Key Point:

The asthma rate among homeless children is 40%—six times the national rate. Most homeless children with asthma do not receive appropriate treatment.

NEW YORK CITY—It is well known that asthma disproportionately affects children of color and those whose families have limited financial resources. New research suggests that an oft-ignored and understudied subgroup of the poor—homeless children—have asthma rates that are six times the national rate.[1] Yet, many of these children have received no treatment for their asthma symptoms.

According to Diane E. McLean, MD, PhD, MPH, lead author of the study, asthma prevalence is markedly higher among homeless children than among other poor children. She attributes this higher rate to a number of factors, including the stress of homelessness itself.

PREVALENCE HIGH

Dr. McLean and colleagues evaluated 740 children whose families entered any of three shelters for homeless families during one 15-month period. The children’s parents completed a one-page survey that inquired about demographic characteristics; their child’s daytime and nighttime symptoms; and whether the child had a physician diagnosis of asthma, was taking any medications, or had visited an emergency department (ED) for asthma within the past year. Most (90.2%) of the families were headed by single parents. More than half of the children were black, and 44% were younger than 5.

Just under 40% of the children had evidence of asthma. Twenty-seven percent had been given a physician diagnosis of asthma at some point in their lives. Another 13% had current symptoms consistent with moderate to severe persistent asthma; 10% had milder disease. To derive a conservative estimate of asthma prevalence, the investigators excluded the children with milder disease; the resulting estimate—40%—was nonetheless higher than had been anticipated.

To exclude the possibility that respiratory tract infections contributed to the high asthma rate, Dr. McLean and colleagues performed a separate analysis of 372 children who entered the shelters during the summer months. Asthma prevalence among these children was similar to that observed in the study overall.

WHY SO HIGH?

Asthma is common in poor children, said Dr. McLean, a postgraduate residency fellow at Columbia University and the New York State Psychiatric Institute, because many live in substandard housing with high exposures to allergens and cigarette smoke. They also are not likely to have an ongoing relationship with a primary health care provider. However, stress may be another important culprit, said Dr. McLean. “Homeless children are exposed to high levels of stress because of the situations that make their families homeless,” she explained. “Stress affects them physiologically, by exacerbating inflammation, and behaviorally, because stress is likely to render the children and adults unable to manage the asthma appropriately.”

Dr. McLean believes that the parents can be taught to do some things to manage their children’s asthma, even within the context of their homelessness. “The most important thing a parent can do is establish a relationship with a primary care provider.” Parents can also be taught to identify the early symptoms of an asthma exacerbation and to understand asthma triggers. In addition to allergens, “triggers also include psychosocial trauma, stress, and depression,” Dr. McLean emphasized. Once the triggers are identified, at least some can be avoided by following steps in an asthma management plan worked out with the primary care provider.

UNDERTREATMENT: AN EPIDEMIC

More than 40% of the children with asthma were not using any asthma medications. Furthermore, the majority of those who did use such medications had prescriptions for bronchodilators only. Inhaled corticosteroids or other anti-inflammatory drugs were being used by only 8% of the children with mild persistent asthma, 12% of those with moderate asthma, and 10% of those with severe disease.

Despite the fact that 100% of the homeless children were eligible for Medicaid, most relied on the ED for treatment. Almost half of the study children with severe asthma had visited the ED at least once in the previous year. Perhaps the most important factor behind the undertreatment is that most of the children lacked a primary health care provider. “ED management is appropriate for acute exacerbations,” explained Dr. McLean, “but not for chronic asthma, which needs to be treated in an ongoing fashion.”

Another reason underlying this problem is that “there is misperception of the child’s symptoms from parents and providers,” asserted Dr. McLean. “Parents don’t recognize night symptoms as part of asthma. ED providers often don’t ask about these symptoms, which are a powerful indicator of severity.” Consequently, the children do not receive the appropriate medication to control their disease.

There are some things that ED physicians can do to treat homeless children’s asthma properly and to facilitate continuity of care. Perhaps most importantly, said Dr. McLean, is that ED physicians can connect the family to a source of primary care. “The parent needs to realize that asthma is chronic and requires ongoing care.” ED physicians can also take a more detailed history so that asthma severity is staged appropriately and thus treated according to guidelines. In addition, Dr. McLean emphasized the importance of communicating the severity to the parent.

WHAT ELSE CAN BE DONE?

Dr. McLean and her team also advocate screening children for asthma upon intake to homeless shelters. “Screening is simple, brief, and effective,” stated Dr. McLean. “It doesn’t diagnose asthma, but it identifies children at risk of having it.” Homeless children can be rescreened periodically because asthma varies according to season and can develop at any age.

Although Dr. McLean and colleagues have no new studies planned yet, they have an ongoing program, the Childhood Asthma Initiative, which provides medical care, psychosocial intervention, and education for homeless children and their families. Because the stress of being homeless is strongly related to asthma severity, it requires further study so that interventions can be tested. “If we only focus on allergies and irritants, we may be missing half of the picture,” Dr. McLean cautioned. “Depression, anxiety, and asthma are all treatable. We need to identify and treat the factors related to asthma because doing so can alter the disease.”

—Tamara Gibb

Reference
1. McLean DE, Bowen S, Drezner K, et al. Asthma among homeless children. Arch Pediatr Adolesc Med. 2004;158: 244-249.

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