Normalization Strategies of Children With Asthma

Asthma rates have increased dramatically in the past 40 years.  12% of Canadian children now live with this chronic disease. Chronic asthma can psychologically affect children.  Children have reported having feelings of  anger, fear, frustration, guilt, loneliness and anxiety. Exploring one’s self-identity is an important task of early adolescence. Children want to be considered “normal”, and be treated by their peers as such.  Living with a chronic illness may affect how children view themselves and their health.

Research Question: How do older children and adolescents perceive living with a chronic illness?  What strategies do they use to help them cope with asthma and “feel normal”?

Researchers interviewed 22 boys and girls 11 years of age. 7 children had mild asthma, 9 had moderate asthma and 6 had severe asthma. Questions were designed to have kids describe their experiences of living with asthma and compare their health to that of their peers.  Children were also asked how they would describe asthma to a friend who had been recently diagnosed?

Findings:

• All children but one acknowledged that asthma had an impact on their  life at least some times and to varying degrees.
• Children describe asthma attacks as painful, “it takes your breath away”, affecting their ability to complete or participate in an event.
• Asthma also affects children emotionally. Some girls said that asthma made them feel different or weird and that asthma was scary. One boy felt that asthma prevented him from getting good marks in gym which made him feel horrible.  
• Asthma sometimes stops children from doing what other kids can do.  These feelings were  motivation for developing strategies to minimize the impact and normalize their life.

What do children do to “normalize” asthma?

• 16 children saw their health as just the same and pretty good.
• 6 children saw their health as all right, but not perfect, due to asthma attacks.
• Many emphasized their abilities and minimized their differences.
• All mention wheezing and coughing but then tend to say “it’s really not that hard to live with” – children look at the activities they can and do take part in rather than those they don’t.
• Children take pride in participating in all activities, at time finding ways to adapt their participation (playing goal).
• Children don't necessariy change their activities but may decrease their physical exertion during an activity.
• All view medications as an important part of managing asthma and permitting participation in activities. 

Conclusion: Children with asthma see themselves as different but develop normalization strategies to fit in with their peers. Children see the use of medication as a means of achieving normalcy.

Understanding a young’s person’s desire to integrate with peers and live as normally as possible could help provide a more holistic dimension to care.  Also asking questions about normalization strategies may help uncover true asthma control.  The desire to keep up with peers may be a way to motivate a young person to follow measures required to maintain asthma control.

Normalization strategies of children with asthma. Protudjer JL, Kozyrskyj AL, Becker AB, Marchessault G. Qual Health Res. 2009 Jan;19(1):94-104. Epub 2008 Nov 7.

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Diagnosing Asthma in Children: What is the role of Bronchoprovocation testing?

Asthma is more common in boys than in girls during childhood.  After puberty, asthma is more common in girls. Many children who have wheezing in the preschool years do not go on to have asthma by school age. Because asthma can be so different from child to child in this age group, diagnosing asthma can be difficult.  This leads to both over diagnosis AND under diagnosis of asthma.

Asthma usually starts before the age of 6 and can be divided into 3 categories:

Transient (temporary) early wheezers,  non-allergic wheezers, and true persistent asthma.  In the 6-11 year age group, the number of children with asthma but no allergies decreases and the number of children with asthma AND allergies increases.

Airway hyperresponsiveness (AHR) is an important symptom of asthma.  AHR means the airways are extra sensitive and tighten when stimulated.  Airways can be stimulated using exercise or chemicals that are inhaled such as histamine or methacholine. Stimulating airways in this manner to see how sensitive they are is called “bronchoprovocation testing”. 

Bronchoprovocation testing using “methacholine”is safe and often used to help confirm or diagnose asthma in school age children. In this test, patients inhale increasing amounts of methacholine. A breathing test is done before every increase to see if their airways have reacted by tightening.  This test is called a "Methacholine challenge" (MCH).

Our research questions:

• Does measuring Airway Hyper-responsiveness through MCH help physicians diagnose asthma? 
• How accurate are the results?  Do most children with asthma have a positive MCH?  Do most children without asthma have a negative MCH?
• Does gender or allergic status influence the results of MCH testing?

Findings:

• 228 children with asthma participated – 151 children had allergic asthma, 77 non-allergic asthma.
• 197 “healthy” children participates. (no asthma, no allergies, no rhinitis (hayfever))

All children performed a MCH test then the results were analyzed.

Using MCH to diagnose asthma in non-allergic school age children (especially boys) is not useful.  In this group of non-allergic children, every time a test is “positive”, there is a 50-50 chance that it is actually a true positive.  Half the time, when the test is “positive”, the child does not actually have asthma.

MCH testing was more useful to confirm a diagnosis of asthma in school age children who have allergies.

Conclusion: Asthma often changes in the school age child with allergies playing a bigger role in the kids with persistent asthma. The best way to diagnoses asthma in this age group is through a detailed history of symptoms, including the presence of allergies.

When interpreting the results of a MCH, it is very important to take note of a child’s gender and the presence of allergies.  In a male child without allergies, the results of a MCH test alone cannot be used to diagnose asthma.

Diagnosing asthma in children: what is the role for methacholine bronchoprovocation testing?  Liem JJ, Kozyrskyj AL, Cockroft DW, Becker AB. Pediatr Pulmonol. 2008 May;43(5):481-9

Questions and answers from the Respiratory Educators Web conferance

Did you know that Asthma Educators across Canada are interested in knowing what was learned through the SAGE study?  Last Thursday, RESPTrec^© (managed by the Lung Associations of Manitoba and Saskatchewan) invited Dr. Becker to present at a web seminar for asthma educators across Canada.
Dr. Becker presented some of the SAGE research findings.  Asthma Educators also had many good questions.  Here is a summary of some of their questions and the answers.

FAQ from Resp Trec Web Ex

1 - Are the rates of asthma the same for children who live in the city and children who live in the country?

No, there is a higher incidence of asthma in city vs. country kids.  14% of children who live in the city have asthma, 10% of children who live in the country have asthma.

2 - How do breast feeding and a child’s weight affect the risk of developing asthma?

Breastfeeding for less than 3 months does not increase risk.

Overweight alone does not increase risk.

BUT the combination of little breastfeeding AND overweight increases risk significantly, especially if the mother has asthma

3 - Is there any research on the use of probiotics?

There is some research regarding the use or probiotics being done in Sweden – their findings show that taking probiotics during pregnancy and while breastfeeding may have some effect on the development of eczema but has no effect on the development of asthma.

4 - Prolonged maternal stress was a risk factor for the development of asthma in children. Is there any research indicating the risk if the pregnancy was planned vs. unplanned?

Weather the pregnancy was planned or not was not asked.  What we do know, is that there is an increased incidence of asthma if the mother is young vs. an older mother.

5 - Does it make a difference if the child was born by cesarean section of vaginally?

There is an increase incidence of asthma in children born by cesarean section (25% increase risk).  The reasons for this are not yet clear.

6 - What about the role that Vitamin D can play?

Vitamin D insufficiency may play a role in the development of wheezing in early childhood but we DON’T KNOW if this leads to asthma.

7 - Does the DAD having asthma play a role in the child’s risk of developing asthma?

Parents having asthma is a risk factor that increases the child’s chance of having asthma.  In the preschool years, it seems that Mom’s asthma has a bigger influence on whether or not the young child will develop asthma.

In the school age years, Dad’s asthma plays a bigger role.

Children’s Perceptions of Healthful Eating and Physical Activity

Obesity has tripled in Canadian children in recent decades. Healthful behaviours have numerous benefits. Little research exists on young people’s perceptions of healthful eating and physical activity.

Our research question: “What do ‘healthful eating’ and ‘physical activity’ mean to children 11 to 12 years old?”

Findings: Children understood  the concept and benefits of healthy eating but it was not a top-of-mind concern.  A small group of children spoke of how this information was reinforced at home, through discussions of what they ought to eat or having nutritious food available.

Boys spoke mainly of food choices based on taste, especially foods eaten away from home. Girls also spoke of taste, but they contrasted this talk with the need to limit certain items for health and physical appearance…….”I don’t want to get too fat”.

Children thought that healthful eating was less fun than eating High-fat High-sugar foods (HFHS) and associated these foods with social times.

Kids also understood that being active is an important part of being healthy. Kids considered physical activity to be a wide range of activities, not only organized or team sports. Nearly all of the children spoke with pride and excitement about participating in a sports group. Most boys and girls described physical activity as an easier way to be healthy because “it’s a lot more fun” and “cuz I can play sports any day”. Nearly 50% of boys and girls spoke of healthful eating as something that they “should”, “gotta,” or “have to” do because it is “good for you” and “you should eat healthier”.

Conclusion: Children think that physical activity is an easier and more fun way to be healthy than healthful eating. Children feel conflicting pressures about healthy eating and physical activity. One solution children have developed in relation to these pressures is to eat High Fat High Salt (HFHS) foods with friends and nutritious foods at home. Another contradictory pressure, which only girls noted, was pressure to eat HFHS foods versus pressure to stay slim. 

Children’s labeling of foods as “healthy” or “bad, but good”, and physical activity as “fun”, tells us how they feel about the role of food and activity in their lives. Since children make situation-specific food choices, nutrition and physical education should stress that a balanced diet can incorporate all foods when physical activity is present. Such education is important because healthful eating is not a priority of adolescents. Understanding this can enhance communication among parents, educators, and young people.

Children's Perceptions of Healthful Eating and Physical Activity. Protudjer JL, Marchessault G, Kozyrskyj AL, Becker AB. Can J Diet Pract Res. 2010 Spring;71(1):19-23.

Body Image and Dieting Attitudes

Body dissatisfaction and a desire to be thin are so prevalent in young girls that these are recognized as a “normative discontent”. Adolescents, especially females, are bombarded with messages from the media about thinness, images of so-called beauty, and ways to achieve a lower body weight. These images, combined with a society that places a high value on physical beauty, send mixed messages to teenagers and may result in unhealthy, frequently unnecessary attempts to lose weight. Peers, as well as parents, can influence a child’s body image, body dissatisfaction, and eating or dieting habits. The primary aim of this investigation was to assess differences in body image and dieting concerns in  preadolescent boys and girls across the body-weight spectrum.  

Our research question: Do girls express more concern with body size, do they report more dieting, and do they receive more advice than boys regarding dieting?

565 preadolescent children who were enrolled in the SAGE study took part in this research. 10  and 11  year old children completed questionnaires focused on weight, dieting, and body image concerns. Height and weight were also measured. Of the 565 children, 15.8% were obese and 17.5% were overweight.

Findings: Overall, 39% of the 565 preadolescent children in this sample wanted to be thinner. This latter finding reinforces other reports that children in this age group, especially girls, desire a body size that is smaller than their current one.

Boys perceived themselves to be larger, and they were more concerned than girls about weighing too little.

Approximately 25% of the children reported receiving frequent advice from mothers, fathers, or friends about weight, exercise, and/or food restriction. Contrary to our research question, girls did not report this more often.

Conclusion: Our results indicate that weight is an important concern for 10 and 11 year old boys and girls. Educational programs and interventions for children, parents, and others who work with children should focus on overall health by encouraging healthful eating and activity patterns, body acceptance, and family involvement, rather than directly on body weight. Parents, caregivers, and children’s peers should be aware that their comments may play a role in a child’s body image. Education promoting body acceptance, a healthy body image, and healthy lifestyles for this age group may encourage healthy habits and beliefs before adolescence. Further research is needed to understand what dieting means to young children.

 

Body image and dieting attitudes among preadolescents. Bernier CD, Kozyrskyj AL, Benoit C, Becker AB, Marchessault G. Can J Diet Pract Res. 2010 Fall;71(3):122