Eastern Society for Pediatric Research (ESPR): Annual Meeting

It’s challenging enough to control chronic asthma in children, but youngsters who live in low-income, inner-city households face some special barriers to optimal asthma management, including their family’s difficulty paying for medication, lack of family understanding about optimal treatment, and denial by the family about treatment compliance.

The best way to deal with at least some of these issues may be a new approach to educating families about their child’s persistent asthma, said Dr. Marina Reznik, a pediatrician at the Children’s Hospital at Montefiore Medical Center in New York. She has launched a study to test the ability of community health workers to improve family awareness and understanding of optimal asthma education and to see if this results in improved patient outcomes.

The study involves randomizing Bronx families who have a child with persistent asthma to receive either standard education materials or six visits from a community health worker, every other week over the course of 10 weeks. The health workers will instruct parents on optimal asthma control therapy, teach them how to administer an inhaled corticosteroid to their young child, and then continue to monitor the therapy over a 10-week period to make sure correct treatment delivery continues. Dr. Reznik plans to compare the outcome results between the intervention and control groups over the subsequent year.

She and her associates gained additional insight into the problems that parents face with administering correct asthma treatment to their children from the results of a pair of studies that they reported in March at the annual meeting of the Eastern Society for Pediatric Research in Philadelphia.

Comparing Perceived Asthma Compliance and Reality

In one study, Dr. Reznik and her associates tested the way that parents of children with asthma perceive their compliance with an inhaled corticosteroid regimen, compared with their actual compliance. They recruited 40 parents of a child aged 2-9 years with persistent asthma who required twice-daily therapy with an inhaled corticosteroid, a total of four puffs per day. All children were patients of the community health care center run by Montefiore. The participating parents averaged 33 years old, two-thirds were Hispanic, and 29% had not graduated high school.

Each parent received an inhaled corticosteroid actuator with an attached dose counter that recorded the number of puffs delivered. Thirty days later, the researchers surveyed the parents about their adherence to the two-puffs twice-daily regimen and also checked the dose counter on the family’s actuator.

Sixteen of the 40 parents (40%) claimed they had been 100% compliant with the regimen, while the dose counters revealed that only two families (5%) had achieved complete compliance. In addition, only one parent (3%) owned up in an interview to being completely nonadherent, while the dose counters showed that four parents (10%) had actually failed to administer any treatment during the study.

The results showed that parental self-reporting is "nonreliable" for assessing compliance with an asthma regimen, Dr. Reznik said. "The results may have implications for physicians using parental self-reports in managing children with persistent asthma."

The disparity between perceived and actual adherence may derive in part from parents’ concerns about the safety of this treatment, she suggested. "They see improved symptoms [in their children], but they are terrified of the drugs. They have misconceptions." Other social factors that make life difficult and complicated for these low-income parents may play a role as well, she said.

Delivering Asthma Medication Appropriately

The second set of results that her group reported at the meeting came from a study that focused on caregiver knowledge of the appropriate way to deliver an inhaled corticosteroid. Again, the study used parents of children aged 2-9 years old seen at the hospital’s community outpatient pediatric clinic. This time, they enrolled 66 caregivers, who averaged 32 years old, with 96% of the study group comprising mothers; 27% of the parents had not finished high school, 59% were unemployed, 59% were Hispanic and 26% were black.

Among the 66 participants, 92% said that they had used a spacer when delivering the inhaled corticosteroid to their child, with 78% saying they used the spacer for every treatment, and 5% saying they never used a spacer. In addition, 97% of the caregivers said that a physician or nurse had explained to them how to use the metered dose inhaler and spacer, 91% said that a physician or nurse had demonstrated the correct treatment technique, and 49% said that at some point a physician or nurse had watched their technique for administering the drug.

A researcher then watched each caregiver deliver two puffs of the inhaled corticosteroid to a doll. Only one of the participants (2%) correctly performed every step of drug administration with the metered dose inhaler and spacer. Although 97% correctly formed a tight seal with the inhaler, the most problematic steps involved waiting the appropriate interval between puffs, done by 27%, and instructing the recipient to exhale before the treatment inhalation, done by 24%. Other steps scored on the assessment involved shaking the inhaler for at least 5 seconds before administering a puff, pressing the inhaler just once for each puff, and administering the correct number of puffs.

Dr. Reznik and her associates concluded that the results highlighted the need for repeated training of caregivers to ensure ongoing, proper delivery of inhaled corticosteroids.

Most physicians don’t have the time to properly teach parents on the correct delivery of inhaled corticosteroids, Dr. Reznik said. In addition, many parents favor treatment with an inhaled, short-acting beta-agonist, such as albuterol, because of the immediate symptom relief it provides. "They don’t see the role of preventive treatment, compared with acute treatment," she said in an interview.

"There is a discrepancy between what physicians say and what parents hear, and there is more to this than education." Parents face the financial challenge of paying for the medications, and they fear the side effects of inhaled corticosteroids. "Physicians try to educate the family as much as possible, but with limited time, that may not be possible." The community health worker approach under development by Dr. Reznik features a user-friendly format in which the health worker goes to the family’s home, a format that she hopes will lead to improved caregiver education and reinforcement, improved drug delivery, and better outcomes.

Dr. Reznik said that she had no disclosures.

It’s challenging enough to control chronic asthma in children, but youngsters who live in low-income, inner-city households face some special barriers to optimal asthma management, including their family’s difficulty paying for medication, lack of family understanding about optimal treatment, and denial by the family about treatment compliance.

The best way to deal with at least some of these issues may be a new approach to educating families about their child’s persistent asthma, said Dr. Marina Reznik, a pediatrician at the Children’s Hospital at Montefiore Medical Center in New York. She has launched a study to test the ability of community health workers to improve family awareness and understanding of optimal asthma education and to see if this results in improved patient outcomes.

The study involves randomizing Bronx families who have a child with persistent asthma to receive either standard education materials or six visits from a community health worker, every other week over the course of 10 weeks. The health workers will instruct parents on optimal asthma control therapy, teach them how to administer an inhaled corticosteroid to their young child, and then continue to monitor the therapy over a 10-week period to make sure correct treatment delivery continues. Dr. Reznik plans to compare the outcome results between the intervention and control groups over the subsequent year.

She and her associates gained additional insight into the problems that parents face with administering correct asthma treatment to their children from the results of a pair of studies that they reported in March at the annual meeting of the Eastern Society for Pediatric Research in Philadelphia.

Comparing Perceived Asthma Compliance and Reality

In one study, Dr. Reznik and her associates tested the way that parents of children with asthma perceive their compliance with an inhaled corticosteroid regimen, compared with their actual compliance. They recruited 40 parents of a child aged 2-9 years with persistent asthma who required twice-daily therapy with an inhaled corticosteroid, a total of four puffs per day. All children were patients of the community health care center run by Montefiore. The participating parents averaged 33 years old, two-thirds were Hispanic, and 29% had not graduated high school.

Each parent received an inhaled corticosteroid actuator with an attached dose counter that recorded the number of puffs delivered. Thirty days later, the researchers surveyed the parents about their adherence to the two-puffs twice-daily regimen and also checked the dose counter on the family’s actuator.

Sixteen of the 40 parents (40%) claimed they had been 100% compliant with the regimen, while the dose counters revealed that only two families (5%) had achieved complete compliance. In addition, only one parent (3%) owned up in an interview to being completely nonadherent, while the dose counters showed that four parents (10%) had actually failed to administer any treatment during the study.

The results showed that parental self-reporting is "nonreliable" for assessing compliance with an asthma regimen, Dr. Reznik said. "The results may have implications for physicians using parental self-reports in managing children with persistent asthma."

The disparity between perceived and actual adherence may derive in part from parents’ concerns about the safety of this treatment, she suggested. "They see improved symptoms [in their children], but they are terrified of the drugs. They have misconceptions." Other social factors that make life difficult and complicated for these low-income parents may play a role as well, she said.

Delivering Asthma Medication Appropriately

The second set of results that her group reported at the meeting came from a study that focused on caregiver knowledge of the appropriate way to deliver an inhaled corticosteroid. Again, the study used parents of children aged 2-9 years old seen at the hospital’s community outpatient pediatric clinic. This time, they enrolled 66 caregivers, who averaged 32 years old, with 96% of the study group comprising mothers; 27% of the parents had not finished high school, 59% were unemployed, 59% were Hispanic and 26% were black.

Among the 66 participants, 92% said that they had used a spacer when delivering the inhaled corticosteroid to their child, with 78% saying they used the spacer for every treatment, and 5% saying they never used a spacer. In addition, 97% of the caregivers said that a physician or nurse had explained to them how to use the metered dose inhaler and spacer, 91% said that a physician or nurse had demonstrated the correct treatment technique, and 49% said that at some point a physician or nurse had watched their technique for administering the drug.

A researcher then watched each caregiver deliver two puffs of the inhaled corticosteroid to a doll. Only one of the participants (2%) correctly performed every step of drug administration with the metered dose inhaler and spacer. Although 97% correctly formed a tight seal with the inhaler, the most problematic steps involved waiting the appropriate interval between puffs, done by 27%, and instructing the recipient to exhale before the treatment inhalation, done by 24%. Other steps scored on the assessment involved shaking the inhaler for at least 5 seconds before administering a puff, pressing the inhaler just once for each puff, and administering the correct number of puffs.

Dr. Reznik and her associates concluded that the results highlighted the need for repeated training of caregivers to ensure ongoing, proper delivery of inhaled corticosteroids.

Most physicians don’t have the time to properly teach parents on the correct delivery of inhaled corticosteroids, Dr. Reznik said. In addition, many parents favor treatment with an inhaled, short-acting beta-agonist, such as albuterol, because of the immediate symptom relief it provides. "They don’t see the role of preventive treatment, compared with acute treatment," she said in an interview.

"There is a discrepancy between what physicians say and what parents hear, and there is more to this than education." Parents face the financial challenge of paying for the medications, and they fear the side effects of inhaled corticosteroids. "Physicians try to educate the family as much as possible, but with limited time, that may not be possible." The community health worker approach under development by Dr. Reznik features a user-friendly format in which the health worker goes to the family’s home, a format that she hopes will lead to improved caregiver education and reinforcement, improved drug delivery, and better outcomes.

Dr. Reznik said that she had no disclosures.

It’s challenging enough to control chronic asthma in children, but youngsters who live in low-income, inner-city households face some special barriers to optimal asthma management, including their family’s difficulty paying for medication, lack of family understanding about optimal treatment, and denial by the family about treatment compliance.

The best way to deal with at least some of these issues may be a new approach to educating families about their child’s persistent asthma, said Dr. Marina Reznik, a pediatrician at the Children’s Hospital at Montefiore Medical Center in New York. She has launched a study to test the ability of community health workers to improve family awareness and understanding of optimal asthma education and to see if this results in improved patient outcomes.

The study involves randomizing Bronx families who have a child with persistent asthma to receive either standard education materials or six visits from a community health worker, every other week over the course of 10 weeks. The health workers will instruct parents on optimal asthma control therapy, teach them how to administer an inhaled corticosteroid to their young child, and then continue to monitor the therapy over a 10-week period to make sure correct treatment delivery continues. Dr. Reznik plans to compare the outcome results between the intervention and control groups over the subsequent year.

She and her associates gained additional insight into the problems that parents face with administering correct asthma treatment to their children from the results of a pair of studies that they reported in March at the annual meeting of the Eastern Society for Pediatric Research in Philadelphia.

Comparing Perceived Asthma Compliance and Reality

In one study, Dr. Reznik and her associates tested the way that parents of children with asthma perceive their compliance with an inhaled corticosteroid regimen, compared with their actual compliance. They recruited 40 parents of a child aged 2-9 years with persistent asthma who required twice-daily therapy with an inhaled corticosteroid, a total of four puffs per day. All children were patients of the community health care center run by Montefiore. The participating parents averaged 33 years old, two-thirds were Hispanic, and 29% had not graduated high school.

Each parent received an inhaled corticosteroid actuator with an attached dose counter that recorded the number of puffs delivered. Thirty days later, the researchers surveyed the parents about their adherence to the two-puffs twice-daily regimen and also checked the dose counter on the family’s actuator.

Sixteen of the 40 parents (40%) claimed they had been 100% compliant with the regimen, while the dose counters revealed that only two families (5%) had achieved complete compliance. In addition, only one parent (3%) owned up in an interview to being completely nonadherent, while the dose counters showed that four parents (10%) had actually failed to administer any treatment during the study.

The results showed that parental self-reporting is "nonreliable" for assessing compliance with an asthma regimen, Dr. Reznik said. "The results may have implications for physicians using parental self-reports in managing children with persistent asthma."

The disparity between perceived and actual adherence may derive in part from parents’ concerns about the safety of this treatment, she suggested. "They see improved symptoms [in their children], but they are terrified of the drugs. They have misconceptions." Other social factors that make life difficult and complicated for these low-income parents may play a role as well, she said.

Delivering Asthma Medication Appropriately

The second set of results that her group reported at the meeting came from a study that focused on caregiver knowledge of the appropriate way to deliver an inhaled corticosteroid. Again, the study used parents of children aged 2-9 years old seen at the hospital’s community outpatient pediatric clinic. This time, they enrolled 66 caregivers, who averaged 32 years old, with 96% of the study group comprising mothers; 27% of the parents had not finished high school, 59% were unemployed, 59% were Hispanic and 26% were black.

Among the 66 participants, 92% said that they had used a spacer when delivering the inhaled corticosteroid to their child, with 78% saying they used the spacer for every treatment, and 5% saying they never used a spacer. In addition, 97% of the caregivers said that a physician or nurse had explained to them how to use the metered dose inhaler and spacer, 91% said that a physician or nurse had demonstrated the correct treatment technique, and 49% said that at some point a physician or nurse had watched their technique for administering the drug.

A researcher then watched each caregiver deliver two puffs of the inhaled corticosteroid to a doll. Only one of the participants (2%) correctly performed every step of drug administration with the metered dose inhaler and spacer. Although 97% correctly formed a tight seal with the inhaler, the most problematic steps involved waiting the appropriate interval between puffs, done by 27%, and instructing the recipient to exhale before the treatment inhalation, done by 24%. Other steps scored on the assessment involved shaking the inhaler for at least 5 seconds before administering a puff, pressing the inhaler just once for each puff, and administering the correct number of puffs.

Dr. Reznik and her associates concluded that the results highlighted the need for repeated training of caregivers to ensure ongoing, proper delivery of inhaled corticosteroids.

Most physicians don’t have the time to properly teach parents on the correct delivery of inhaled corticosteroids, Dr. Reznik said. In addition, many parents favor treatment with an inhaled, short-acting beta-agonist, such as albuterol, because of the immediate symptom relief it provides. "They don’t see the role of preventive treatment, compared with acute treatment," she said in an interview.

"There is a discrepancy between what physicians say and what parents hear, and there is more to this than education." Parents face the financial challenge of paying for the medications, and they fear the side effects of inhaled corticosteroids. "Physicians try to educate the family as much as possible, but with limited time, that may not be possible." The community health worker approach under development by Dr. Reznik features a user-friendly format in which the health worker goes to the family’s home, a format that she hopes will lead to improved caregiver education and reinforcement, improved drug delivery, and better outcomes.

Dr. Reznik said that she had no disclosures.

PHILADELPHIA – Children who present to the emergency department with mild community-acquired pneumonia probably do not require a routine blood culture, but blood cultures can help in the management of children with moderate to severe pneumonia, based on a review of 291 patients.

"The benefit of blood cultures is likely limited to the patient subgroups who are at increased risk for bacteremia," Maria H. Dugan said at the annual meeting of the Eastern Society for Pediatric Research. In the study population, bacteremia occurred with a significantly higher prevalence in patients with pneumonia complications, especially pulmonary complications, said Ms. Dugan, a researcher at Children’s Hospital of Philadelphia (CHOP).

The analysis also showed that in five of the six pneumonia patients in the series identified as having bacteremia, the culture results led to a change in management.

"Even though blood cultures were infrequently positive, the positive results often led to meaningful changes in clinical management," said Dr. Samir S. Shah, a pediatric infectious diseases physician at CHOP and the senior investigator for this study. "Equally important, those children with more severe forms of pneumonia, such as empyema, had fairly high rates of bacteremia, about 13%. We think this is sufficiently high to warrant a blood culture," he said in an interview.

Ms. Dugan and her associates performed this analysis because blood cultures are often obtained from children who present to an emergency department with community-acquired pneumonia, even though blood cultures rarely influence the management of adults with pneumonia. The study tried to assess the impact that culture results have on management in children.

"In studies of adults with pneumonia, investigators have found that blood cultures were uncommonly positive, and that even when blood cultures were positive, physicians seldom did anything different as a result. We found a very different story in children," Dr. Shah said.

The investigators’ review included children aged 0-18 from 35 primary care pediatric practices affiliated with CHOP in Pennsylvania, New Jersey, and Delaware who were seen in the emergency department at CHOP during 2006 or 2007 with a discharge diagnosis of pneumonia. The 877 patients evaluated in the emergency department averaged 4 years old, with 78% aged 5 or younger.

The emergency department staff obtained blood cultures on 291 (34%) of the 877 children with pneumonia. The decision of whether to obtain a culture rested solely with the physicians who cared for each child. "There is no protocol [at CHOP] regarding the decision to obtain blood cultures in children with pneumonia," Dr. Shah explained. "We suspect that blood cultures were more commonly obtained in children with a higher degree of illness severity."

Comparison of the children who underwent culturing and those who did not showed that the cultured children were older, with 38% older than 5 years, compared with 13% in this age range among those who were not cultured. Greater disease severity also appeared to distinguish the children who underwent culturing. The cultured children had a higher prevalence of hypoxia, and more often their records said that they appeared ill at presentation, compared with the children who did not undergo culturing, Dr. Shah said.

Six (2%) of the 291 children tested by culturing had a confirmed positive culture. Three additional cultures initially tested positive, but subsequent study showed contaminations that made these cultures false positives. The six true-positive cultures included four with Streptococcus pneumoniae, one with Staphylococcus aureus, and one with Haemophilus influenzae.

Patients with an infiltrate on their chest x-ray, and patients who eventually required hospitalization did not have a significantly higher prevalence of a positive culture compared with the other children. But the analysis showed a statistically significant higher level of positive cultures among the children who presented with any pneumonia complication (8%), and especially in those with pulmonary complications (13%).

For four (1.4%) children, results from the blood culture led the hospital staff to narrow their antibiotic treatment compared with the initial treatment the children received, and in two cases (0.7%) the culture results led to a broadening of the antibiotic coverage. In one of these patients, the culture results led to both broadening and narrowing of the treatment regimen. Dr. Shah explained that in this case when the culture initially showed positive, the medical staff broadened the child’s antibiotic coverage. Soon after, when they had identified the specific pathogen as S. pneumoniae, the staff narrowed the antibiotic treatment. For the sixth patient, the blood culture results led to no change from the initial, empiric regimen. This patient had responded well to the initial regimen of amoxicillin, and was subsequently found infected by an S. pneumoniae strain sensitive to amoxicillin, so no change occurred, Dr. Shah said.

Ms. Dugan and Dr. Shah said that they had no relevant financial disclosures.

PHILADELPHIA – Children who present to the emergency department with mild community-acquired pneumonia probably do not require a routine blood culture, but blood cultures can help in the management of children with moderate to severe pneumonia, based on a review of 291 patients.

"The benefit of blood cultures is likely limited to the patient subgroups who are at increased risk for bacteremia," Maria H. Dugan said at the annual meeting of the Eastern Society for Pediatric Research. In the study population, bacteremia occurred with a significantly higher prevalence in patients with pneumonia complications, especially pulmonary complications, said Ms. Dugan, a researcher at Children’s Hospital of Philadelphia (CHOP).

The analysis also showed that in five of the six pneumonia patients in the series identified as having bacteremia, the culture results led to a change in management.

"Even though blood cultures were infrequently positive, the positive results often led to meaningful changes in clinical management," said Dr. Samir S. Shah, a pediatric infectious diseases physician at CHOP and the senior investigator for this study. "Equally important, those children with more severe forms of pneumonia, such as empyema, had fairly high rates of bacteremia, about 13%. We think this is sufficiently high to warrant a blood culture," he said in an interview.

Ms. Dugan and her associates performed this analysis because blood cultures are often obtained from children who present to an emergency department with community-acquired pneumonia, even though blood cultures rarely influence the management of adults with pneumonia. The study tried to assess the impact that culture results have on management in children.

"In studies of adults with pneumonia, investigators have found that blood cultures were uncommonly positive, and that even when blood cultures were positive, physicians seldom did anything different as a result. We found a very different story in children," Dr. Shah said.

The investigators’ review included children aged 0-18 from 35 primary care pediatric practices affiliated with CHOP in Pennsylvania, New Jersey, and Delaware who were seen in the emergency department at CHOP during 2006 or 2007 with a discharge diagnosis of pneumonia. The 877 patients evaluated in the emergency department averaged 4 years old, with 78% aged 5 or younger.

The emergency department staff obtained blood cultures on 291 (34%) of the 877 children with pneumonia. The decision of whether to obtain a culture rested solely with the physicians who cared for each child. "There is no protocol [at CHOP] regarding the decision to obtain blood cultures in children with pneumonia," Dr. Shah explained. "We suspect that blood cultures were more commonly obtained in children with a higher degree of illness severity."

Comparison of the children who underwent culturing and those who did not showed that the cultured children were older, with 38% older than 5 years, compared with 13% in this age range among those who were not cultured. Greater disease severity also appeared to distinguish the children who underwent culturing. The cultured children had a higher prevalence of hypoxia, and more often their records said that they appeared ill at presentation, compared with the children who did not undergo culturing, Dr. Shah said.

Six (2%) of the 291 children tested by culturing had a confirmed positive culture. Three additional cultures initially tested positive, but subsequent study showed contaminations that made these cultures false positives. The six true-positive cultures included four with Streptococcus pneumoniae, one with Staphylococcus aureus, and one with Haemophilus influenzae.

Patients with an infiltrate on their chest x-ray, and patients who eventually required hospitalization did not have a significantly higher prevalence of a positive culture compared with the other children. But the analysis showed a statistically significant higher level of positive cultures among the children who presented with any pneumonia complication (8%), and especially in those with pulmonary complications (13%).

For four (1.4%) children, results from the blood culture led the hospital staff to narrow their antibiotic treatment compared with the initial treatment the children received, and in two cases (0.7%) the culture results led to a broadening of the antibiotic coverage. In one of these patients, the culture results led to both broadening and narrowing of the treatment regimen. Dr. Shah explained that in this case when the culture initially showed positive, the medical staff broadened the child’s antibiotic coverage. Soon after, when they had identified the specific pathogen as S. pneumoniae, the staff narrowed the antibiotic treatment. For the sixth patient, the blood culture results led to no change from the initial, empiric regimen. This patient had responded well to the initial regimen of amoxicillin, and was subsequently found infected by an S. pneumoniae strain sensitive to amoxicillin, so no change occurred, Dr. Shah said.

Ms. Dugan and Dr. Shah said that they had no relevant financial disclosures.

PHILADELPHIA – Children who present to the emergency department with mild community-acquired pneumonia probably do not require a routine blood culture, but blood cultures can help in the management of children with moderate to severe pneumonia, based on a review of 291 patients.

"The benefit of blood cultures is likely limited to the patient subgroups who are at increased risk for bacteremia," Maria H. Dugan said at the annual meeting of the Eastern Society for Pediatric Research. In the study population, bacteremia occurred with a significantly higher prevalence in patients with pneumonia complications, especially pulmonary complications, said Ms. Dugan, a researcher at Children’s Hospital of Philadelphia (CHOP).

The analysis also showed that in five of the six pneumonia patients in the series identified as having bacteremia, the culture results led to a change in management.

"Even though blood cultures were infrequently positive, the positive results often led to meaningful changes in clinical management," said Dr. Samir S. Shah, a pediatric infectious diseases physician at CHOP and the senior investigator for this study. "Equally important, those children with more severe forms of pneumonia, such as empyema, had fairly high rates of bacteremia, about 13%. We think this is sufficiently high to warrant a blood culture," he said in an interview.

Ms. Dugan and her associates performed this analysis because blood cultures are often obtained from children who present to an emergency department with community-acquired pneumonia, even though blood cultures rarely influence the management of adults with pneumonia. The study tried to assess the impact that culture results have on management in children.

"In studies of adults with pneumonia, investigators have found that blood cultures were uncommonly positive, and that even when blood cultures were positive, physicians seldom did anything different as a result. We found a very different story in children," Dr. Shah said.

The investigators’ review included children aged 0-18 from 35 primary care pediatric practices affiliated with CHOP in Pennsylvania, New Jersey, and Delaware who were seen in the emergency department at CHOP during 2006 or 2007 with a discharge diagnosis of pneumonia. The 877 patients evaluated in the emergency department averaged 4 years old, with 78% aged 5 or younger.

The emergency department staff obtained blood cultures on 291 (34%) of the 877 children with pneumonia. The decision of whether to obtain a culture rested solely with the physicians who cared for each child. "There is no protocol [at CHOP] regarding the decision to obtain blood cultures in children with pneumonia," Dr. Shah explained. "We suspect that blood cultures were more commonly obtained in children with a higher degree of illness severity."

Comparison of the children who underwent culturing and those who did not showed that the cultured children were older, with 38% older than 5 years, compared with 13% in this age range among those who were not cultured. Greater disease severity also appeared to distinguish the children who underwent culturing. The cultured children had a higher prevalence of hypoxia, and more often their records said that they appeared ill at presentation, compared with the children who did not undergo culturing, Dr. Shah said.

Six (2%) of the 291 children tested by culturing had a confirmed positive culture. Three additional cultures initially tested positive, but subsequent study showed contaminations that made these cultures false positives. The six true-positive cultures included four with Streptococcus pneumoniae, one with Staphylococcus aureus, and one with Haemophilus influenzae.

Patients with an infiltrate on their chest x-ray, and patients who eventually required hospitalization did not have a significantly higher prevalence of a positive culture compared with the other children. But the analysis showed a statistically significant higher level of positive cultures among the children who presented with any pneumonia complication (8%), and especially in those with pulmonary complications (13%).

For four (1.4%) children, results from the blood culture led the hospital staff to narrow their antibiotic treatment compared with the initial treatment the children received, and in two cases (0.7%) the culture results led to a broadening of the antibiotic coverage. In one of these patients, the culture results led to both broadening and narrowing of the treatment regimen. Dr. Shah explained that in this case when the culture initially showed positive, the medical staff broadened the child’s antibiotic coverage. Soon after, when they had identified the specific pathogen as S. pneumoniae, the staff narrowed the antibiotic treatment. For the sixth patient, the blood culture results led to no change from the initial, empiric regimen. This patient had responded well to the initial regimen of amoxicillin, and was subsequently found infected by an S. pneumoniae strain sensitive to amoxicillin, so no change occurred, Dr. Shah said.

Ms. Dugan and Dr. Shah said that they had no relevant financial disclosures.

PHILADELPHIA – Children who present to the emergency department with mild community-acquired pneumonia probably do not require a routine blood culture, but blood cultures can help in the management of children with moderate to severe pneumonia, based on a review of 291 patients.

"The benefit of blood cultures is likely limited to the patient subgroups who are at increased risk for bacteremia," Maria H. Dugan said at the annual meeting of the Eastern Society for Pediatric Research. In the study population, bacteremia occurred with a significantly higher prevalence in patients with pneumonia complications, especially pulmonary complications, said Ms. Dugan, a researcher at Children’s Hospital of Philadelphia (CHOP).

The analysis also showed that in five of the six pneumonia patients in the series identified as having bacteremia, the culture results led to a change in management.

"Even though blood cultures were infrequently positive, the positive results often led to meaningful changes in clinical management," said Dr. Samir S. Shah, a pediatric infectious diseases physician at CHOP and the senior investigator for this study. "Equally important, those children with more severe forms of pneumonia, such as empyema, had fairly high rates of bacteremia, about 13%. We think this is sufficiently high to warrant a blood culture," he said in an interview.

Ms. Dugan and her associates performed this analysis because blood cultures are often obtained from children who present to an emergency department with community-acquired pneumonia, even though blood cultures rarely influence the management of adults with pneumonia. The study tried to assess the impact that culture results have on management in children.

"In studies of adults with pneumonia, investigators have found that blood cultures were uncommonly positive, and that even when blood cultures were positive, physicians seldom did anything different as a result. We found a very different story in children," Dr. Shah said.

The investigators’ review included children aged 0-18 from 35 primary care pediatric practices affiliated with CHOP in Pennsylvania, New Jersey, and Delaware who were seen in the emergency department at CHOP during 2006 or 2007 with a discharge diagnosis of pneumonia. The 877 patients evaluated in the emergency department averaged 4 years old, with 78% aged 5 or younger.

The emergency department staff obtained blood cultures on 291 (34%) of the 877 children with pneumonia. The decision of whether to obtain a culture rested solely with the physicians who cared for each child. "There is no protocol [at CHOP] regarding the decision to obtain blood cultures in children with pneumonia," Dr. Shah explained. "We suspect that blood cultures were more commonly obtained in children with a higher degree of illness severity."

Comparison of the children who underwent culturing and those who did not showed that the cultured children were older, with 38% older than 5 years, compared with 13% in this age range among those who were not cultured. Greater disease severity also appeared to distinguish the children who underwent culturing. The cultured children had a higher prevalence of hypoxia, and more often their records said that they appeared ill at presentation, compared with the children who did not undergo culturing, Dr. Shah said.

Six (2%) of the 291 children tested by culturing had a confirmed positive culture. Three additional cultures initially tested positive, but subsequent study showed contaminations that made these cultures false positives. The six true-positive cultures included four with Streptococcus pneumoniae, one with Staphylococcus aureus, and one with Haemophilus influenzae.

Patients with an infiltrate on their chest x-ray, and patients who eventually required hospitalization did not have a significantly higher prevalence of a positive culture compared with the other children. But the analysis showed a statistically significant higher level of positive cultures among the children who presented with any pneumonia complication (8%), and especially in those with pulmonary complications (13%).

For four (1.4%) children, results from the blood culture led the hospital staff to narrow their antibiotic treatment compared with the initial treatment the children received, and in two cases (0.7%) the culture results led to a broadening of the antibiotic coverage. In one of these patients, the culture results led to both broadening and narrowing of the treatment regimen. Dr. Shah explained that in this case when the culture initially showed positive, the medical staff broadened the child’s antibiotic coverage. Soon after, when they had identified the specific pathogen as S. pneumoniae, the staff narrowed the antibiotic treatment. For the sixth patient, the blood culture results led to no change from the initial, empiric regimen. This patient had responded well to the initial regimen of amoxicillin, and was subsequently found infected by an S. pneumoniae strain sensitive to amoxicillin, so no change occurred, Dr. Shah said.

Ms. Dugan and Dr. Shah said that they had no relevant financial disclosures.

PHILADELPHIA – Children who present to the emergency department with mild community-acquired pneumonia probably do not require a routine blood culture, but blood cultures can help in the management of children with moderate to severe pneumonia, based on a review of 291 patients.

"The benefit of blood cultures is likely limited to the patient subgroups who are at increased risk for bacteremia," Maria H. Dugan said at the annual meeting of the Eastern Society for Pediatric Research. In the study population, bacteremia occurred with a significantly higher prevalence in patients with pneumonia complications, especially pulmonary complications, said Ms. Dugan, a researcher at Children’s Hospital of Philadelphia (CHOP).

The analysis also showed that in five of the six pneumonia patients in the series identified as having bacteremia, the culture results led to a change in management.

"Even though blood cultures were infrequently positive, the positive results often led to meaningful changes in clinical management," said Dr. Samir S. Shah, a pediatric infectious diseases physician at CHOP and the senior investigator for this study. "Equally important, those children with more severe forms of pneumonia, such as empyema, had fairly high rates of bacteremia, about 13%. We think this is sufficiently high to warrant a blood culture," he said in an interview.

Ms. Dugan and her associates performed this analysis because blood cultures are often obtained from children who present to an emergency department with community-acquired pneumonia, even though blood cultures rarely influence the management of adults with pneumonia. The study tried to assess the impact that culture results have on management in children.

"In studies of adults with pneumonia, investigators have found that blood cultures were uncommonly positive, and that even when blood cultures were positive, physicians seldom did anything different as a result. We found a very different story in children," Dr. Shah said.

The investigators’ review included children aged 0-18 from 35 primary care pediatric practices affiliated with CHOP in Pennsylvania, New Jersey, and Delaware who were seen in the emergency department at CHOP during 2006 or 2007 with a discharge diagnosis of pneumonia. The 877 patients evaluated in the emergency department averaged 4 years old, with 78% aged 5 or younger.

The emergency department staff obtained blood cultures on 291 (34%) of the 877 children with pneumonia. The decision of whether to obtain a culture rested solely with the physicians who cared for each child. "There is no protocol [at CHOP] regarding the decision to obtain blood cultures in children with pneumonia," Dr. Shah explained. "We suspect that blood cultures were more commonly obtained in children with a higher degree of illness severity."

Comparison of the children who underwent culturing and those who did not showed that the cultured children were older, with 38% older than 5 years, compared with 13% in this age range among those who were not cultured. Greater disease severity also appeared to distinguish the children who underwent culturing. The cultured children had a higher prevalence of hypoxia, and more often their records said that they appeared ill at presentation, compared with the children who did not undergo culturing, Dr. Shah said.

Six (2%) of the 291 children tested by culturing had a confirmed positive culture. Three additional cultures initially tested positive, but subsequent study showed contaminations that made these cultures false positives. The six true-positive cultures included four with Streptococcus pneumoniae, one with Staphylococcus aureus, and one with Haemophilus influenzae.

Patients with an infiltrate on their chest x-ray, and patients who eventually required hospitalization did not have a significantly higher prevalence of a positive culture compared with the other children. But the analysis showed a statistically significant higher level of positive cultures among the children who presented with any pneumonia complication (8%), and especially in those with pulmonary complications (13%).

For four (1.4%) children, results from the blood culture led the hospital staff to narrow their antibiotic treatment compared with the initial treatment the children received, and in two cases (0.7%) the culture results led to a broadening of the antibiotic coverage. In one of these patients, the culture results led to both broadening and narrowing of the treatment regimen. Dr. Shah explained that in this case when the culture initially showed positive, the medical staff broadened the child’s antibiotic coverage. Soon after, when they had identified the specific pathogen as S. pneumoniae, the staff narrowed the antibiotic treatment. For the sixth patient, the blood culture results led to no change from the initial, empiric regimen. This patient had responded well to the initial regimen of amoxicillin, and was subsequently found infected by an S. pneumoniae strain sensitive to amoxicillin, so no change occurred, Dr. Shah said.

Ms. Dugan and Dr. Shah said that they had no relevant financial disclosures.

PHILADELPHIA – Children who present to the emergency department with mild community-acquired pneumonia probably do not require a routine blood culture, but blood cultures can help in the management of children with moderate to severe pneumonia, based on a review of 291 patients.

"The benefit of blood cultures is likely limited to the patient subgroups who are at increased risk for bacteremia," Maria H. Dugan said at the annual meeting of the Eastern Society for Pediatric Research. In the study population, bacteremia occurred with a significantly higher prevalence in patients with pneumonia complications, especially pulmonary complications, said Ms. Dugan, a researcher at Children’s Hospital of Philadelphia (CHOP).

The analysis also showed that in five of the six pneumonia patients in the series identified as having bacteremia, the culture results led to a change in management.

"Even though blood cultures were infrequently positive, the positive results often led to meaningful changes in clinical management," said Dr. Samir S. Shah, a pediatric infectious diseases physician at CHOP and the senior investigator for this study. "Equally important, those children with more severe forms of pneumonia, such as empyema, had fairly high rates of bacteremia, about 13%. We think this is sufficiently high to warrant a blood culture," he said in an interview.

Ms. Dugan and her associates performed this analysis because blood cultures are often obtained from children who present to an emergency department with community-acquired pneumonia, even though blood cultures rarely influence the management of adults with pneumonia. The study tried to assess the impact that culture results have on management in children.

"In studies of adults with pneumonia, investigators have found that blood cultures were uncommonly positive, and that even when blood cultures were positive, physicians seldom did anything different as a result. We found a very different story in children," Dr. Shah said.

The investigators’ review included children aged 0-18 from 35 primary care pediatric practices affiliated with CHOP in Pennsylvania, New Jersey, and Delaware who were seen in the emergency department at CHOP during 2006 or 2007 with a discharge diagnosis of pneumonia. The 877 patients evaluated in the emergency department averaged 4 years old, with 78% aged 5 or younger.

The emergency department staff obtained blood cultures on 291 (34%) of the 877 children with pneumonia. The decision of whether to obtain a culture rested solely with the physicians who cared for each child. "There is no protocol [at CHOP] regarding the decision to obtain blood cultures in children with pneumonia," Dr. Shah explained. "We suspect that blood cultures were more commonly obtained in children with a higher degree of illness severity."

Comparison of the children who underwent culturing and those who did not showed that the cultured children were older, with 38% older than 5 years, compared with 13% in this age range among those who were not cultured. Greater disease severity also appeared to distinguish the children who underwent culturing. The cultured children had a higher prevalence of hypoxia, and more often their records said that they appeared ill at presentation, compared with the children who did not undergo culturing, Dr. Shah said.

Six (2%) of the 291 children tested by culturing had a confirmed positive culture. Three additional cultures initially tested positive, but subsequent study showed contaminations that made these cultures false positives. The six true-positive cultures included four with Streptococcus pneumoniae, one with Staphylococcus aureus, and one with Haemophilus influenzae.

Patients with an infiltrate on their chest x-ray, and patients who eventually required hospitalization did not have a significantly higher prevalence of a positive culture compared with the other children. But the analysis showed a statistically significant higher level of positive cultures among the children who presented with any pneumonia complication (8%), and especially in those with pulmonary complications (13%).

For four (1.4%) children, results from the blood culture led the hospital staff to narrow their antibiotic treatment compared with the initial treatment the children received, and in two cases (0.7%) the culture results led to a broadening of the antibiotic coverage. In one of these patients, the culture results led to both broadening and narrowing of the treatment regimen. Dr. Shah explained that in this case when the culture initially showed positive, the medical staff broadened the child’s antibiotic coverage. Soon after, when they had identified the specific pathogen as S. pneumoniae, the staff narrowed the antibiotic treatment. For the sixth patient, the blood culture results led to no change from the initial, empiric regimen. This patient had responded well to the initial regimen of amoxicillin, and was subsequently found infected by an S. pneumoniae strain sensitive to amoxicillin, so no change occurred, Dr. Shah said.

Ms. Dugan and Dr. Shah said that they had no relevant financial disclosures.

PHILADELPHIA – Having emergency physicians start children with persistent asthma on a prescription of an inhaled corticosteroid failed to have a significant impact on the rate at which the families filled a second, follow-up prescription for the same drug from their primary care pediatrician, according to a controlled study with 153 children.

But the study results did show, for the first time in a controlled study of children, that intervention with an inhaled corticosteroid can significantly improve asthma symptoms over the short term, Dr. Esther M. Sampayo said at the annual meeting of the Eastern Society for Pediatric Research.

"National guidelines have recommended that emergency physicians consider initiating control medications [for children with asthma] in the emergency department," she said. When children don’t receive such a prescription, it’s "a missed opportunity for children who are high emergency department utilizers," said Dr. Sampayo, a pediatric emergency physician at Children’s Hospital of Philadelphia.

"We found that at 2 months [after the index emergency department visit], fewer than 20% of children actually filled a second prescription for their control medication," with similar rates in both the control and intervention groups of the study. This level of failure occurred even though when each child received the initial prescription, the researchers told the family to fill a follow-up prescription from the child’s primary care pediatrician, each pediatrician received an alert to write the second prescription, and virtually all the families had public or private insurance that covered the drug’s cost.

"We’re now testing a new intervention, sending parents a text message to remind them to refill their child’s prescription," Dr. Sampayo said in an interview.

The findings also highlighted the important role that emergency physicians can play in starting children on an inhaled corticosteroid. In prior studies, researchers asked emergency physicians why they generally did not start children with poorly controlled asthma on control medication. The physicians said that they didn’t view it as their appropriate role, and that this task was best reserved for primary care physicians. "All the pediatricians in our study said that the emergency department physicians should write the prescription. They want the emergency physician to do it," she said.

The study enrolled children seen in the emergency department of Children’s Hospital of Philadelphia with an average age of 5 years (range, 1-18 years) during 2006-2009. After randomization, the families of 74 children received a starter prescription for a 30-day supply of an inhaled corticosteroid, either budesonide for children aged 4 or younger, or fluticasone for those aged 5 or older, as well as educational materials and other standard discharge medications for asthma. The 78 control families received the same educational materials and discharge medications but no prescription for a corticosteroid.

By 8 weeks after the emergency department visit, about 63% of the intervention families had filled their initial corticosteroid prescription, compared with about 27% of the control families, a statistically significant difference. But the rate at which the intervention families filled the second prescription – the one they had to get from the child’s primary care pediatrician – dropped to roughly 20% of the intervention families, no different from the 18% rate among the control families. The researchers have not yet examined whether the breakdown in follow-up prescriptions occurred at the level of the primary care pediatrician or in the family’s failure to fill a second prescription that they received.

The follow-up data also showed that while on the initial course of an inhaled steroid, the children had, on average, a significant 2-day drop in the number of days they coughed while asleep, and a significant halving of the number of days when they experienced shortness of breath.

In addition, the first course of an inhaled corticosteroid led to a significant reduction in the use of albuterol as a rescue medication. Children in the intervention group had a 43% rate of never using albuterol or using it less than twice during follow-up, compared with 21% having this usage rate among the control children. At the other end of the spectrum, children in the intervention group had a 44% rate of using albuterol either daily or every other day during follow-up, compared with a 65% rate of such heavy use by the control children.

Dr. Sampayo said that she and her associates had no relevant financial disclosures.

PHILADELPHIA – Having emergency physicians start children with persistent asthma on a prescription of an inhaled corticosteroid failed to have a significant impact on the rate at which the families filled a second, follow-up prescription for the same drug from their primary care pediatrician, according to a controlled study with 153 children.

But the study results did show, for the first time in a controlled study of children, that intervention with an inhaled corticosteroid can significantly improve asthma symptoms over the short term, Dr. Esther M. Sampayo said at the annual meeting of the Eastern Society for Pediatric Research.

"National guidelines have recommended that emergency physicians consider initiating control medications [for children with asthma] in the emergency department," she said. When children don’t receive such a prescription, it’s "a missed opportunity for children who are high emergency department utilizers," said Dr. Sampayo, a pediatric emergency physician at Children’s Hospital of Philadelphia.

"We found that at 2 months [after the index emergency department visit], fewer than 20% of children actually filled a second prescription for their control medication," with similar rates in both the control and intervention groups of the study. This level of failure occurred even though when each child received the initial prescription, the researchers told the family to fill a follow-up prescription from the child’s primary care pediatrician, each pediatrician received an alert to write the second prescription, and virtually all the families had public or private insurance that covered the drug’s cost.

"We’re now testing a new intervention, sending parents a text message to remind them to refill their child’s prescription," Dr. Sampayo said in an interview.

The findings also highlighted the important role that emergency physicians can play in starting children on an inhaled corticosteroid. In prior studies, researchers asked emergency physicians why they generally did not start children with poorly controlled asthma on control medication. The physicians said that they didn’t view it as their appropriate role, and that this task was best reserved for primary care physicians. "All the pediatricians in our study said that the emergency department physicians should write the prescription. They want the emergency physician to do it," she said.

The study enrolled children seen in the emergency department of Children’s Hospital of Philadelphia with an average age of 5 years (range, 1-18 years) during 2006-2009. After randomization, the families of 74 children received a starter prescription for a 30-day supply of an inhaled corticosteroid, either budesonide for children aged 4 or younger, or fluticasone for those aged 5 or older, as well as educational materials and other standard discharge medications for asthma. The 78 control families received the same educational materials and discharge medications but no prescription for a corticosteroid.

By 8 weeks after the emergency department visit, about 63% of the intervention families had filled their initial corticosteroid prescription, compared with about 27% of the control families, a statistically significant difference. But the rate at which the intervention families filled the second prescription – the one they had to get from the child’s primary care pediatrician – dropped to roughly 20% of the intervention families, no different from the 18% rate among the control families. The researchers have not yet examined whether the breakdown in follow-up prescriptions occurred at the level of the primary care pediatrician or in the family’s failure to fill a second prescription that they received.

The follow-up data also showed that while on the initial course of an inhaled steroid, the children had, on average, a significant 2-day drop in the number of days they coughed while asleep, and a significant halving of the number of days when they experienced shortness of breath.

In addition, the first course of an inhaled corticosteroid led to a significant reduction in the use of albuterol as a rescue medication. Children in the intervention group had a 43% rate of never using albuterol or using it less than twice during follow-up, compared with 21% having this usage rate among the control children. At the other end of the spectrum, children in the intervention group had a 44% rate of using albuterol either daily or every other day during follow-up, compared with a 65% rate of such heavy use by the control children.

Dr. Sampayo said that she and her associates had no relevant financial disclosures.

PHILADELPHIA – Having emergency physicians start children with persistent asthma on a prescription of an inhaled corticosteroid failed to have a significant impact on the rate at which the families filled a second, follow-up prescription for the same drug from their primary care pediatrician, according to a controlled study with 153 children.

But the study results did show, for the first time in a controlled study of children, that intervention with an inhaled corticosteroid can significantly improve asthma symptoms over the short term, Dr. Esther M. Sampayo said at the annual meeting of the Eastern Society for Pediatric Research.

"National guidelines have recommended that emergency physicians consider initiating control medications [for children with asthma] in the emergency department," she said. When children don’t receive such a prescription, it’s "a missed opportunity for children who are high emergency department utilizers," said Dr. Sampayo, a pediatric emergency physician at Children’s Hospital of Philadelphia.

"We found that at 2 months [after the index emergency department visit], fewer than 20% of children actually filled a second prescription for their control medication," with similar rates in both the control and intervention groups of the study. This level of failure occurred even though when each child received the initial prescription, the researchers told the family to fill a follow-up prescription from the child’s primary care pediatrician, each pediatrician received an alert to write the second prescription, and virtually all the families had public or private insurance that covered the drug’s cost.

"We’re now testing a new intervention, sending parents a text message to remind them to refill their child’s prescription," Dr. Sampayo said in an interview.

The findings also highlighted the important role that emergency physicians can play in starting children on an inhaled corticosteroid. In prior studies, researchers asked emergency physicians why they generally did not start children with poorly controlled asthma on control medication. The physicians said that they didn’t view it as their appropriate role, and that this task was best reserved for primary care physicians. "All the pediatricians in our study said that the emergency department physicians should write the prescription. They want the emergency physician to do it," she said.

The study enrolled children seen in the emergency department of Children’s Hospital of Philadelphia with an average age of 5 years (range, 1-18 years) during 2006-2009. After randomization, the families of 74 children received a starter prescription for a 30-day supply of an inhaled corticosteroid, either budesonide for children aged 4 or younger, or fluticasone for those aged 5 or older, as well as educational materials and other standard discharge medications for asthma. The 78 control families received the same educational materials and discharge medications but no prescription for a corticosteroid.

By 8 weeks after the emergency department visit, about 63% of the intervention families had filled their initial corticosteroid prescription, compared with about 27% of the control families, a statistically significant difference. But the rate at which the intervention families filled the second prescription – the one they had to get from the child’s primary care pediatrician – dropped to roughly 20% of the intervention families, no different from the 18% rate among the control families. The researchers have not yet examined whether the breakdown in follow-up prescriptions occurred at the level of the primary care pediatrician or in the family’s failure to fill a second prescription that they received.

The follow-up data also showed that while on the initial course of an inhaled steroid, the children had, on average, a significant 2-day drop in the number of days they coughed while asleep, and a significant halving of the number of days when they experienced shortness of breath.

In addition, the first course of an inhaled corticosteroid led to a significant reduction in the use of albuterol as a rescue medication. Children in the intervention group had a 43% rate of never using albuterol or using it less than twice during follow-up, compared with 21% having this usage rate among the control children. At the other end of the spectrum, children in the intervention group had a 44% rate of using albuterol either daily or every other day during follow-up, compared with a 65% rate of such heavy use by the control children.

Dr. Sampayo said that she and her associates had no relevant financial disclosures.

PHILADELPHIA – Having emergency physicians start children with persistent asthma on a prescription of an inhaled corticosteroid failed to have a significant impact on the rate at which the families filled a second, follow-up prescription for the same drug from their primary care pediatrician, according to a controlled study with 153 children.

But the study results did show, for the first time in a controlled study of children, that intervention with an inhaled corticosteroid can significantly improve asthma symptoms over the short term, Dr. Esther M. Sampayo said at the annual meeting of the Eastern Society for Pediatric Research.

"National guidelines have recommended that emergency physicians consider initiating control medications [for children with asthma] in the emergency department," she said. When children don’t receive such a prescription, it’s "a missed opportunity for children who are high emergency department utilizers," said Dr. Sampayo, a pediatric emergency physician at Children’s Hospital of Philadelphia.

"We found that at 2 months [after the index emergency department visit], fewer than 20% of children actually filled a second prescription for their control medication," with similar rates in both the control and intervention groups of the study. This level of failure occurred even though when each child received the initial prescription, the researchers told the family to fill a follow-up prescription from the child’s primary care pediatrician, each pediatrician received an alert to write the second prescription, and virtually all the families had public or private insurance that covered the drug’s cost.

"We’re now testing a new intervention, sending parents a text message to remind them to refill their child’s prescription," Dr. Sampayo said in an interview.

The findings also highlighted the important role that emergency physicians can play in starting children on an inhaled corticosteroid. In prior studies, researchers asked emergency physicians why they generally did not start children with poorly controlled asthma on control medication. The physicians said that they didn’t view it as their appropriate role, and that this task was best reserved for primary care physicians. "All the pediatricians in our study said that the emergency department physicians should write the prescription. They want the emergency physician to do it," she said.

The study enrolled children seen in the emergency department of Children’s Hospital of Philadelphia with an average age of 5 years (range, 1-18 years) during 2006-2009. After randomization, the families of 74 children received a starter prescription for a 30-day supply of an inhaled corticosteroid, either budesonide for children aged 4 or younger, or fluticasone for those aged 5 or older, as well as educational materials and other standard discharge medications for asthma. The 78 control families received the same educational materials and discharge medications but no prescription for a corticosteroid.

By 8 weeks after the emergency department visit, about 63% of the intervention families had filled their initial corticosteroid prescription, compared with about 27% of the control families, a statistically significant difference. But the rate at which the intervention families filled the second prescription – the one they had to get from the child’s primary care pediatrician – dropped to roughly 20% of the intervention families, no different from the 18% rate among the control families. The researchers have not yet examined whether the breakdown in follow-up prescriptions occurred at the level of the primary care pediatrician or in the family’s failure to fill a second prescription that they received.

The follow-up data also showed that while on the initial course of an inhaled steroid, the children had, on average, a significant 2-day drop in the number of days they coughed while asleep, and a significant halving of the number of days when they experienced shortness of breath.

In addition, the first course of an inhaled corticosteroid led to a significant reduction in the use of albuterol as a rescue medication. Children in the intervention group had a 43% rate of never using albuterol or using it less than twice during follow-up, compared with 21% having this usage rate among the control children. At the other end of the spectrum, children in the intervention group had a 44% rate of using albuterol either daily or every other day during follow-up, compared with a 65% rate of such heavy use by the control children.

Dr. Sampayo said that she and her associates had no relevant financial disclosures.

PHILADELPHIA – Having emergency physicians start children with persistent asthma on a prescription of an inhaled corticosteroid failed to have a significant impact on the rate at which the families filled a second, follow-up prescription for the same drug from their primary care pediatrician, according to a controlled study with 153 children.

But the study results did show, for the first time in a controlled study of children, that intervention with an inhaled corticosteroid can significantly improve asthma symptoms over the short term, Dr. Esther M. Sampayo said at the annual meeting of the Eastern Society for Pediatric Research.

"National guidelines have recommended that emergency physicians consider initiating control medications [for children with asthma] in the emergency department," she said. When children don’t receive such a prescription, it’s "a missed opportunity for children who are high emergency department utilizers," said Dr. Sampayo, a pediatric emergency physician at Children’s Hospital of Philadelphia.

"We found that at 2 months [after the index emergency department visit], fewer than 20% of children actually filled a second prescription for their control medication," with similar rates in both the control and intervention groups of the study. This level of failure occurred even though when each child received the initial prescription, the researchers told the family to fill a follow-up prescription from the child’s primary care pediatrician, each pediatrician received an alert to write the second prescription, and virtually all the families had public or private insurance that covered the drug’s cost.

"We’re now testing a new intervention, sending parents a text message to remind them to refill their child’s prescription," Dr. Sampayo said in an interview.

The findings also highlighted the important role that emergency physicians can play in starting children on an inhaled corticosteroid. In prior studies, researchers asked emergency physicians why they generally did not start children with poorly controlled asthma on control medication. The physicians said that they didn’t view it as their appropriate role, and that this task was best reserved for primary care physicians. "All the pediatricians in our study said that the emergency department physicians should write the prescription. They want the emergency physician to do it," she said.

The study enrolled children seen in the emergency department of Children’s Hospital of Philadelphia with an average age of 5 years (range, 1-18 years) during 2006-2009. After randomization, the families of 74 children received a starter prescription for a 30-day supply of an inhaled corticosteroid, either budesonide for children aged 4 or younger, or fluticasone for those aged 5 or older, as well as educational materials and other standard discharge medications for asthma. The 78 control families received the same educational materials and discharge medications but no prescription for a corticosteroid.

By 8 weeks after the emergency department visit, about 63% of the intervention families had filled their initial corticosteroid prescription, compared with about 27% of the control families, a statistically significant difference. But the rate at which the intervention families filled the second prescription – the one they had to get from the child’s primary care pediatrician – dropped to roughly 20% of the intervention families, no different from the 18% rate among the control families. The researchers have not yet examined whether the breakdown in follow-up prescriptions occurred at the level of the primary care pediatrician or in the family’s failure to fill a second prescription that they received.

The follow-up data also showed that while on the initial course of an inhaled steroid, the children had, on average, a significant 2-day drop in the number of days they coughed while asleep, and a significant halving of the number of days when they experienced shortness of breath.

In addition, the first course of an inhaled corticosteroid led to a significant reduction in the use of albuterol as a rescue medication. Children in the intervention group had a 43% rate of never using albuterol or using it less than twice during follow-up, compared with 21% having this usage rate among the control children. At the other end of the spectrum, children in the intervention group had a 44% rate of using albuterol either daily or every other day during follow-up, compared with a 65% rate of such heavy use by the control children.

Dr. Sampayo said that she and her associates had no relevant financial disclosures.

PHILADELPHIA – Having emergency physicians start children with persistent asthma on a prescription of an inhaled corticosteroid failed to have a significant impact on the rate at which the families filled a second, follow-up prescription for the same drug from their primary care pediatrician, according to a controlled study with 153 children.

But the study results did show, for the first time in a controlled study of children, that intervention with an inhaled corticosteroid can significantly improve asthma symptoms over the short term, Dr. Esther M. Sampayo said at the annual meeting of the Eastern Society for Pediatric Research.

"National guidelines have recommended that emergency physicians consider initiating control medications [for children with asthma] in the emergency department," she said. When children don’t receive such a prescription, it’s "a missed opportunity for children who are high emergency department utilizers," said Dr. Sampayo, a pediatric emergency physician at Children’s Hospital of Philadelphia.

"We found that at 2 months [after the index emergency department visit], fewer than 20% of children actually filled a second prescription for their control medication," with similar rates in both the control and intervention groups of the study. This level of failure occurred even though when each child received the initial prescription, the researchers told the family to fill a follow-up prescription from the child’s primary care pediatrician, each pediatrician received an alert to write the second prescription, and virtually all the families had public or private insurance that covered the drug’s cost.

"We’re now testing a new intervention, sending parents a text message to remind them to refill their child’s prescription," Dr. Sampayo said in an interview.

The findings also highlighted the important role that emergency physicians can play in starting children on an inhaled corticosteroid. In prior studies, researchers asked emergency physicians why they generally did not start children with poorly controlled asthma on control medication. The physicians said that they didn’t view it as their appropriate role, and that this task was best reserved for primary care physicians. "All the pediatricians in our study said that the emergency department physicians should write the prescription. They want the emergency physician to do it," she said.

The study enrolled children seen in the emergency department of Children’s Hospital of Philadelphia with an average age of 5 years (range, 1-18 years) during 2006-2009. After randomization, the families of 74 children received a starter prescription for a 30-day supply of an inhaled corticosteroid, either budesonide for children aged 4 or younger, or fluticasone for those aged 5 or older, as well as educational materials and other standard discharge medications for asthma. The 78 control families received the same educational materials and discharge medications but no prescription for a corticosteroid.

By 8 weeks after the emergency department visit, about 63% of the intervention families had filled their initial corticosteroid prescription, compared with about 27% of the control families, a statistically significant difference. But the rate at which the intervention families filled the second prescription – the one they had to get from the child’s primary care pediatrician – dropped to roughly 20% of the intervention families, no different from the 18% rate among the control families. The researchers have not yet examined whether the breakdown in follow-up prescriptions occurred at the level of the primary care pediatrician or in the family’s failure to fill a second prescription that they received.

The follow-up data also showed that while on the initial course of an inhaled steroid, the children had, on average, a significant 2-day drop in the number of days they coughed while asleep, and a significant halving of the number of days when they experienced shortness of breath.

In addition, the first course of an inhaled corticosteroid led to a significant reduction in the use of albuterol as a rescue medication. Children in the intervention group had a 43% rate of never using albuterol or using it less than twice during follow-up, compared with 21% having this usage rate among the control children. At the other end of the spectrum, children in the intervention group had a 44% rate of using albuterol either daily or every other day during follow-up, compared with a 65% rate of such heavy use by the control children.

Dr. Sampayo said that she and her associates had no relevant financial disclosures.