|Year : 2014 | Volume
| Issue : 1 | Page : 8-12
Symptom monitoring and quality of life in children with asthma: Scope for self-management in routine care
Farzana K. Beig1, Sandeep Sachdeva2, Ayesha Ahmad1
1 Department of Paediatrics, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
2 Department of Community Medicine, Sarojini Naidu Medical College, Agra, India
|Date of Web Publication||11-Jun-2014|
Department of Community Medicine, Sarojini Naidu Medical College, Agra - 282 002, Uttar Pradesh
Source of Support: Department of Paediatrics, JN Medical College, AMU, Aligarh, Conflict of Interest: None
Objectives: To observe correlation between parental and child reporting of change in asthma symptoms and objective parameters of lung function over time. Design: Prospective cohort study. Materials and Methods: Children (n = 125) were divided into two age groups (6-10 years and 11-15 years) and were classified into intermittent, mild persistent, and moderate persistent grades of severity. Parental and child reporting of quality of life (QoL) scores were recorded on a pretested questionnaire on the initial visit and at 4 and 8 weeks. At each session, appropriate counseling regarding the disease and its primary management at home was done. The change in scores from first and second follow-up visits was statistically correlated with changes in symptom score recorded on symptom diary, peak expiratory flow rates (PEFR), and spirometry. Results : There was significant improvement in the subjective and objective parameters compared at the two follow-up visits. The magnitude of improvement in parental global rating of QOL was similar to improvement in objective measures of pulmonary function in children 6-10 years of age, whereas both parental and child rating correlated well with objective parameters in children 11-15 years of age. Also, symptom score emerged as a stronger predictor of acute exacerbation in PEFR in candidate children who had breakthrough attacks. Conclusion: Improvement in QoL score is a sensitive measure of functional improvement in asthmatic children on treatment and may complement objective measurements. Health education has a positive impact on treatment outcome. Self monitoring of symptoms at home fosters more patient involvement and promotes better management at all levels of care.
Keywords: Childhood asthma, objective parameters, quality of life, symptom diary
|How to cite this article:|
Beig FK, Sachdeva S, Ahmad A. Symptom monitoring and quality of life in children with asthma: Scope for self-management in routine care. Indian J Allergy Asthma Immunol 2014;28:8-12
|How to cite this URL:|
Beig FK, Sachdeva S, Ahmad A. Symptom monitoring and quality of life in children with asthma: Scope for self-management in routine care. Indian J Allergy Asthma Immunol [serial online] 2014 [cited 2019 Oct 17];28:8-12. Available from: http://www.ijaai.in/text.asp?2014/28/1/8/134209
| Introduction|| |
Asthma is the most prevalent chronic disease in children  and is proclaimed to be the third ranking cause of non-injury-related hospitalization among children less than 15 years of age.  During the past two decades, many scientific advances have improved our understanding of asthma and our ability to manage and control it effectively. However, only a part of the patients reach the goals of control set out by the Global Initiative for Asthma (GINA). , Management of bronchial asthma is conventionally guided by objective clinical and spirometric assessment. These criteria, though reproducible and time tested, fail to address the quality of life (QoL) of children afflicted with this chronic disease. Besides, children with similar symptoms and pulmonary function tests ( PFT) may experience different levels of distress and dysfunction in their lives.  This makes a case for a multipronged approach to childhood asthma management that addresses qualitative issues like symptom monitoring by patients and their parents, thereby ensuring active participation in the assessment and improvement of their QoL indicators. Several studies conducted in the past have explored this idea and come up with convincing results. ,,] The present study aims to fulfill the following objectives toward this direction:
- To observe the difference in parental and child perception of changes in asthma symptoms
- To establish correlation, if any, between the perceived change in asthma symptoms and objective parameters of pulmonary function
- To determine whether change in symptom score or decline in PEFR is a better indicator of acute exacerbation.
| Materials and methods|| |
This is a hospital-based prospective cohort study carried out over the period from February 2009 to July 2010. The subjects were 125 consecutive children between 6-15 years of age with a diagnosis of intermittent or moderate persistent asthma as per the guidelines of International Pediatric Consensus Group for asthma. The sample size was based on a convenient sample design considering the weekly scheduled posting of the data collector in the asthma clinic and the logistic and time constraints inherent to the thorough survey of each child including his/her follow up. A n = 125 was, however, the minimum sample size decided for the study. They were divided two age groups, namely, 6-10 and 11-15 years, considering the fact that children in these two different age groups would describe their symptoms differently and also home management of children in these two age groups would be different. Informed and written consent of all children was taken from their parents/wards after having explained to them the purpose and objectives of the study. Besides, only those children who assented to their participation in the study were further studied. Children and/or parents who were unable to perform or read peak flow measurements, children above 10 years who were unable to perform spirometry, and children and/or parents who were unable to understand or fill the symptom diary were excluded from the study. Permission for conducting the study was taken from the Institutional Ethical Committee (Aligarh Muslim University).
- Clinical questionnaire: A pretested proforma was administered to each child with questions on the sociodemographic profile, history of current illness, general physical examination including nutritional status, and results of investigations including hemogram, absolute eosinophil count, routine urine and stool examination, Montaux test, and skiagrams of chest and paranasal sinuses
- Symptom diary: A symptom diary was handed over to each child to be filled under parental supervision. This included questions related to clinical symptoms, day time/nocturnal cough, wheezing, sleeping time, school absenteeism, playing regular games, use of bronchodilators or oral steroids, and any emergency visits or hospitalization. This also included recording of daily peak flowmetry readings
- QoL questionnaire: The QoL questionnaire was adapted from the one originally designed by Elizabeth Jupiner. This included questions pertaining to three domains, namely, activity, emotions, and symptoms, and global rating was performed separately, both for the patient and parent. A global rating score ranging from −4 to +4 was assigned to each child. This was a modification from the original version that scored symptoms from points spanning −7 to +7 as the study subjects or their parents could not appreciate subtle differences in perception of the additional points
- Peak flowmetry: PEFR was done in all patients with the help of Mini Wright Peak Flowmeter, Clement Clark International Limited, England, Model CE 0120. Patients were instructed to record PEFR twice a day after demonstrating them the appropriate technique. A separate instrument was handed over to each child, and they were asked to note the daily readings in the symptom diary. The recorded values were compared with the reference standards of PEFR of Indian children according to height 
- Spirometry: Pulmonary function test was performed on Spirolab II MIR, Italy, Model no. S/N: A 23:050XXX among children above 10 years of age in the presence of the parent. The value of forced expiratory volume in 1 second (FEV1) was recorded.
All children (n = 125) who fulfilled the inclusion criteria were subjected to clinical assessment for the severity of asthma, PEFR measurement, and spirometry (in children above 10 years) along with instructions to fill the symptom diary by the child on the first visit. All patients were managed as per the guidelines for diagnosis and management of asthma, National Heart, Lung, and Blood Institute (NHLBI), 1997 (http://www.nhlbi.nih.gov/guidelines/asthma/index.htm). They were instructed to report acute exacerbations to the physician (author) telephonically or by visit to the hospital. Patients enrolled were followed up for 2 months. At the first follow-up visit (4 weeks), the patients were clinically assessed and were asked to submit their filled up symptom diary. Mean daily symptom score and PEFR values were calculated for each child. Spirometry was done to observe the FEV1 in candidate children. The QoL questionnaire was now administered to both the child and the parent (who used to spend more time with the child) separately, and global rating of the impact of symptoms was assessed for both. The values of all objective parameters (symptom score, PEFR, and FEV1) and global rating of the child's and parent's perception of symptoms recorded at the first follow-up visit were regarded as baseline. At the same time, the patients and parents were counseled regarding domiciliary recognition and management of symptoms and instructed to comply with therapy and report to hospital/consult telephonically should need arise. The patients were again followed up at 8 weeks. The second symptom diary was submitted and QoL questionnaire again filled up separately by child and parent. The perception of the patients and parents regarding their change in the asthma symptoms in the two follow-up visits was correlated statistically with the change in mean symptom score and PEFR and consecutive FEV1 values.
The change in symptom score at 4 and 8 weeks was analyzed using the paired 't' test, and correlation between parental and child's perception of global change with objective parameters like PEFR and FEV1 was done using the Pearson's correlation test.
| Results|| |
[Table 1] depicts the chief sociodemographic and clinical characteristics of the study population. The subjects were divided into two distinct age groups, namely, 6-10 years (mean 7.57 ± 1.13 years) and 11-15 years (mean 11.17 ± 1.24 years). Males comprised the majority of cases among both the age groups (53.1 and 68.9%, respectively). As many as two-thirds of the children belonged to affluent socioeconomic classes and majority (>90%) hailed from urban dwellings. Family history of asthma and/or atopy was present in around 39% of cases in both age groups. As high as 59.3 and 65.5% of children, respectively, in both the age groups were exposed to passive smoking in their households. A staggering proportion of the children in both the age groups (75 and 83.6%, respectively) were undernourished. Most of the share of undernutrition was claimed by stunting, reflective of chronic malnutrition. [Figure 1] shows that a majority of the cases in both the groups had mild persistent asthma (40.6 and 45.9%, respectively). There were more moderate persistent asthmatics in group B as compared with Group A, but the difference in the two groups was not statistically significant (P > 0.05). There was an increase in the mean PEFR score and FEV1 (feasible in Group B only) from 4 weeks (197.1 ± 49.8, 79.8 ± 6.2, respectively) to 8 weeks (245.9 ± 57.5, 89.0 ± 5.6, respectively), whereas the mean daily symptom score dropped from 1.79 ± 0.57 at 4 weeks to 0.64 ± 0.51 at 8 weeks. The improvement reflected in the change in the three variables from 4 to 8 weeks assumed significant (P < 0.01) [Table 2]. [Table 3] depicts that in the younger age group (Group A, 6-10 years), parental perception of overall improvement of symptoms correlated more strongly with changes in mean daily symptom scores (r = 0.61) than the child's report (r = 0.01), whereas in the older age group (Group B, 11-15 years), child's report was as significant as those of parents (r = 0.55 and 0.57, respectively) [Table 4]. In both the age groups [Table 3] and [Table 4], parental global rating had a stronger correlation with the objective parameters, namely, PEFR in Group A and FEV1 in Group B (r = 0.54 and 0.51, respectively) than the child's report (r = 0.23 in Group A and 0.23 and 0.22 in Group B, respectively). [Table 5] shows that 27 patients had acute exacerbation during the 8-week study period with maximum number of patients (51.8%) having mild exacerbation with a symptom score of 3.8. Those with moderate (PEFR 60-80%) and severe (PEFR <60%) exacerbation had symptom scores of 3.2 and 4.1, respectively. All patients had a score of >3 but <6. The correlation was better with symptom score than with PEFR; however, it was not statistically significant
|Figure 1: Distribution of study subjects according to the severity of asthma|
Click here to view
|Table 1: Sociodemographic and clinical characteristics of the study population|
Click here to view
|Table 2: Objective parameters of pulmonary function during the first 4 week and second 4 week (follow up) period|
Click here to view
|Table 3: Correlation between parental and child's reports of overall changes in asthma symptoms and changes in other measures among children 6-10 years of age|
Click here to view
|Table 4: Correlation between parental and child's reports of overall changes in asthma symptoms and changes in other measures among children 10-15 years of age|
Click here to view
|Table 5: Predicted PEFR and mean symptom score on the day preceding and pulmonary score on the day of exacerbatio|
Click here to view
| Discussion|| |
The male preponderance of the study subjects is in accordance with other studies. , An important factor in this regard was the gender bias as regards health care seeking behavior of the parents. Majority of the patients belonged to the higher socioeconomic strata of the society (70.2% in group A and 63.8% in Group B), consistent with the findings of Strachan DP  who proposed this to be a manifestation of respiratory maladaptation to modern lifestyle. It is remarkable that despite the high proportion of families from higher social classes, more than two-third of children in both the groups were undernourished (75% in Group A and 83.6% in Group B). Other studies have also noted the same  and suggested a bidirectional model of cause and effect, i.e., chronic asthma leading to undernutrition and undernutrition predisposing to acute infections, triggering acute attacks. The most frequent grade of asthma was mild persistent, similar to the observation by Zhang et al. 
Researchers have increasingly been using the QoL questionnaire as a primary outcome measure of treatment, as it has been easy to determine statistical significance of change.  Several such tools to assess QoL have been developed and evolved overtime like the Childhood Asthma Questionnaire Version B (CAQ B) (Australia)  and health-related quality of life (HRQOL) (Netherlands) questionnaires.  Ours was an adaptation of the pediatric asthma QoL (PAQOL) questionnaire and measured the change in symptom domain on the child's and parental narrative. , Conventionally, objective parameters like the PEFR and FEV1 have been the major tools to assess pulmonary function and guage the efficacy of treatment, but these tests demand a high degree of patient cooperation and interpretation may be marred by subjective factors. Also, they reflect point measures of pulmonary function, whereas combining them with QoL facilitates assessment over a period of time. Parental perception of symptoms in children among younger age group and both child's and parent's perception in older age group correlated with changes in symptom score, PEFR and FEV1. This observation was in consonance with the findings of our model study and also with that of a Chandigarh study, that used an indigenously developed QoL questionnaire for Indian children. , However, still in older children, asking the child and not the parent about changes in asthma symptoms has definite advantages, as recommended by Zhang et al.  It is remarkable herein that despite being subjective, the tests are fairly accurate and correlate clinically.
Secondly, in patients with acute exacerbations before first or second follow-up visits, none had a PEFR reduction of 30-40% as observed by other workers as well. , The concomitant increase in symptom score emerged as a more sensitive predictor of acute exacerbation in such children.
| Conclusion|| |
Bronchial asthma is a chronic disease, widely recognized to cause severe QoL impairment in affected children. Symptom monitoring is an important component of asthma management. Parental narrative of change in asthma symptoms in younger children 6-10 years of age and both child and parental reporting in older children 11-15 years are useful adjuncts to monitor control and guide treatment along with objective parameters of FEV1, PEFR, and symptom score. Also, symptom score is a reliable predictor of acute exacerbation than PEFR in children. The authors recommend the routine application of validated symptom monitoring techniques in children with asthma, also in resource scarce primary care settings where objective tests of pulmonary function may not be logistically feasible.
| References|| |
|1.||WHO. Asthma Fact Sheet N0 307; 2011. |
|2.||Kozak LJ, DeFrances CJ, Hall MJ. National hospital discharge survey: 2004 annual summary with detailed diagnosis and procedure data. Vital Health Stat 13 2006;1-209. |
|3.||Ricci G, Dondi A, Calamelli E, Dell′omo V, Pagliara L, Belotti T, et al. Not all children with under-control asthma are controlled. Open Respir Med J 2008;2:1-6. |
|4.||Gustafsson PM, Watson L, Davis KJ, Rabe KF. Poor asthma control in children: Evidence from epidemiological surveys and implications for clinical practice. Int J Clin Pract 2006;60:321-34. |
|5.||Singh M, Mathew JL, Malhi P, Srinivas BR, Kumar L. Comparison of improvement in quality of life score with objective parameters of pulmonary function in Indian asthmatic children receiving inhaled corticosteroid therapy. Indian Pediatr 2004;41:1143-7. |
|6.||Yoos HL, Kitzman H, McMullen A, Henderson C, Sidora K. Symptom monitoring in childhood asthma: A randomized clinical trial comparing peak expiratory flow rate with symptom monitoring. Ann Allergy Asthma Immunol 2002;88:283-91. |
|7.||Kamps AW, Brand PL. Education, self-management and home peak flow monitoring in childhood asthma. Paediatr Respir Rev 2001;2:165-9. |
|8.||Paramesh H. Normal peak expiratory flow rate in urban and rural children. Indian J Pediatr 2003;70:375-7. |
|9.||Morbidity and Mortality Report. National Centre for Health Statistics. U.S. Centre for Disease Control; 2003. |
|10.||Asthma Statistics. National Heart, Lung, and Blood Institute.Data Fact Sheet January;1999. |
|11.||Strachan DP. Family size, infection and atopy: The first decade of ′hygiene hypothesis′. Thorax 2000;55 Suppl 1:S2-10. |
|12.||Singh M. Newer drugs for asthma. Indian J Pediatr 2004;71:221-7. |
|13.||Zhang AL, Leyraud L, Grassi RT, Bonfanti T, Ferruzi E. Accuracy of parental and child report of changes in symptoms of childhood asthma. Indian Pediatr 2005;42:1220. |
|14.||Junifer EF, Guyatt GH, William A, Griffith LE. Determining a minimal important change in a disease specific quality of life questionnaire. J Clin Epidemiol 1994;47:81-5. |
|15.||Clough JB, Sly PD. Association between lower respiratory tract symptoms and falls in peak expiratory flow in children. Eur Respir J 1995;8:718-22. |
|16.||Sawyer MG, Spurries N, Whaites L, Kennedy D, Martin AJ, Baghurst P. The relationship between asthma. severity, family functioning and the health-related quality of life of children with asthma. Qual Life Res 2000;9:1105-15. |
|17.||Chhabra SK, Kaushik S. Validation of the asthma quality of life questionnaire (AQLQ-UK English version) in Indian asthmatic subjects. Indian J Chest Dis Allied Sci 2005;47:167-73. |
|18.||Ricci G, Dondi A, Baldi E, Bendandi B, Giannetti A, Masi M. Use of the Italian version of the pediatric asthma quality of life questionnaire in the daily practice: Results of a prospective study. BMC Pediatr 2009;9:30. |
|19.||Juniper EF, Guyatt GH, Ferrie PJ, Griffith LE. Measuring quality of life in asthma. Am Rev Respir Dis 1993;147:832-8. |
|20.||Chan-Yeung M, Chang JH, Manfreda J, Ferguson A, Becker A. Changes in peak flow symptom score and the use of medications during exacerbations of asthma. Am J Respir Crit Care Med 1996;15:889-93. |
|21.||Handbook on Asthma Management by Ed: Joshi M. 3 rd ed. 2004; Cipla 16 Pub. Jaypee Brothers. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]