Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity from chronic disease as measured by school absences, emergency department visits, and hospitalisation. During the past two decades, many scientific advances have improved our understanding of asthma and our ability to manage and control it effectively. However, in children 5 years and younger, the clinical symptoms of asthma are variable and non-specific. Furthermore, neither airflow limitation nor airway inflammation, the main pathologic hallmarks of the condition, can be assessed routinely in this age group. For this reason, to aid in the diagnosis of asthma in young children, a symptoms-only descriptive approach that includes the definition of various wheezing phenotypes has been recommended. In 1993, the Global Initiative for Asthma (GINA) was implemented to develop a network of individuals, organizations, and public health officials to disseminate information about the care of patients with asthma while at the same time assuring a mechanism to incorporate the results of scientific investigations into asthma care. Since then, GINA has developed and regularly revised a Global Strategy for Asthma Management and Prevention. Publications based on the Global Strategy for Asthma Management and Prevention have been translated into many different languages to promote international collaboration and dissemination of information. In this report, Global Strategy for Asthma Management and Prevention in Children 5 Years and Younger, an effort has been made to present the special challenges that must be taken into account in managing asthma in children during the first 5 years of life, including difficulties with diagnosis, the efficacy and safety of drugs and drug delivery systems, and the lack of data on new therapies. Approaches to these issues will vary among populations in the world based on socioeconomic conditions, genetic diversity, cultural beliefs, and differences in healthcare access and delivery. Patients in this age group are often managed by pediatricians and general practitioners routinely faced with a wide variety of issues related to childhood diseases.

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Global strategy for the diagnosis and management of asthma in children 5 years and younger.

Background
Asthma is the most common chronic childhood illness and is a leading cause for paediatric admission to hospital. Asthma management for children results in substantial costs. There is evidence to suggest that hospital admissions could be reduced with effective education for parents and children about asthma and its management.

Objectives
To conduct a systematic review of the literature and update the previous review as to whether asthma education leads to improved health outcomes in children who have attended the emergency room for asthma.

Search methods
We searched the Cochrane Airways Group Trials Register, including the MEDLINE, EMBASE and CINAHL databases, and reference lists of trials and review articles (last search May 2008).

Selection criteria
We included randomised controlled trials of asthma education for children who had attended the emergency department for asthma, with or without hospitalisation, within the previous 12 months.

Data collection and analysis
Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We pooled dichotomous data with a fixed-effect risk ratio. We used a random-effects risk ratio for sensitivity analysis of heterogenous data.

Main results
A total of 38 studies involving 7843 children were included. Following educational intervention delivered to children, their parents or both, there was a significantly reduced risk of subsequent emergency department visits (RR 0.73, 95% CI 0.65 to 0.81, N = 3008) and hospital admissions (RR 0.79, 95% CI 0.69 to 0.92, N = 4019) compared with control. There were also fewer unscheduled doctor visits (RR 0.68, 95% CI 0.57 to 0.81, N = 1009). Very few data were available for other outcomes (FEV1, PEF, rescue medication use, quality of life or symptoms) and there was no statistically significant difference between education and control.

Authors' conclusions
Asthma education aimed at children and their carers who present to the emergency department for acute exacerbations can result in lower risk of future emergency department presentation and hospital admission. There remains uncertainty as to the long-term effect of education on other markers of asthma morbidity such as quality of life, symptoms and lung function. It remains unclear as to what type, duration and intensity of educational packages are the most effective in reducing acute care utilisation.

/pdf/interventions-for-educating-children-who-are-at-risk-of-kb2jtan908.pdf

Interventions for educating children who are at risk of asthma-related emergency department attendance

OBJECTIVE: Recognition of the complexity of asthma management has led to the development of asthma treatment guidelines that include the recommendation that all pediatric asthma patients receive a written asthma action plan. We assessed the readability, suitability, and characteristics of asthma action plans, elements that contribute to the effectiveness of action plan use, particularly for those with limited literacy. METHODS: This was a descriptive study of 30 asthma action plans (27 state Department of Health (DOH)–endorsed, 3 national action plans endorsed by 6 states). Outcome measures: (1) readability (as assessed by Flesch Reading Ease, Flesch-Kincaid, Gunning Fog, Simple Measure of Gobbledygook, Forcast), (2) suitability (Suitability Assessment of Materials [SAM], adequate: ≥0.4; unsuitable: RESULTS: Mean (SD) overall readability grade level was 7.2 (1.1) (range = 5.7–9.8); 70.0% were above a sixth-grade level. Mean (SD) suitability score was 0.74 (0.14). Overall, all action plans were found to be adequate, although 40.0% had an unsuitable score in at least 1 factor. The highest percent of unsuitable scores were found in the categories of layout/typography (30.0%), learning stimulation/motivation (26.7%), and graphics (13.3%). There were no statistically significant differences between the average grade level or SAM score of state DOH developed action plans and those from or adapted from national organizations. Plans varied with respect to terms used, symptoms included, and recommended actions. CONCLUSIONS: Specific improvements in asthma action plans could maximize patient and parent understanding of appropriate asthma management and could particularly benefit individuals with limited literacy skills.

Readability, Suitability, and Characteristics of Asthma Action Plans: Examination of Factors That May Impair Understanding

Objectives To evaluate the independent effect of a written action plan vs no plan and to compare different plans to identify characteristics of effective plans in children with asthma. Data Sources We searched the Cochrane Airways Group Clinical Trials Register until March 2006, including MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials, for randomized controlled trials that evaluated asthma action plans in the pediatric population. Study Selection Eligible studies were randomized or quasi-randomized controlled trials with participants aged 0 to 17 years diagnosed with asthma. Of 428 citations, 1 trial compared a peak flow–based plan with none and 4 parallel-group trials compared symptom-based plans with peak flow–based plans. Intervention Provision of a written action plan. Control groups received no action plan or another type of plan. All cointerventions (both medical and educational) were similar in both groups. Main Outcome Measure The number of children with at least 1 acute care asthma visit. Results Written action plan use significantly reduced acute care visits per child as compared with control subjects. Children using plans also missed less school, had less nocturnal awakening, and had improved symptom scores. As compared with peak flow–based plans, symptom-based plans significantly reduced the risk of a patient requiring an acute care visit. Conclusions Although there are limited data to firmly conclude that provision of an action plan is superior to none, there is clear evidence suggesting that symptom-based plans are superior to peak flow–based plans in children and adolescents.

https://jamanetwork.com/journals/jamapediatrics/articlepdf/379087/pra70008_157_163.pdf

Systematic review of randomized controlled trials examining written action plans in children: what is the plan?

https://www.pedneur.com/article/S0887-8994(11)00361-4/pdf

Genetic and Biologic Classification of Infantile Spasms

The management of childhood asthma necessitates a comprehensive approach including pharmacological treatment as well as education about self-evaluation and home management of the condition. The aim was to evaluate the efficacy of adding an individualized written home-management plan in the control of moderate persistent asthma. Children with moderate persistent asthma were randomized to receive either an individualized written home-management plan or no plan in addition to standard asthma therapy including education. They were followed up with serial measurement of outcome variables. Children receiving an individualized written home-management plan had fewer acute asthma events fewer lost school days lower symptom score and less nocturnal awakening than those who did not receive a written plan. The addition of a written individualized home-management plan improves overall control in children with moderate persistent asthma. (authors)

Efficacy of an individualized written home-management plan in the control of moderate persistent asthma: a randomized, controlled trial.

The utility of the WHO Ten Questions Screen (TQS) was studied in a rural community of North India. The study was done in three villages, in two phases. In phase 1, the TQS was administered to parents of children aged between 2 and 9 years, during a house-to-house survey. In phase 2, all children screened positive and a random sample of 110 screened negative were clinically evaluated in detail. The total population of the three villages was 5830 with 1763 children aged between 2 and 9 years. Seventy-six children were positive on the TQS, of these, 38 were found to have significant disability, 18 had protein energy malnutrition and 19 were found normal on clinical evaluation. All the 110 screen-negative children were normal. Significantly larger numbers of boys were positive on TQS as compared to girls [Odd Ratio (OR) 1.5]. The sensitivity of the TQS for significant disability was 100%; the positive predictive value was 50% and was higher for boys than for girls. Of the 50% children classified as false positive 23% had mild delays due to malnutrition. The estimated prevalence of disability was 16/1000. The TQS was found to be a sensitive tool for detection of significant disabilities among children 2-9 years of age. The low-positive predictive value would lead to over referrals but a large number of these children would benefit from medical attention.

Utility of the WHO Ten Questions Screen for Disability Detection in a Rural Community—the North Indian Experience

Child maltreatment is a global problem but is more difficult to assess and manage in developing countries such as India where one-fifth of the world's total child population resides. Certain forms of maltreatment such as feticide, infanticide, abandonment, child labour, street-begging, corporal punishment and battered babies are particularly prevalent in India. Most physicians still need to be sensitized in order to suspect child abuse on the basis of unexplained trauma, multiple fractures, parental conflict and other corroborative evidence. This article summarizes the various aspects of this major problem in resource-poor settings in the hope that it will assist in the planning of services addressing child physical and sexual abuse and neglect in India and in other developing countries. A culture of non-violence towards children needs to be built into communities in order to provide an environment conducive to the overall development of the child. Rehabilitation of abused children and their families requires a multi-disciplinary service including paediatricians, child psychologists and social workers, and the training of police forces in how to tackle the problem.

Child maltreatment in India

Exposure to household air pollution during first 3 years of life and IQ level among 6-8-year-old children in India - A cross-sectional study.

BACKGROUND Our aim was to study long-term clinical and radiologic outcome in children with parenchymal neurocysticercosis (NCC) and its predictors. METHOD Five hundred children with NCC registered in the pediatric NCC clinic between January 1996 and December 2002 and followed till December 2009 were enrolled. Demographic details, clinical presentations and therapy received were recorded. Outcome was evaluated in terms of seizure recurrence and resolution of lesions on neuroimaging. Various factors that could influence outcome were studied. RESULTS Mean age at presentation was 8 ± 2.7 years, and the mean duration of follow-up was 8.8 ± 2.03 years; 79.6% (398) had single lesion, and 20.4% (102) had multiple lesions at presentation; 14.5% (58) of children with single lesion, and 28.4% (29) of children with multiple lesions had recurrent seizures (P < 0.001) during follow-up. At 6-month follow-up neuroimaging, resolution was seen in 52.7% (210) and 31.3% (32) of children with single and multiple lesions, respectively (P < 0.001). On prolonged follow-up, 94.6% (384) of single-lesion NCC and 88% (90) of multiple-lesion NCC (P < 0.001) had radiologic resolution. Single-lesion NCC, radiologic resolution and cysticidal therapy were associated with better seizure outcome (P < 0.05). Children with multiple lesions had significantly higher percentage of calcified lesions on long-term follow-up compared with those with a single lesion (11.7% vs. 3.6%, P < 0.05). CONCLUSIONS Children with a single-lesion NCC have favorable outcome with resolution of most of the lesions and few seizure recurrences. Cysticidal therapy leads to better seizure control and increased resolution of lesions on short-term follow-up.

Prabhjot Malhi

Papers

Efficacy of an individualized written home-management plan in the control of moderate persistent asthma: a randomized, controlled trial.

Utility of the WHO Ten Questions Screen for Disability Detection in a Rural Community—the North Indian Experience

Child maltreatment in India

Exposure to household air pollution during first 3 years of life and IQ level among 6-8-year-old children in India - A cross-sectional study.

Long-term Clinical and Radiologic Outcome in 500 Children With Parenchymal Neurocysticercosis.