Adherence in childhood asthma: a growing challenge

Adherence can be a challenging topic to tackle in the clinic, particularly in the management of children with asthma. A parent may think their child is taking their medication as prescribed, yet clinical outcomes and objective adherence measurements may suggest otherwise.

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One study investigated adherence in inner-city US children aged 2–12 with asthma who had at least 2 emergency department visits or had been hospitalized at least once in the previous year.1 In total, 250 children (mean age 7 years, 62% male) were recruited from a pediatric emergency department between 2001 and 2003. Participants were randomized to receive one of three support tools: an asthma education booklet (UC), home visits by a trained asthma educator (ABC) or home visits by an asthma educator in addition to objective feedback on adherence and goal setting support (AMF). Treatment adherence was measured by assessing caregiver-reported adherence to ICS and evaluation of participants’ pharmacy ICS refill records alongside asthma morbidity measures. Caregiver-reported adherence was high across all groups throughout the 18-month assessment period, with an average of over 80% (highest in the UC group). In contrast, the objective pharmacy-based ICS average quarterly refill rate was reported to be less than 1 across all groups (lowest in the UC group). This being less than a third of that expected.1 Overall, both the ABC and AMF groups demonstrated improvements in selected asthma outcomes versus the UC control, supporting the role of education to improve treatment adherence and asthma outcomes.1

Physicians may believe it is possible to identify those who don’t accurately report their adherence, but this may not always be the case. For instance, in a 1-month study to electronically monitor the use of preventive medication in 51 children (age 18 months to 7 years) with asthma, median use of the inhaler as reported electronically was 70.5% while parent-reported verbal and questionnaire estimates suggested 85.1 and 84.2% use, respectively. Moreover, clinicians only correctly identified 55% of the patients who were inaccurately reporting their adherence.2,3

But while some may welcome the colder weather and the wintry activities that come with it, for the 26 million people living with asthma, the change in season can wreak havoc on their respiratory health.1,2

The plummeting temperatures bring cold, dry air, which can irritate the airways of people with asthma, COPD or bronchitis.1 The combination of low temperature and low humidity is thought to affect the respiratory epithelium, inducing hyper-responsiveness and narrowing of the respiratory airways. This can lead to chronic inflammation, which in turn causes an increase in wheezing, coughing, and shortness of breath.3

And with the winter months comes cold and flu season, which can be hard to avoid for almost everyone, but carries extra risks for some. Those with respiratory conditions have to face more than just the symptoms of the virus itself: cold and flu can aggravate chronic respiratory disease symptoms through increased bronchial inflammation, putting people at a heightened risk of a potentially life-threatening asthma attack.1,4

So what can people do to help prevent their symptoms from becoming worse? Aside from taking standard precautions to avoid contracting and spreading a cold or the flu, or in more serious cases pneumonia, people are recommended to keep an eye on the weather forecast, limit outdoor exercise, and invest in an air humidifier.1,5 Even a simple scarf wrapped loosely around the nose and mouth can help to warm the air before it enters the lungs, preventing any sudden changes in temperature which could trigger symptoms.6 People should also be encouraged to monitor air quality forecasts, as air pollution can be high in the winter, particularly in areas where wood burning is prevalent.1


  1. Otsuki M et al. Pediatrics 2009; 124(6): 1513–1521.
  2. Morton RW et al. Arch Dis Child 2014; 99(10): 949–953.
  3. Burgess SW et al. Respirology 2008; 13(4): 559–563.
  4. Klok T et al. Pediatr Allergy Immunol 2015; 26(3): 197–205.
  5. Rottier BL et al. Eur Respir Rev 2015; 24: 194–203.
  6. Klok T et al. Breathe 2013; 9: 268–277.
  7. Ingerski LM et al. J Pediatr 2011; 159(4) 528-534

RESP-41961 November 2019

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