Inhaled corticosteroids (ICS) are the mainstay in
therapy and prevention of asthma, and result in improvement in respiratory
symptoms(9). We conducted this study to ascertain the impact of inhaled
corticosteroids therapy in the alleviation of lifestyle restrictions in
children with asthma.
Methods
The study was conducted from June 2005 to March 2006
and included 200 children with bronchial asthma admitted consecutively to
the unit. Children with lower respiratory tract infections, foreign body
inhalation, wheeze associated with gastro-esophgeal reflux and
tuberculosis, were excluded. The diag-nosis of asthma was based on the
history of recurrent episodes of cough, wheeze, and breathlessness. The
diagnosis and classification of severity were made according to the Sri
Lanka Medical Association Asthma Guidelines(10), which is in keeping with
the British Asthma Guidelines and The Global Initiative for Asthma
Guidelines(9,11).
The mother/guardian of each child recruited was given a
self-administered questionnaire to obtain information on the child’s
asthma symptoms and life-style restrictions. The questionnaire was in
Sinhala (local dialect) and was pretested on a group of mothers of
children with asthma attending the pediatric clinic. Restrictions in the
preceding six months with regard to bathing, food (natural and commercial)
and outdoor play activities (in children over 2 years) and school
absenteeism (in children over 3 years attending preschool/school) were
evaluated. Utilization of healthcare services, leave taken by parents from
work due to the child’s illness, and economic implications were also
evaluated.
Out of the 200 children recruited, 111 required
prophylactic therapy and were commenced on beclomethasone dipropionate as
per the following dosing schedule: for mild persistent asthma under one
year of age 50 µg twice a day, 1 to 5 years of age 100 µg twice a day and
over 5 years of age 200 µg twice a day; for moderate and severe persistent
asthma under one year of age 100 µg twice a day, 1 to 5 years 200 µg twice
a day and over 5 years of age 200-300 µg twice a day. The drug was
delivered by a metered dose inhaler with a spacer. The inhaler technique
was taught to the children and parents by the researchers. These children
were reviewed one week later to assess inhaler technique and comp-liance.
The first 90 out of 111 with persistent asthma recruited were followed up.
This was based on the adequacy of sample size required for analysis of
comparison before and after ICS therapy. They were reviewed at 3 months to
assess the alleviation of symptoms and lifestyle restrictions.
Informed, written consent was obtained prior to
recruitment. All participants were educated (by printed leaflets)
regarding childhood asthma and its management. Ethical clearance was
obtained from the Ethics Committee, Faculty of Medicine, University of
Kelaniya, Sri Lanka.
Statistical analysis: Data were analyzed using Epi
info version 6 and Pepi analysis. Chi square test was used to study the
significance for the categorical variables. Matched pair analysis through
McNemar chi square test was used to compare variables before and after ICS
therapy.
Results
The mean age of the study sample (n=200) was 4.3
y (0.7-11.8 y). Children with mild intermittent, mild persistent, moderate
persistent, and severe persistent asthma constituted 45% (90), 38% (76),
15% (30), and 2% (4), respectively. Restrictions on bathing were seen in
186 (93%) children. Of them, 67(36%) had restrictions only during
exacerbations, 51(27%) did not have a head bath up to one month after an
exacerbation and 68(37%) for more than a month. Bathing restrictions were
imposed by the parents in 162(87%), by medical personnel in 21(11%) and
remainder by grandparents and other relatives. Food restrictions were
observed in 174 (87%) children. Restricted food items included ice-cream
(51%), chilled food/drinks (38%), tomatoes (39%), cow’s milk formulae
(21%), King coconut water (a liquid drink from tender coconut) (57%), eggs
(20%) and banana (9%). Food restrictions were imposed by parents in 148
(85%), by medical personnel in 12 (7%) and remainder by grandparents and
other relatives.
Overall, play activities were restricted in 152 (76%)
children. 54/152 (33%) reported to have exercise induced asthma; and 63
(39%) had restrictions only during exacerbations. 60 (37%) had
restrictions irrespective of the presence of exacerbations. Play
activities were restricted by the parents in 133 (82%) and remainder by
grandparents and other relatives. In 63 (39%), parents had restricted
participation in group play activities. School absenteeism up to 2 days/
month was noted in 48/94 (51%) children, and more than 2 days/month in 44
(47%).
There was no significant difference in restrictions
imposed on bathing, food and play activities in relation to severity of
asthma (intermittent vs persistent). Ninety children received ICS
and were reviewed 3 months later. At three months review, 64 (71%) were
continuing ICS. In 5 (6%) ICS was discontinued by the parents despite
medical advice. The rest (n=21, 23%) were lost to follow up. There
was a reduction in day and night symptoms in 45/63 (71%) and 47/64 (73%)
children, respectively (P<0.001). Also noted was a reduction in the
number of hospital admissions in 43/64 (67%), outpatient visits in
45/63(71%), and the need for nebulizations in 47/64 (73%) (P<0.001).
Restrictions on bathing, food, play activities and school attendance had
been waived off in 17/64 (27%, P<0.001), 15/64 (23%, P
0.008), 16/50 (32% P<0.001) and 21/38 (55%, P<0.001),
respectively.
Discussion
This study brought to light several important facts
about the impact of bronchial asthma on the lifestyles of Sri Lankan
children. It highlights the extent to which parents impose lifestyle
restrictions on their children with asthma with regard to bathing, food
and play activities. Lodha, et al.(8) reported food restrictions in
82% and restrictions on physical activity in 66% in their study conducted
in India. In contrast to their findings, our study did not show a
significant difference in restrictions with regard to asthma severity.
This implies that the practice of lifestyle restrictions may be mainly
related to myths and beliefs that prevail in our society, rather than to
the symptoms of the disease itself.
Inhaled corticosteroid (ICS) therapy improved asthma
symptoms significantly. Bathing and food restrictions remained unchanged
in about 70% and play activities in more than 50%. Hence, the impact of
ICS was more towards symptom improvement than on lifestyles. This
emphasizes the role played by ingrained beliefs. 25% of children who were
on ICS therapy were lost to follow-up at 3 months. If we assume that all
defaulters had worsening of their symptoms, nearly 75% of the study
population showed an improvement in their symptoms. Hence, it is likely
that the group lost to follow up would have minimal influence on the
outcome of our follow up results.
This study reiterates the positive impact of ICS on
alleviating symptoms and lifestyle restrictions of childhood asthma.
However, the imposition of restrictions on lifestyles seems to be related
to myths and beliefs ingrained in the society despite good improvement of
asthma symptoms. Therefore, health education to dispel myths is required
in the holistic management of children with bronchial asthma.
Acknowledgments
Prof A Pathmeswaran, Department of Public Health,
Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka for his
assistance in data analysis.