceptual, and clinical suggestions presented for future research.

Objective This article presents a summary of findings from asthma studies focusing on immigration and acculturation-related factors. A study examining associations between these processes, family cohesion and social support networks, and asthma morbidity in a sample of Dominican and Puerto Rican caregivers residing in the mainland U.S., is also described. Methods Latino children with asthma (n = 232), ages 7–16 (49% female) and their caregivers completed interview-based questionnaires on immigration and acculturation-related processes, family characteristics, and asthma morbidity. Results The frequency of ED use due to asthma may be higher for children of caregivers born in Puerto Rico. Acculturative stress levels were higher for Puerto Rican born caregivers residing in the mainland U.S. Conclusion Asthma-related educational and intervention programs for Latino children and families should be tailored to consider the effects that the immigration and acculturation experience can have on asthma management. Specific family-based supports focused on decreasing stress related to the acculturation process, and increasing social and family support around the asthma treatment process may help to reduce asthma morbidity in Latino children.

This study examined the relationship between obesity and asthma symptom perception in 200 youth with asthma. Repeated subjective and objective peak flow measurements were summarized using the Asthma Risk Grid (Klein et al., 2004), resulting in Accurate, Symptom Magnification and Danger Zone scores. Analyses were stratified by age and included ethnicity. For younger children, obesity was not significantly related to perception scores. For older children, a significant obesity-by-ethnicity interaction for Accurate Symptom Perception scores indicated that obese white children had lower accuracy than white nonobese children, while there was no difference for obese versus nonobese minority children. Obesity was also related to higher Symptom Magnification scores regardless of ethnicity for older children. These findings suggest that obesity may complicate asthma management by interfering with the ability to accurately perceive symptoms for some patients. More remains to be learned about the role of sociodemographic factors underlying this relationship.

Objective: Disparities in asthma outcomes exist between Latino and non-Latino white (NLW) children. We examined rates of medication use, medication beliefs, and perceived barriers to obtaining medication in US and island Puerto Rican parents of children with asthma. Hypotheses: Island PR parents would report the lowest rates of controller medication use, followed by RI Latino and RI NLW parents; Latino parents would report more medication concerns than NLW parents; and Island PR parents would report the most barriers to medication use. Study Design: Five hundred thirty families of children with persistent asthma participated, including 231 Island PR, 111 RI NLW, and 188 RI Latino. Parents completed survey measures. Results: Group differences were found on reported use of ICS (X2 = 50.96, P

Background Epidemiologic studies have documented higher rates of asthma prevalence and morbidity in minority children compared to non-Latino white (NLW) children. Few studies focus on the mechanisms involved in explaining this disparity, and fewer still on the methodological challenges involved in rigorous disparities research. Objectives and Methods This article provides an overview of challenges and potential solutions to research design for studies of health disparities. The methodological issues described in this article were framed on an empirical model of asthma health disparities that views disparities as resulting from several factors related to the healthcare system and the individual/community system. The methods used in the Rhode Island–Puerto Rico Asthma Center are provided as examples, illustrating the challenges in executing disparities research. Results Several methods are described: distinguishing ethnic/racial differences from methodological artifacts, identifying and adapting culturally sensitive measures to explain disparities, and addressing the challenges involved in determining asthma and its severity in Latino and other minority children. The measures employed are framed within each of the components of the conceptual model presented. Conclusions Understanding ethnic and/or cultural disparities in asthma morbidity is a complicated process. Methodologic approaches to studying the problem must reflect this complexity, allowing us to move from documenting disparities to understanding them, and ultimately to reducing them. Pediatr Pulmonol. 2009; 44:899–908. © 2009 Wiley-Liss, Inc.

RATIONALE: This study assesses the relationships between ADHD symptoms, specific family asthma management domains, and pediatric asthma morbidity. METHODS: Participants were 110 children with asthma and a respective parent (ages 7-17, X = 11.6 years, 25% ethnic/racial minority). Parents completed measures of asthma morbidity and report of child ADHD symptoms. Children completed measures of attention, concentration, and impulsivity. Families participated in the Family Asthma Management System Scale (FAMSS) interview to assess the effectiveness of eight features of asthma management. RESULTS: Parent report of ADHD symptoms and poor child performance on a computerized task of sustained visual attention were associated with asthma morbidity. Paper and pencil tasks of visual attention, and an index of auditory attention, were not related to asthma morbidity. Modest associations were found between parent report of ADHD symptoms, child performance-based indicators of attention and concentration, and features of family asthma management, although not across all measures. The family response to asthma partially mediated the relationship between ADHD symptoms and morbidity. CONCLUSIONS: ADHD symptoms are modestly associated with difficulties in family asthma management.

Background Inaccurate symptom perception contributes to asthma morbidity and mortality in children and adults. Various methods have been used to quantify perceptual accuracy, including psychophysical (resistive loading) approaches, ratings of dyspnea during induced bronchoconstriction, and in vivo monitoring, but it is unclear whether the different methods identify the same individuals as good or poor perceivers. The objectives of the study were as follows: (1) to compare in the same asthmatic children two methods of quantifying perceptual ability: threshold detection of added resistive loads and in vivo symptom perception; and (2) to determine which method best predicts asthma morbidity. Methods Seventy-eight asthmatic children 7 to 16 years of age completed two threshold detection protocols in the laboratory and recorded their subjective estimates of lung function prior to spirometry at home twice daily for 5 to 6 weeks. Summary measures from both methods were compared to each other and to asthma morbidity (as measured with the Rosier asthma functional severity scale). Results Symptom perception ability, as summarized by either method, varied greatly from child to child. Neither of the resistive load detection thresholds were significantly related to any of the three in vivo perception scores, nor were they related to asthma morbidity. The three in vivo scores did show a significant or marginal relationship with morbidity (p Conclusions Resistive loading techniques may not be useful in assessing symptom perception ability in children. Measuring estimates of symptoms in relation to naturally occurring asthma can identify children at risk for greater asthma morbidity.

The purpose of this study was to examine the association between asthma symptom perception measured during a 5–6 week baseline and functional morbidity measured prospectively across a 1-year follow-up. Symptom perception was measured by comparing subjective ratings with peak expiratory flow rate (PEFR) and forced expiratory volume in one second (FEV1). We hypothesized that accurate symptom perception (ASP) would be associated with less functional morbidity. Participants consisted of 198 children with asthma ages 7–17 recruited from three sites. The children used a programmable electronic spirometer in the home setting to guess their PEFR prior to exhalation. Each “subjective” guess was classified as being in an ASP, dangerous symptom perception (DSP; underestimation of symptoms), or symptom magnification (SM; overestimation) zone based upon the corresponding measurement of PEFR or FEV1. An index of functional morbidity was collected by parent report at baseline and across 1-year follow-up. A greater proportion of ASP blows and a lower proportion of DSP blows based on PEFR predicted less functional morbidity reported at baseline, independent of asthma severity and race/ethnicity. A greater proportion of ASP blows (using PEFR and FEV1) and a lower proportion of SM blows (using FEV1) predicted less functional morbidity across 1-year follow-up. Symptom perception was not associated with emergency department visits for asthma at baseline or across follow-up. In comparison to PEFR, FEV1 more frequently detected a decline in pulmonary function that children did not report. Symptom perception measured in naturalistic settings was associated with functional morbidity at baseline and prospectively across 1-year follow-up. Support was found for including multiple measures of pulmonary function in the assessment of asthma symptom perception. Pediatr Pulmonol. 2007; 42:339–347. © 2007 Wiley-Liss, Inc.

Purpose: We present our experience with robot-assisted laparoscopic repair of a ureteropelvic junction (UPJ) disruption in a child. Case Report: An 11-year-old boy was found to have a UPJ disruption after being struck by an automobile. After unsuccessful retrograde ureteral-stent placement, a percutaneous nephrostomy tube was placed for a planned delayed repair because of the patient's multiple injuries. One month later, the patient underwent laparoscopic repair with the DaVinci robotic system using a four-port transperitoneal technique. At 3 months' follow-up, a diuretic renogram demonstrated no obstruction. Conclusion: A minimally invasive laparoscopic approach using the DaVinci system is feasible in the repair of a traumatic UPJ disruption.

Background: We examined the relationship between three different indicators of childhood asthma (asthma diagnosis, ever had an asthma attack, and asthma hospitalization) and having any psychiatric disorder, comorbid disorders, or specific disorders. Three study hypotheses were examined: 1) there will be subject variability in responses to the asthma indicators; 2) there will be different observed associations between the three asthma indicators and psychiatric disorders; and 3) maternal mental health, family income, and maternal education will confound the associations between childhood asthma and psychiatric disorders. Method: Data were drawn from a community-based, random sample of 1,891 island Puerto Rican children aged 4–17 years. Information was collected through direct interview with children and adolescents and their primary caretakers. The Diagnostic Interview Schedule for Children (DISC) was used to determine DSM-IV diagnoses. Results: Thirty-two percent of the children had been diagnosed with asthma but only 22 % had ever experienced an asthma attack. Seventeen percent of the children had been hospitalized for asthma. Having been hospitalized for asthma was not associated with any of the psychiatric disorders, having a diagnosis was associated with some of the disorders, and having experienced an asthma attack was associated with almost all the disorders, after controlling for family income and maternal education and mental health. Conclusions: Determining and measuring asthma may be difficult because of confusion and differing perceptions of what constitutes asthma or an asthma attack. Future studies should consider the problems in capturing perceptions of asthma and severity in Puerto Rican children and should continue to explore the relationship between asthma and mental illness.

Objectives To identify children demonstrating “good” sleep health in a sample of urban children with persistent asthma; to compare sociocontextual, asthma clinical characteristics, and sleep behaviors in children with “good” versus “poor” sleep health; and to examine protective effects of family-based health behaviors on sleep health. Methods Participants were 249 Black (33%), Latino (51%) and non-Latino White (16%) children with asthma, ages 7–9 years, and their primary caregivers. Results 32 percent of children had “good” sleep health. Well-controlled asthma and better lung function were more likely in this group. In the context of urban risks, sleep hygiene appeared to be a protective factor associated with better sleep quality. The protective effect of asthma management functioned differently by ethnic group. Conclusions This study identifies protective processes that may guard against urban risks to optimize sleep health in children with asthma. Intervention programs can be tailored to consider specific supports that enhance sleep health in this high-risk group.

Abstract This paper reports the differences between two methodologies for threshold detection of added resistive loads in children and adolescents. The first-generation apparatus utilized a series of laminar flow screens to present various total resistances, while in the second generation the apparatus utilized a servo-controlled cone that occluded an aperture to varying degrees. Protocol modifications in the second generation methodology included forced choice, attentional enhancements, and larger increments of added resistance. Two studies conducted 2 years apart provided data on the first and second generations of methodology. All participants in Study 1 (N = 33) and Study 2 (N = 33) were children with asthma. Subjects were matched for both age and asthma severity. Results showed the methodologic improvements in the second generation to be significant. Tracking and random thresholds were achieved by 85% and 82% of the subjects in Study 2 compared to 76% and 42% in Study 1, respectively. The correlation between the mean tracking and random thresholds was .40 in Study 2 compared to a statistically insignificant result in Study 1, indicating improved reliability. Raw thresholds were correlated with intrinsic resistance in both studies (r = .29-.88), supporting the use of Weber's Law in resistive loading studies of children. Results using the second generation methodologic improvements demonstrate that children as young as age 7 can complete resistance loading protocols. Standard methodology will enhance the comparability between studies.

Threshold detection of added resistive loads was studied in asthmatic children and compared to data previously obtained in a group of healthy children. The relationships between possible psychological predictors of perceptual ability, the perceptual threshold, and functional morbidity variables were also investigated. Our subjects were 103 children (mean age, 10.9 years) with asthma who completed two laboratory protocols in which they were asked to distinguish breaths with varying degrees of added resistance from unloaded breaths. Using two different computer-driven protocols, resistances were presented as percentages of each child's intrinsic respiratory system resistance (Rrs). Cognitive ability was assessed through subtests of the Wechsler Intelligence Scale for Children, 3rd edition (WISC-III), and functional morbidity was quantified through a combination of school absences, emergency medical visits, and days hospitalized. Detection thresholds for both protocols were highly correlated with intrinsic resistance (r = 0.49 and 0.66; P < 0.001). Weber fraction thresholds were significantly lower for asthmatic children than healthy controls. Thresholds were not significantly related to either intelligence or pulmonary functional abnormalities due to asthma. Methodologic limitations require cautious interpretation of the results, but we conclude that psychophysical approaches may be useful in the study of symptom perception in pediatric asthma. Pediatr Pulmonol. 1999; 28:271–276. © 1999 Wiley-Liss, Inc.

Objective To determine whether physiological severity of asthma is associated with increased psychological symptoms in children. Method Participants were 337 children, aged 7 to 19 years (mean 11.9, SE 0.13), and a parent of each child. Children's asthma severity was rated by experienced pediatric asthma specialists using current guidelines from the National Heart, Lung, and Blood Institute. Children filled out the Children's Manifest Anxiety Scale and the Weinberger Adjustment Inventory. Parents reported on their child's medical history, completed the Child Behavior Checklist (CBCL) about their child, and completed the Pennebaker Inventory of Linguid Languidness as a measure of their own physical symptoms. Result Child-rated anxiety symptoms were unrelated to asthma severity or to markers of asthma functional morbidity. Parental ratings of internalizing symptoms in their children were related to severity. Parent physical symptoms explained 10.2 % of the variance in CBCL Internalizing symptoms, and asthma severity added an additional 6.7% to the variance. Conclusion Asthma severity may be a more salient stressor to parents, who in turn report higher levels of child internalizing symptoms for children with severe asthma, than to children themselves. Contrary to prior hypotheses, children with severe asthma did not rate themselves as having higher levels of anxiety than those with mild or moderate asthma or than standardized norms.

OBJECTIVE: Latino children of Caribbean descent remain at high risk for poorly controlled asthma. Controller medications improve asthma control; however, medication adherence remains suboptimal, particularly among minorities. This study assessed socioeconomic, family-based, and parent factors in medication adherence among children with asthma from Rhode Island (RI; Latino and non-Latino white [NLW]) and Puerto Rico. METHODS: Data collection occurred as part of a multicenter study of asthma disparities. Our sample included children (ages 7–16) prescribed objectively monitored controller medications (n = 277; 80 island Puerto Rico, 114 RI Latino, 83 RI NLW). Parents completed questionnaires regarding family background and beliefs about medications. Families participated in an interview regarding asthma management. Multilevel analyses (maximum likelihood estimates) accounting for children being nested within site and ethnic group assessed the contribution of social context, family, and parent variables to medication adherence. RESULTS: Medication adherence differed by ethnic group (F2, 271 = 7.46, P < .01), with NLW families demonstrating the highest levels of adherence. Multilevel models indicated that parental beliefs about medication necessity and family organization regarding medication use were significant predictors of adherence, even for families below the poverty threshold. With family factors in the model, a substantial improvement in model fit occurred (Akaike Information Criterion change of 103.45). CONCLUSIONS: Adherence to controller medications was lower among Latino children in our sample. Targeted interventions that capitalize on existing family resources, emphasize structure, and address parental beliefs about the importance of medications may be of benefit to families from different cultural backgrounds.

Objective The goal of this study is to identify individual, family/cultural, and illness-related protective factors that may minimize asthma morbidity in the context of multiple urban risks in a sample of inner-city children and families. Methods Participating families are from African-American (33), Latino (51) and non-Latino white (47) backgrounds. A total of 131 children with asthma (56% male), ages 6-13 years and their primary caregivers were included. Results Analyses supported the relationship between cumulative risks and asthma morbidity across children of the sample. Protective processes functioned differently by ethnic group. For example, Latino families exhibited higher levels of family connectedness, and this was associated with lower levels of functional limitation due to asthma, in the context of risks. Conclusions This study demonstrates the utility of examining multilevel protective processes that may guard against urban risks factors to decrease morbidity. Intervention programs for families from specific ethnic groups can be tailored to consider individual, family-based/cultural and illness-related supports that decrease stress and enhance aspects of asthma treatment.

The purpose of this study was to determine whether the use of pictorial anchors improved a visual analog scale (VAS) designed to assess asthma episodes. The sample consisted of 77 children with moderate to severe asthma attending a summer camp. They rated one of two VASs, either nonpictorial (39 subjects in year 1) or pictorial (38 subjects in year 2), three times a day for 2 weeks to report the severity of their asthma symptoms. Immediately after the subjects rated the VAS, pulmonary function testing was obtained. The mean VAS scores increased 64% using the pictorial VAS while the mean PEFRs in the 2 years were almost identical, suggesting that changes on the VAS were not due to differences in pulmonary functioning. For boys, the increase in individual mean VAS score in year 2 using the pictorial VAS was 44%; for girls, the increase in individual mean VAS scores was 112%. Use of a pictorial VAS increases the range of severity of symptoms reported by children with asthma. The instrument may be a useful tool in the systematic quantifiable assessment of subjective symptomatology in pediatric asthma.

This study determines asthma-related health care access and utilization patterns for Latino children of Puerto Rican and Dominican origin residing in Rhode Island (RI) and Latino children residing in Puerto Rico (Island). Data included 804 families of children with persistent asthma recruited from clinics. Island children were less likely to receive regular asthma care and care from a consistent provider and more likely to have been to the emergency department and hospitalized for asthma than RI children. Island children were 2.33 times more likely to have used the emergency department for asthma compared with RI non-Latino White (NLW) children. Latino children residing in both Island and RI were less likely to have used specialty care and more likely to have had a physician visit for asthma in the past year than RI NLW children. The differences might reflect the effects of the different delivery systems on pediatric health care utilization and asthma management.

The objective of this study was to examine associations between specific dimensions of the multi-dimensional cumulative risk index (CRI) and asthma morbidity in urban, school-aged children from African American, Latino and Non-Latino White backgrounds. An additional goal of the study was to identify the proportion of families that qualify for high-risk status on each dimension of the CRI by ethnic group. A total of 264 children with asthma, ages 7-15 (40% female; 76% ethnic minority) and their primary caregivers completed interview-based questionnaires assessing cultural, contextual, and asthma-specific risks that can impact asthma morbidity. Higher levels of asthma-related risks were associated with more functional morbidity for all groups of children, despite ethnic group background. Contextual and cultural risk dimensions contributed to more morbidity for African-American and Latino children. Analyses by Latino ethnic subgroup revealed that contextual and cultural risks are significantly related to more functional morbidity for Puerto Rican children compared to Dominican children. Findings suggest which type of risks may more meaningfully contribute to variations in asthma morbidity for children from specific ethnic groups. These results can inform culturally sensitive clinical interventions for urban children with asthma whose health outcomes lag far behind their non-Latino White counterparts.

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Over 3 years, 972 families participated in an after-school asthma program at their child's school. Parents and children attended concurrent 2(1/2)-hour workshops. Parents were 74% Latino; 45% non-English speaking, with 77% of children on Medicaid. Asthma symptoms were significantly reduced, from multiple times per week to less than once per week on average. Oral steroid use decreased to one third of baseline use. Hospital days decreased from 11% to 2%; emergency visits decreased 35% to 4%; and school days missed decreased 48% to 20%. This program has now become sustainable with both private and Medicaid insurance coverage.

Objective To determine whether a multi-dimensional cumulative risk index (CRI) is a stronger predictor of asthma morbidity in urban, school-aged children with asthma, than poverty or severity alone. Methods A total of 163 children with asthma, ages 7–15 years (42% female; 69% ethnic minority) and their primary caregivers completed interview-based questionnaires, focusing on potential cultural, contextual, and asthma-specific risks that can impact asthma morbidity. Results Higher levels of cumulative risks were associated with more asthma morbidity, after controlling for poverty level or asthma severity. Analyses by ethnic group and subgroup also supported the relationship between the CRI and specific indices of asthma morbidity. Conclusions This study demonstrates the utility of multiple-dimensional risk models for predicting variations in asthma morbidity in urban children. Research efforts with urban families who have children with asthma need to consider the context of urban poverty as it relates to children’s cultural backgrounds and specific asthma outcomes.

Objective To determine whether family response to asthma symptoms mediates the relationship between child symptom perception and morbidity. Methods A total of 122 children with asthma, aged between 7 and 17 years (47% females; 25% ethnic minorities), were recruited from three sites. Participants completed a family asthma management interview and 5–6 weeks of symptom perception assessment. Results Family response to symptoms mediated the relationship between child underestimation of symptoms and asthma morbidity and partially mediated the relationship between accurate symptom perception and morbidity. In contrast, although child overestimation of symptoms and family response to symptoms were independently related to asthma morbidity, a mediational model was not supported. Conclusions Our study found support for the role of family response to symptoms in mediating the relationship between child symptom perception and morbidity, particularly with regard to underestimation of symptoms, underscoring the need for behavioral tools to accurately recognize and optimally respond to exacerbations.

The ability to perceive accurately the onset and intensity of asthma symptoms is a cornerstone of effective asthma management. Research in pediatric and adult asthma patients has shown the important role of symptom perception in asthma management, morbidity, and mortality. Assessment of symptom perception ability has largely remained an empiric methodology rather than an applied clinical tool. The Asthma Risk Grid represents a clinical application of symptom perception measurement, and pediatric cases are described as clinical examples. Clinical and research applications of the Asthma Risk Grid are presented.

OBJECTIVE To assess child adherence to preventive asthma medications; to investigate relations between knowledge, reasoning about asthma, and responsibility for management and adherence; and to determine the association between adherence and morbidity. METHODS Participants were 106 children with asthma and their parents. Medication adherence was electronically monitored for 1 month. Participants completed self-report measures. Children were interviewed to assess reasoning about asthma. RESULTS Children's adherence was approximately 48% of prescribed doses. Adherence was negatively related to age (r = -.21, p

The objectives of the present study were to: 1) assess spirometric indices and respiratory impedance with forced oscillation (FO), using impulse oscillometry (IOS) in clinically stable asthmatic children over 3 consecutive days; 2) assess FO reactance (X), using an integrated index and resistance (R) separately during inspiration and expiration; and 3) assess effects on FO of hand support of cheeks vs. no hand support. Our hypotheses were: 1) because of increased sensitivity, IOS manifests day-to-day variability not demonstrable by spirometry; 2) IOS R during expiration exceeds that during inspiration; and 3) hand support of cheeks affects IOS R and X only minimally. We obtained triplicate twice-daily measures of IOS R and X in asthmatic adolescents at summer camp, in a convenience sample of children willing, with parental permission, to undergo repeated testing on consecutive days. Subjects received all medications between 6:30-7:30 AM, and were bronchodilated at time of testing. Subjects underwent IOS tests without hand support of cheeks, followed by tests with both hands supporting cheeks. ANOVA and regression analyses were used to discern technique differences.Significant differences in IOS inspiratory R5, R5 - R15 (frequency dependence of R), and low frequency reactance area (AX) occurred across 3 days, but spirometric indices were unchanged. Inspiratory R at 5 Hz (R5) was significantly smaller than expiratory R5 (P < 0.0001). ANOVA revealed no significant differences between hand and facial muscle cheek support for IOS R and X below 15 Hz, but significant differences occurred above 15 Hz. In conclusion, inspiratory R5, R5 - R15, and AX are sensitive measures for detecting changes in bronchomotor tone in adolescent asthmatic subjects, while expiratory R5 may be influenced by additional factors. Manual support of cheeks does not appear to affect IOS indices of peripheral airway obstruction in adolescent asthmatics. IOS is a practical method for quantifying respiratory mechanics, and its potential role in disease management warrants further study.

Urban children with asthma and allergic rhinitis (AR) are at risk for experiencing worse AR-related quality of life (QOL). Although AR may be underdiagnosed and undertreated in urban minority children, research has not considered which illness-related indicators (eg, AR control) may contribute to AR QOL in this population.To examine associations among AR control, asthma control, allergy symptoms, asthma symptoms, and AR QOL in a sample of 195 urban caregivers and their children with asthma (7-9 years of age) from African American, Latino, and non-Latino white backgrounds. Racial and ethnic differences in AR QOL were also examined.Families resided in 1 of 4 cities selected as recruitment sources because of their high concentrations of ethnic minority and non-Latino white, urban families. Caregivers and children completed a series of interview-based and clinician-based assessments across one academic year and 4-week periods to track daily asthma and nasal symptoms.Better AR control was associated with higher AR QOL (β = -.32, P.01) and all QOL subscales. AR control predicted AR QOL over and above asthma control (β = -.28, P.01). Controlling for AR control, non-Latino white children reported better QOL related to practical problems than both Latino and African American children (P.05).Findings suggest that strategies to enhance AR control in urban children with asthma may assist in improving AR QOL. Non-Latino white children may experience less impairment of their AR QOL because of practical problems (eg, blow nose) than African American or Latino children with asthma.

Objective: The present study implements an experimental paradigm to examine airway reactivity to stress in children with asthma and controls. Method: 114 children with asthma and 30 controls (ages 9–15) participated. The protocol involved 5 min of baseline physiological measurements followed by a 5-min stressful task. Skin conductance (EDG), skin temperature, and heart rate were measured continuously. Airway resistance was measured at baseline and after the task. Results: 110 children (76% of the sample) were significantly “stressed” as shown by physiological changes. Asthmatics and controls differed on overall airway resistance, F(1,108)=12.3, P

Delineated methodologic issues in the study of symptom perception in childhood asthma. A review of past and recent psychophysiological and clinical studies of both adults and children presents the methodologic and analytic approaches that have been applied to quantify perceptual accuracy. Peak expiratory flow rate, forced expiratory volume in the first second, and force expiratory flow can serve as objective measures of asthma. A visual analog scale, a numerical guess, and a categorical description as subjective measures all have clear strengths and weaknesses. Correlational analysis of subjective-objective data, arithmetic differences between subjective guess and objective value, and an error grid categorization can each be applied to calculate an accuracy index on an individual subject. Illustrative examples reveal that the same data lead to different indices depending on the method chosen. Empirical research is needed to standardize various methodologic approaches. Given the increasing prevalence, severity, and morbidity of pediatric asthma, the study of symptom perception may be a critical component in our understanding of asthma management, and will likely lead to useful clinical interventions.

The objective of this study was to determine patterns of pulmonary function abnormalities and to evaluate how adequately peak flow monitoring was correlated to other spirometric indices in childhood asthma. Ninety-one children, aged 8-15 years, with moderate-to-severe asthma were repeatedly tested in a summer camp. On-site medical staff permitted 24-hour-a-day supervision. Subjective and objective clinical evaluations of asthma status were made over 14 consecutive days. Detailed clinical history and clinical observations were made by an experienced staff, and a total of 2,663 pulmonary function tests were performed regularly three times daily and whenever a child sensed asthma symptoms. Patterns of obstruction were divided into large airway abnormalities and small airway abnormalities. There was a low concordance between standard large airway measures, such as the peak expiratory flow rate (PEFR) or the forced expiratory volume in 1 second (the FEV1), and measures of small airway obstruction, such as the forced expiratory flow rate 25-75% (FEF25–75). Normal PEFR measurements do not always indicate that all other pulmonary function measures are normal. In fact, 18% of children with a normal PEFR had abnormal FEF25–75 values. Results demonstrated that the FEF25–75 was the most specific and sensitive measure of airway obstruction. PEFR is widely used to monitor asthma symptoms objectively because it is technically simple to perform, relatively inexpensive, and helpful in most cases. It is, therefore, appropriate for asthma education programs to recommend PEFR as an objective measure to guide in making therapeutic decisions. Our data and clinical observations support the “Guidelines for the Diagnosis and Management of Asthma” of the NIH Health Asthma Education Program that suggest that children have more complete pulmonary function testing along with frequent PEFR measures. Many children may appear asymptomatic, while recording normal PEFR measures, and still having significant asthma. Repeated pulmonary function testing and evaluation of the pattern of respiratory obstruction aids in managing this challenging group. We recommend that efforts be made to develop a simple and inexpensive method of measuring FEF25–75 that will allow this measurement to be made even at home. Pediatr Pulmonol. 1995; 20:372–379. © 1995 Wiley-Liss, Inc.

Allergic reactions to latex, varying from urticaria to life-threatening IgE-mediated anaphylaxis, have been described in patients with spina bifida. In a study of 50 patients 60% had a latex allergy identified by history, a radioallergosorbent test and/or a skin prick test. Latex allergic patients had undergone statistically more surgical procedures than nonallergic patients (9.5 versus 6.7) with a p value of 0.03. The presence of latex allergy did not correlate with the number of intra-abdominal procedures (1.9 versus 1.4) or with the number of years on clean intermittent catheterization (7.7 versus 5.9). These results suggest that latex allergy is acquired through multiple exposures due to breakdown of blood tissue barriers. Therefore, we recommend that all patients with spina bifida undergoing surgery be evaluated for latex allergy and that all surgical procedures in spina bifida patients, from the time of birth, be performed in a latex-free environment.

The lifetime prevalence of self-reported asthma among Puerto Ricans is very high, with increased asthma hospitalizations, emergency department visits, and mortality rates. Differences in asthma severity between the mainland and island, however, remain largely unknown.We sought to characterize differences in asthma severity and control among 4 groups: (1) Island Puerto Ricans, (2) Rhode Island (RI) Puerto Ricans, (3) RI Dominicans, and (4) RI whites.Eight hundred five children aged 7 to 15 years completed a diagnostic clinic session, including a formal interview, physical examination, spirometry, and allergy testing. Using a visual grid adapted from the Global Initiative for Asthma, asthma specialists practicing in each site determined an asthma severity rating. A corresponding level of asthma control was determined by using a computer algorithm.Island Puerto Ricans had significantly milder asthma severity compared with RI Puerto Ricans, Dominicans, and whites (P.001). Island Puerto Ricans were not significantly different from RI whites in asthma control. RI Puerto Ricans showed a trend toward less control compared with island Puerto Ricans (P = .061). RI Dominicans had the lowest rate of controlled asthma. Paradoxically, island Puerto Ricans had more emergency department visits in the past 12 months (P.001) compared with the 3 RI groups.Potential explanations for the paradoxic finding of milder asthma in island Puerto Ricans in the face of high health care use are discussed. Difficulties in determining guideline-based composite ratings for severity versus control are explored in the context of disparate groups.

Severe anaphylactic reaction secondary to latex allergy has latelybeen recognized and reported especially in individuals with spina bifida. We report a case of severe intraoperative anaphylactic reaction due to latex allergy. Preoperative testing for latex allergy may be helpful in determining latex allergy. We suggest a preoperative management protocol for patients who are thought to have latex allergy. An increased awareness to latex allergy will help avoid this potentially catastrophic event.