Talking%20to%20Parents%20about%20their%20Children

1
Talking to Parents about their Childrens Asthma

• Sally E. Findley
• Professor of Clinical Population and Family
  Health (in Pediatrics)
• Mailman School of Public Health
• Columbia University

2
Asthma Prevalence Increased 1980-99

• Annual prevalence of asthma has increased
  steadily between 1980-1996, from 31.4 to 38.4
  (per 1000).
• Asthma rates are 1.14 times higher among
  communities of color.
• Highest prevalence is among young children, 5-14
  years of age (56.4 per 1000).
• Source MMWR Surveillance Summaries, March 29,
  2002/51 (SS01), 1-13.

3
US Annual Prevalence of Self-reported Asthma
Episodes by Age, 1980-1999
Source MMWR Surveillance Summaries, March
29,2002, 51(SS01) 1-13.
4
US Asthma-Related Emergency Department Visits,
Hospitalizations, and Office Visits by Age, 1999
Source MMWR Surveillance Summaries, March
29,2002, 51(SS01) 1-13.
5
The youngest children bear a disproportionate
share of the asthma burden

• Children 0-4 years have the highest ED visit and
  hospitalization rates
• Asthma management programs need to expand down to
  the younger age groups

6
Source New York City Childhood Asthma
Initiative, NYC DOH
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Asthma also keeps children from school

• 14 million school-days are lost per year for
  children, 1996-99
• Each year a child with asthma can expect to be
  absent 4 days per year due to asthma.
• 24 of school-age children also suffer activity
  limitation due to their asthma

8
Asthma episodes can be prevented

• We do not know yet how to prevent or cure asthma,
  but asthma can be managed to reduce the
  severity and frequency of asthma episodes.
• Current high rates of asthma-related
  hospitalizations, ED visits and school absences
  can be reduced through providing access to
  appropriate management of asthma.

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Background to Our Approach

• In 1999, through the Northern Manhattan Community
  Voices project we began working with a group of
  NYC early childhood centers and Head Starts to
  help them manage asthma.
• We have developed a program to train the staff,
  identify children with asthma, and assist the
  parents in developing a strong partnership with
  their doctors and the staff to manage their
  childrens asthma.
• Presentation today grows out of this work.

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What did Educators want?

• A systematic way of knowing if children had
  asthma (not just a cold or flu).
• Know what to do when children had exacerbations
• Help parents overcome fears and better manage
  asthma so children would not have to stay home
  when having asthma symptoms

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What did Parents Want?

• Prompt diagnosis of asthma to avoid the dark
  time of ER trips without knowing what is going
  on.
• More explanations about medications how they
  work, any side effects, limits to their
  effectiveness
• More advice on what to do besides medications,
  including combining with traditional treatments
• Assistance in dealing with indoor environmental
  triggers

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Shared Desire for Confidence in Asthma Management

• Know who has asthma
• Have confidence that the management program is
  helping the child
• Feel good about how they are handling asthma
  exacerbations at home or school

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The Bottom Line for Parents and Educators Make
asthma less scary for the children
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Gaps in the Application of Asthma Treatment
Guidelines

• NHLBI guidelines released in 1997 outline both
  diagnostic and treatment guidelines, yet surveys
  of physicians repeatedly show that many patients
  do not receive the recommended management.
• The guidelines are not followed because of
• Lack of awareness or familiarity w. details
• Lack of agreement with guidelines
• Lack of self-efficacy to carry it out properly
• Lack of confidence in outcomes
• Inertia of previous practice
• Source Cabana and Lewis. Improving Physician
  Adherence to Asthma Guidelines. JCOM. 8(3), March
  2001.

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What makes application of the guidelines so hard
for physicians?

• Hard to Track People with asthma usually are
  asymptomatic for most of the time, and asthma can
  be overlooked during office visits.
• Continuity of Care problematic Many episodes
  occur at night, when physician offices are
  closed, leaving treatment to on-call and ED
  services.
• Medication Tailoring Medications need to be
  tailored to individual asthma severity.
• Medications only part of the solution Part of
  the management is in trigger management at home
  and school.

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What makes asthma management so hard for
parents/patients?

• Here today, gone tomorrow Periods of symptoms
  interspersed with symptom-free periods
• Daily medications, even when feeling fine
• Unpredictability Dont know exactly what
  triggers the episode
• Complicated medication plan, varies with symptom
  intensity and disease severity
• Need to monitor asthma symptoms, the signals for
  medication changes
• Fears about medication side-effects
• Medications only part of plan Trigger reduction
  also needed.

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Helping parents and providers move beyond the
difficulties

• Promote early diagnosis
• Develop tools to clarify and simplify the
  complicated medication management steps
• Find ways to build asthma management into a
  regular routine, both for providers and patients.
  
• Promote the reduction of environmental and
  behavioral triggers to asthma in the childs
  daily life

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Physician Asthma Care Education Program

• PACE Program to help physicians talk about asthma
  with parents/patients, proven effective in
  studies conducted by Columbia University
  researchers in work with NYC practices
• Outlines clear steps for incorporating NHLBI
  recommendations into daily practice
• Promotes communication strategies for promoting
  family and self-management of asthma.
• Source Clark, NM et al. Impact of education for
  physicians on patient outcomes. Pediatrics 1998
  101 831-36.

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PACE Suggestions for Talking with Parents about
Asthma

• Be attentive Make eye contact, sit same level,
  no desk or barriers between you, lean into the
  conversation
• Ask open-ended questions What about asthma is
  hard for you or your child?
• Get fears out on the table and deal with fears
  and concerns right away
• Be reassuring
• Share information interactively
• Tailor the regimen to the familys daily routines
• Plan how the family and you will make decisions
  together
• Set goals for asthma treatment Find out what the
  family wants to achieve

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Explaining Asthma

• Provider message Explain what happens during an
  asthma attack
• Inflammation Airway lining swells and produces
  too much mucus
• Bronchospasm Airway muscles squeeze too much
• Asthma episodes are reversible

• Parent/Patient message
• Wants an explanation that takes away the mystery
  about asthma, so can see what is going on in
  the lungs
• Wants to be reassured that asthma is manageable
  and can get better

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Communication Tips for Explaining Asthma

• Make it simple and use pictures of airways
• Use the fist example, asking parent/patient to
  do it with you.
• Convey the dynamic of open/shut airways

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Asthma Can Be Managed Key Message

• With proper therapy, the child can be symptom
  free
• Goal is to use as little medicine as possible,
  increasing on an as-needed basis.
• Long-term goal of reducing or even stopping
  regular medication
• Emphasis on as little as possible addresses
  parents fears of overmedication and dependence

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Explain About Quick-Relief Medications

• Provider message
• Quick- relief medications act fast, so that
  breathing is easy again within minutes
• Quick-relief medications relax the muscles after
  they have tightened during an attack
• Parents are in charge of helping their children
  breathe through the quick-relief medications

• Parent Message
• Know that medicines will open up lungs and child
  wont suffocate
• Know that reaction is not instant may take a
  few minutes
• Quick relief medicines are parents ticket to
  helping child breathe

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Communication Tip for Quick-Relief Medications

• Use a physical example Unclamp fist to show how
  medicines work
• Ask parent about fears about child during an
  asthma episode
• Discuss concerns parents may have about
  medications
• Jitteriness anxiety
• Other side effects parents may fear
  (dependence)
• Be accurate about risks but reinforce message
  that medicines work!

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Explaining about Controller Medications

• Provider Message
• Anti-inflammatory medicines dont relieve
  symptoms
• Do reduce inflammation and prevent frequent or
  severe episodes
• Needed if asthma symptoms more than every 2
  months
• Effective only if taken regularly

• Parent Message
• Anti-inflammatory meds are like a flu shot, to
  help keep away the bad asthma episodes
• Anti-inflammatory medicines are like vitamins
  they need to be taken all the time, even if not
  sick

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Communication Tips about Controller Medicines

• Explain the different types of controllers
  (parents want to know the names), and why more
  than one may be used
• Convey clearly information about any risks or
  side effects
• Discuss fears about medication dependence
• Low Doses of Inhaled Corticosteroids do not cause
  side effects
• Not the same as the body-building steroids
• Emphasize safety of the medications when used as
  prescribed on the plan.

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Talking about Alternative Asthma Treatments

• Provider Message
• Asthma medications work and are safe when used as
  prescribed.
• Traditional teas and herbal remedies can also be
  used, but not instead of medications.
• Work out how the two can be paired, if parents
  wish.

• Parent Message
• Needs to hear that it is OK to use traditional
  remedies with medications
• Sense of respect for own traditions when provider
  brings up alternative therapies

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Asthma Action Plan as a Tool

• Asthma Action Plan is a problem solving tool.
• Plan is based on information from both parent and
  provider
• Parent/patient Symptoms in each zone triggers
• Provider Medications and action steps
• Parent/patient involvement in developing the plan
  will increase chance that is used appropriately.
• Makes sure fits for the family
• What if helps the family see how it can help
  solve asthma management problems

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Developing the Asthma Action Plan

• Begin filling out the asthma action plan as you
  talk about each medication, so that you build the
  plan as you go. (simpler, easier for parents to
  stay with you)
• Give the daily dose level for the child
• Outline how to change the quick relief doses if
  the child becomes symptomatic
• Use the stop light image to categorize normal
  (green), caution (yellow), and danger (red)
• Give the limits for quick relief medications
• maximum sets of 4 puffs per day

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Example of An Asthma Action Plan
Asthma Zone Symptoms Medications How much? What else?
GO Good breathing Sleep at night Peakflowgt80 Quick Relief Controller 2 puffs X 2 /day 2 puffs X2 / day Child can play go to school
Caution Cough Wheeze Peak flow lt80 Quick Relief Controller 4 puffs now 4Xday 4 puffs 2X/day Call doctor watch child See doctor to change meds
Danger Asthma worse fast Meds dont work Peakflowlt50 Quick Relief Controller 4 puffs right now 4 puffs bid Urgent call to doctor go to ED if cant reach doctor
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Communication Tips for the Asthma Action Plan

• Color Code the Explanation
• Show what the different colors mean in terms of
  the childs symptoms
• Explain how to use the plan to adjust medications
  
• Give parent confidence to read childs symptoms
• Make sure parent knows you can be called if
  parent has questions, and must be called if
  danger zone.

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Review Plan with Parents/Patients

• The plan is only a piece of paper if you dont
  help the parent use it.
• Underscore that the plan is tailored especially
  for their child
• Give example of how to use the plan if child gets
  a cold or flu
• Shift preventively into Yellow Zone medications
• Reassure parent that you are always there if not
  sure what to do.
• Make sure parent knows how to reach you 24 hours
  a day.

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Practice Using the Plan

• Make sure parent understands how to read
  childs breathing in each zone
• Encourage parent to talk often to child about
  their breathing
• Go over what to do if breathing changes
• Ask parent to identify when/how meds will be
  given in daily routine
• Ask the parent to do a mock trial with a nurse
  on changing symptoms

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Asthma Action Plans Need to be Updated

• Follow-up call to parents w/in 1 month
• Ask parents to come in to review plan regularly
  to make sure it is still right
• Ask parents to come in for a medication change if
  symptoms persist or worsen.
• Stays in yellow zone too long
• Doesnt sleep through night
• Asthma triggered by play

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Explaining How to Take Medicines

• Provider Message
• Demonstrate how to use inhaler and spacer
• Show how to use peak flow meter
• Give step-by-step instructions

• Parents Message
• Need to feel comfortable with the technology
• Need to know how/where to get spacers, etc.
• What to do if run out of medicine

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Communication Tips on Medication Use

• Ask parent to demonstrate technique in the office
• Reassure parent and child that spacer is meant to
  allow slow, easy intake of medication
• Reassure parent about using alternative
  treatments with medications (teas, herbal
  remedies)

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Explaining Peak Flow Meters

• Provider Message
• Peak flow meter helps identify breathing changes
  before an episode occurs
• Useful only if breathing is monitored regularly
• Not used in children under age 6

• Parent Message
• Peak flow meter signals whats going on inside
  the lungs before it gets bad
• Peak flow meter use needs to be a habit

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Communication Tips for Peak Flow Meters

• Use a small, easy to use meter
• Give steps to establish childs personal best
• Best of three puffs every morning for 2-3 weeks
  when asthma is under control
• Show how to mark gauge with childs zones
  (personal best, caution, danger)
• Help parent establish a routine for peak flow
  measurements each morning
• Remind the parent to adjust medications if peak
  flow reading is lt80 of normal/personal best.

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What about Triggers?

• Provider Message
• Some childrens asthma is triggered by
  allergies, irritants, or exercise
• If there are triggers, steps can be done to
  reduce the childs exposure to them

• Parent Message
• Asthma management is not just medicines. Need to
  control triggers.
• Many triggers are very common in our homes, and
  having a trigger like dust in the home doesnt
  mean parent is bad housekeeper.
• Can do something about some but not all triggers.
  

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Communication Tips about Triggers

• Ask parents about what triggers asthma
• Give a trigger checklist parents can use to
  identify possible triggers in their home
• Recommend skin testing to determine specific
  allergens (dust, cockroach, pet dander, mold),
  and follow with de-sensitization as needed
• Make recommendations for steps parents can take
  to control triggers
• Use of quick-relief medicines before exposure or
  exercise
• Cleaning/control tips
• Smoking cessation if there is a smoker in home
• Who to contact for help with triggers

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Reaching out for Support Early Childhood Centers
and Schools

• Goal Reduce asthma-related absences to only if
  very bad or fever/sore throat
• Steps towards a partnership with schools
• Inform center/school about childs asthma
• Center/school should have a plan for what to do
  if child has asthma episode
• Agreements/plans for medications as needed at
  school
• Trigger identification and removal

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An Example The ABC Asthma Solutions Program with
Early Childhood Educators

• Complementary Asthma Solutions Handbooks for
  early childhood educators and parents
• 3 part training series for early childhood
  educators
• Asthma screening program through the early
  childhood centers
• 2 part training program for parents
• Follow-up by the centers staff
• Integration of asthma units and improved
  management into the child care program
• It Takes a Village approach to environmental
  triggers

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The Experience of 14 Centers One in Five had
Asthma
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Need for Enhanced Screening of Preschoolers

• Clear need for early screening programs 20 of
  the children in the day care centers already had
  a diagnosis, and another 39 had asthma symptoms.
  
• Screen children whose parents have/had asthma
  Children with asthma symptoms were over 2 times
  more likely to have a parent with asthma.
• State-of-the-art now includes recommendations on
  diagnosis and management of asthma among
  pre-schoolers.
• Source Special Supplement on Asthma among
  Preschoolers, Pediatrics, Oct. 2001.

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Diagnosed Children with Asthma Action Plans
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The Need to Improve Asthma Management

• One-fourth (26) of symptomatic children had been
  to the ER for asthma in the past year
• Only 13 of diagnosed symptomatic diagnosed
  children had been to a doctor about asthma in the
  past year.
• One-third (37) of the symptomatic, undiagnosed
  children had seen a doctor but not been
  diagnosed.
• Asthma symptoms are keeping children from school,
  at a cost to themselves and their parents, with
  2-3 times more absences than among
  non-symptomatic children.
• Most (57) parents of diagnosed children do not
  have an asthma action plan.

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Need for Better Links to Providers

• Providers need to be proactive about diagnosing
  asthma, even among young children
• Early Childhood Centers and parents seek
  providers who will be partners in asthma
  management
• Proactive providers can help ensure regular
  asthma check-ups, appropriate medications guided
  by an asthma action plan, and reduced school
  absences.