Evidence of Benefits of Allergy Assessment in Patients With Asthma

In children with persistent asthma, allergy testing reduced symptoms.

The most common chronic medical problem that we pediatricians treat is asthma. We do our best to manage our patients' asthma by prescribing controller medications, providing asthma action plans, and guiding families through acute exacerbations. We often ask about possible environmental triggers, such as tobacco smoke and cockroaches, and we advise patients to reduce their exposure to those triggers.

 However, we may not know the specific allergens that affect a given patient, which makes it difficult to effectively counsel his or her family on what to avoid. This is despite the fact that the National Heart, Lung, and Blood Institute (NHLBI) recommends assessing all patients with asthma for allergies, and testing (with skin or in vitro methods) those with persistent asthma.¹ 

 In a recent article in the Journal of Allergy and Immunology, Stingone and Claudio² investigated how often children with asthma are evaluated for allergies. Questionnaires were distributed to parents of children in kindergarten through fifth grade in the New York City public school system; study participants came from schools in areas of the city with high, median, and low rates of asthma hospitalization. The questionnaire, which was available in English, Spanish, and Chinese, included questions on such topics as demographics, home environment, asthma diagnosis, asthma symptoms, allergy diagnosis, and allergy testing.

Of the 5250 children whose parents returned questionnaires, 13.0% had had symptoms of asthma in the past year. Despite the NHLBI recommendations, only 59.5% of those who had symptoms of persistent asthma had been tested for allergies. Children from households with an income between $20,000 and $40,000 per year were less likely to have been tested than were those from households with an annual income of more than $75,000. Those without insurance or with public insurance were less likely to have been tested than were those who had private insurance.

The children who had been tested for allergies were found to have had fewer recent asthma symptoms. They were also less likely to be exposed to common allergens such as carpets, mold, cats, and water leaks in their home. The authors note that children may have been referred for allergy testing but may never have been tested because of various barriers to care. They also acknowledge that several of their end points are interrelated. For example, the presence of allergens such as mold and water leaks in the home may correlate with socioeconomic status rather than with a lack of allergy testing. In addition, the study was limited by its reliance on parental reports.

 Despite these limitations, the Stingone and Claudio study sheds light on one way in which we could potentially improve the care we provide for our patients with asthma, regardless of income or insurance. Avoiding asthma exacerbations not only improves the physical health of our patients, it also reduces the number of days of school and work that are missed. By evaluating all patients with asthma for allergic triggers, and by testing all patients with persistent asthma, we can provide targeted avoidance education and hopefully make significant progress in the care of our patients.

References:

•  National Heart Lung and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, Summary Report 2007. National Institutes of Health Publication Number 08-5846. http://www.nhlbi.nih.gov/guidelines/asthma/ asthsumm.pdf. Accessed November 17, 2008.

•  Stingone JA, Claudio L. Disparities in allergy testing and health outcomes among urban children with asthma. J Allergy Clin Immunol. 2008;122:748-753.