Publications by authors named "Pavadee Poowuttikul"

17 Publications

  • Page 1 of 1

Approach to Children with Hives.

Pediatr Ann 2021 May 1;50(5):e191-e197. Epub 2021 May 1.

Urticaria (or hives) is a pruritic and erythematous skin rash. Angioedema commonly occurs with urticaria. The term "chronic urticaria" is used when hives are present for more than 6 weeks. Acute urticaria is common in children, whereas chronic urticaria is rare. Causes of urticaria can be identified in many cases of acute urticaria with a thorough medical history. Laboratory evaluation may be needed to confirm the etiology of acute urticaria. Chronic urticaria is often idiopathic. Clinicians should avoid universal allergy testing for food allergens or aeroallergens in chronic urticaria as it usually does not help in identifying the cause, can lead to false-positive results, and unnecessary avoidance of allergens or foods. Urticarial vasculitis should be considered for lesions that are painful, present for more than 48 hours, leave scars/hyperpigmentation, or present with systemic symptoms such as fever, weight loss, and arthritis. Skin biopsy should be considered for suspected urticarial vasculitis. .
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http://dx.doi.org/10.3928/19382359-20210422-02DOI Listing
May 2021

Allergic Broncho-Pulmonary Aspergillosis.

Pediatr Ann 2021 May 1;50(5):e214-e221. Epub 2021 May 1.

Allergic broncho-pulmonary aspergillosis (ABPA) is an immunologically mediated lung disease that usually occurs in people with a diagnosis of asthma or cystic fibrosis. It is a noninvasive lung disease caused by colonization of the airways with . In people who are susceptible, leads to an exaggerated immune response and ultimately pulmonary inflammation and lung damage. Patients with ABPA typically present with poorly controlled asthma, recurrent pulmonary infiltrates, and bronchiectasis. Diagnosis of ABPA is established based on a combination of clinical manifestations as well as laboratory and radiological evaluations. Delay in diagnosis can result in airway destruction and pulmonary fibrosis, which may result in significant morbidity and mortality. This article discusses the clinical characteristics, diagnosis, and management of patients with ABPA. It aims to serve as a tool for pediatricians to aid in early recognition of this debilitating disease and consider referral, facilitating early diagnosis and treatment. .
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http://dx.doi.org/10.3928/19382359-20210421-01DOI Listing
May 2021

Treatment for Severe Asthma in Children: What About Biologics?

Pediatr Ann 2021 May 1;50(5):e206-e213. Epub 2021 May 1.

Asthma is the most common pulmonary disease in children age 5 to 17 years. Asthma is characterized by chronic airway inflammation and heterogeneous clinical phenotypes. A small proportion of patients (approximately 5% to 10%) diagnosed with severe asthma are unable to achieve asthma control even with intensive therapy. Severe asthma in children is characterized by poor asthma control, uncontrolled symptoms, poor quality of life, disrupted school-related activities and increased risk of exacerbations, health care use, and morbidities due to asthma. Several new biologic agents targeting the mediators of asthma inflammation that are now approved are likely to improve asthma outcomes in children with severe asthma. This article outlines the various biologic agents currently approved for use in children. .
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http://dx.doi.org/10.3928/19382359-20210420-01DOI Listing
May 2021

Contact Dermatitis in Children.

Pediatr Ann 2021 May 1;50(5):e198-e205. Epub 2021 May 1.

Contact dermatitis (CD) is commonly encountered in the pediatric population. Allergic and irritant are the two forms of CD and both cause significant clinical problems in children, but they are often underrecognized. The skin lesions in CD may be polymorphic and closely mimic other common pediatric skin diseases. The diagnosis usually requires patch testing after obtaining a detailed history and performing a physical examination. Metals, fragrances, and certain preservatives are the most common causative agents in children. This article discusses the pathophysiology, diagnosis, and management of this common skin condition in the pediatric population. .
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http://dx.doi.org/10.3928/19382359-20210418-01DOI Listing
May 2021

Are primary care physicians following National Institute of Allergy and Infectious Disease guidelines for the prevention of peanut allergy? A survey-based study.

Allergy Asthma Proc 2020 05;41(3):167-171

Division of Allergy and Immunology, University of Michigan, Ann Arbor, Michigan, and.

The 2017 addendum to the National Institute of Allergy and Infectious Diseases (NIAID) guidelines on peanut allergy prevention significantly altered recommendations for patients at risk of developing peanut allergies. It is unknown if primary care physicians are aware of or are following these guidelines. To assess the knowledge and practice of the NIAID guidelines among primary care physicians. A survey was developed to assess the knowledge, awareness, and practice behaviors of the NIAID guidelines. It was distributed to pediatric, family medicine, and medicine-pediatric residents and attending physicians at two large academic centers. Responses were analyzed with binary logistic regression. The survey was distributed to 605 providers, with a response rate of 35% ( = 210). The average score was 4.8 of seven questions answered correctly. Of the participants, 53% incorrectly recommended at-home peanut introduction in patients with egg allergy. In addition, 40% of the participants incorrectly believed that the earliest age for peanut introduction was >1 year of age. More than half of the participants were unaware of the new guidelines. On logistic regression, factors associated with adequate knowledge assessment scores were awareness of the guidelines (odds ratio [OR] 2.98 [confidence interval {CI}, 1.34-6.60]), graduation from residency within 5 years (OR 3.60 [95% CI, 1.14-11.35]), and affiliation with the medicine-pediatrics department (OR 4.59 [95% CI, 1.07-19.65]). The primary care providers incorrectly answer one-third of the questions related to the prevention of peanut allergy. Increasing awareness of the 2017 NIAID guidelines may provide an opportunity to improve patient outcomes. There is an urgent need to develop innovative education strategies to publicize these guidelines.
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http://dx.doi.org/10.2500/aap.2020.41.200019DOI Listing
May 2020

New Concepts and Technological Resources in Patient Education and Asthma Self-Management.

Clin Rev Allergy Immunol 2020 Aug;59(1):19-37

Department of Pediatrics, Division of Allergy/Immunology, Children's Hospital of Michigan, Wayne State University School of Medicine, 3950 Beaubien, 4th Floor, Pediatric Specialty Building, Detroit, MI, 48201, USA.

Asthma is a chronic disease that is associated with significant morbidity and mortality. In general, the use of technology resources or electronic health (e-health) has been shown to have beneficial effects on patients with asthma. E-health can impact a broad section of patients and can be cost-effective and associated with high patient satisfaction. E-health may enable remote delivery of care, as well as timely access to health care, which are some of the common challenges faced by patients with asthma. Web-based asthma self-management systems have been found to improve quality of life, self-reported asthma symptoms, lung function, reduction in asthma symptoms/exacerbations, and self-reported adherence for adults. Social media is commonly being used as a platform to disseminate information on asthma to increase public awareness. It can facilitate asthma self-management in a patient friendly manner and has shown to improve asthma control test scores as well as self-esteem. Text massages reminders can increase awareness regarding asthma treatment and control, thus potentially can improve adherence to medications and asthma outcome. Mobile health applications can support asthma self-management, improve a patient's quality of life, promote medication adherence, and potentially reduce the overall costs for asthma care. Inhaler trackers have shown to be beneficial to asthma outcome in various populations by improving adherence to asthma medications. Barriers such as physician financial reimbursement as well as licensing for rendering tele-healthcare services are important concerns. Other limitations of using technology resources in health care are related to liability, professionalism, and ethical issues such as breach of patient confidentiality and privacy. Additionally, there may be less face-to-face interaction and care of the patient when e-health is used.
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http://dx.doi.org/10.1007/s12016-020-08782-wDOI Listing
August 2020

T Cell Profile After Systemic Steroid Burst in Inner-City Asthmatic Children with Recurrent Infections.

Pediatr Allergy Immunol Pulmonol 2019 Jun 17;32(2):56-62. Epub 2019 Jun 17.

Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michigan.

Systemic corticosteroids are the standard of care for acute asthma exacerbation. Respiratory infections are known as common triggers of asthma exacerbation, but the risk of immune suppression from frequent periodic use of systemic steroids in poorly controlled asthmatic children is not well studied. We conducted a retrospective chart review of 26 children, 3-15 years old with poorly controlled, moderate-to-severe persistent asthma who received ≥2 systemic corticosteroid/year. The data collected include absolute T cell, B cell, and natural killer (NK) cell counts; lymphocyte proliferation studies to phytohemagglutinin (PHA), concanavalin A (CON A), and pokeweed mitogen; immunoglobulin G and M; and antibody titers to tetanus, diphtheria, and pneumococcus. Frequency tables and crosstabs were used to analyze the data. Low CD4 T cell counts were found in 47.8% of the patients, and 45.8% had low CD3 T cell counts. The lymphocyte proliferation studies data exhibited variability, but 21.4%-75% of the subjects who demonstrated normal T cell counts had decreased lymphocyte proliferation studies to PHA and CON A. All the patients had normal immunoglobulins, B cell, and NK cell counts. All but 1 patient had adequate antibody responses to . Frequent systemic corticosteroid use may suppress T cell number and function in asthmatic children. This can potentially lead to increase susceptibility for future infections and asthma exacerbations. Depressed lymphocyte proliferations are observed even in patients who demonstrated normal T cell counts. This emphasizes the importance of adherence to asthma controller medications, and control of asthma triggers, to limit the frequency of steroid use.
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http://dx.doi.org/10.1089/ped.2018.0988DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6733054PMC
June 2019

Anaphylaxis in Children and Adolescents.

Pediatr Clin North Am 2019 10 5;66(5):995-1005. Epub 2019 Aug 5.

Children's Hospital of Michigan, Wayne State University School of Medicine, 3950 Beaubien, Detroit, MI 48201, USA.

Anaphylaxis is an acute, potentially life-threatening systemic hypersensitivity reaction. Classically, anaphylaxis is an immunoglobulin (Ig) E-mediated reaction; however, IgG or immune complex complement-related immunologic reactions that lead to degranulation of mast cells can also cause anaphylaxis. Food allergy is the most common cause of anaphylaxis, followed by drugs. Patients with anaphylaxis commonly present with symptoms involving skin or mucous membranes, followed by respiratory and gastrointestinal symptoms. Epinephrine is the drug of choice for treating anaphylaxis. Patients and caregivers should be educated on the use of epinephrine autoinjectors with periodic review of symptoms and emergency action plan for anaphylaxis.
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http://dx.doi.org/10.1016/j.pcl.2019.06.005DOI Listing
October 2019

Pediatric Inner-City Asthma.

Pediatr Clin North Am 2019 10 5;66(5):967-979. Epub 2019 Aug 5.

Division of Allergy/Immunology, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA.

Inner-city children with asthma are known to have high disease mortality and morbidity. Frequently, asthma in this high-risk population is difficult to control and more severe in nature. Several factors, including socioeconomic hardship, ability to access to health care, adherence to medication, exposure to certain allergens, pollution, crowd environment, stress, and infections, play an important role in the pathophysiology of inner-city asthma. Comprehensive control of home allergens and exposure to tobacco smoke, the use of immune based therapies, and school-based asthma programs have shown promising results in asthma control in this population.
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http://dx.doi.org/10.1016/j.pcl.2019.06.012DOI Listing
October 2019

Humoral Immune Deficiencies of Childhood.

Pediatr Clin North Am 2019 10;66(5):897-903

Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, 3950 Beaubien Boulevard, Detroit, MI 48201, USA. Electronic address:

The most common primary immune deficiencies are those of the humoral immune system, and most of these present in childhood. The severity of these disorders ranges from transient deficiencies to deficiencies that are associated with a complete loss of ability to make adequate or functional antibodies, and have infectious as well as noninfectious complications. This article reviews, in a case-based discussion, the most common of the humoral immune deficiencies; their presentations, diagnoses, treatments; and, when known, the genetic defects.
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http://dx.doi.org/10.1016/j.pcl.2019.06.010DOI Listing
October 2019

Inner-City Asthma in Children.

Clin Rev Allergy Immunol 2019 Apr;56(2):248-268

Division of Allergy/Immunology, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3950 Beaubien, 4th Floor, Pediatric Specialty Building, Detroit, MI, 48201, USA.

Asthma in inner-city children is often severe and difficult to control. Residence in poor and urban areas confers increased asthma morbidity even after adjusting for ethnicity, age, and gender. Higher exposure to household pests, such as cockroaches and mice, pollutants and tobacco smoke exposure, poverty, material hardship, poor-quality housing, differences in health care quality, medication compliance, and heath care access also contribute to increased asthma morbidity in this population. Since 1991, the National Institutes of Allergy and Infectious Diseases established research networks: the National Cooperative Inner-City Asthma Study (NCICAS), the Inner-City Asthma Study (ICAS), and the Inner-City Asthma Consortium (ICAC), to improve care for this at risk population. The most striking finding of the NCICAS is the link between asthma morbidity and the high incidence of allergen sensitization and exposure, particularly cockroach. The follow-up ICAS confirmed that reductions in household cockroach and dust mite were associated with reduction in the inner-city asthma morbidity. The ICAC studies have identified that omalizumab lowered fall inner-city asthma exacerbation rate; however, the relationship between inner-city asthma vs immune system dysfunction, respiratory tract infections, prenatal environment, and inner-city environment is still being investigated. Although challenging, certain interventions for inner-city asthma children have shown promising results. These interventions include family-based interventions such as partnering families with asthma-trained social workers, providing guidelines driven asthma care as well as assured access to controller medication, home-based interventions aim at elimination of indoor allergens and tobacco smoke exposure, school-based asthma programs, and computer/web-based asthma programs.
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http://dx.doi.org/10.1007/s12016-019-08728-xDOI Listing
April 2019

Poor Adherence With Medication Refill and Medical Supplies Maintenance as Risk Factors for Inpatient Asthma Admission in Children.

Glob Pediatr Health 2017 30;4:2333794X17710588. Epub 2017 May 30.

Wayne State University, Detroit, MI, USA.

Asthma results in significant pediatric hospitalizations in the inner city. Many asthmatic children were admitted to our hospital as a result of lack of medications or medical supplies that had been previously prescribed ("ran out," "broken," or "lost"). To identify the incidence of children admitted for asthma because of lack of prescribed medications/supplies and to assess risk factors for poor adherence between groups. This was a prospective chart review of 200 asthmatic children admitted to Children's Hospital of Michigan, Detroit. The data included asthma severity, lack of prescribed medications/medical supplies, and outpatient management. In all, 35.5% or 71/200 of asthmatic children admitted had lack of prescribed medication/supplies (9% lacked both). The most common deficiency was β2-agonist (20.5%; 41/200). Teenagers had the highest lack of medications/medical supplies (55.6%; 5/9) compared with toddlers (17.2%; 16/93) and preschoolers (17.9%; 5/28). Patients with severe persistent asthma had a higher incidence of lacking medicine (31.8%; 7/22) compared with 25% (14/56) with moderate persistent asthma and 23.4% (15/64) of mild asthmatics. We found the lack of asthma medical supplies, including nonfunctioning or lost nebulizers/spacers, in 44.4% (4/9) of teenagers, 17.2% (16/93) of toddlers, and 21.4% (6/28) of preschool-aged children. We found no significant difference in these deficiencies whether patients were managed by asthma specialists or primary care providers. Significant numbers of asthmatic children admitted reported lack of prescribed medications/medical supplies. The most severe asthmatics were most likely to run out of medications. Interventions targeted at these deficiencies may avoid hospitalizations.
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http://dx.doi.org/10.1177/2333794X17710588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5453628PMC
May 2017

Pneumococcal Antibody Titers: A Comparison of Patients Receiving Intravenous Immunoglobulin Versus Subcutaneous Immunoglobulin.

Glob Pediatr Health 2017 21;4:2333794X16689639. Epub 2017 Feb 21.

Children's Hospital of Michigan, Detroit MI, USA; Wayne State University, Detroit, MI, USA.

Immunoglobulin replacement is the mainstay treatment in patients with humoral immunodeficiencies, yet a handful of patients continue to develop sinopulmonary infections while on therapy. The objective of our study was to compare immunoglobulin G (IgG) pneumococcal antibody levels in patients with humoral immune deficiencies who have been on intravenous immunoglobulin (IVIG) replacement for at least 1 year to those on subcutaneous immunoglobulin (SCIG) therapy for at least 1 year. A retrospective chart review was completed on 28 patients. These patients' ages ranged between 1 and 61 years. Pneumococcal serotype titers obtained at least 1 year after initiating therapy were compared between patients on IVIG (19 patients) and SCIG (9 patients). A comparison between the groups demonstrated that SCIG achieved a higher percentage of serotype titers protective for noninvasive disease (≥1.3) and 100% protection for invasive disease (≥0.2). Our data also demonstrated a similar lack of protection (less than 50% ≥1.3) in 9N, 12F, and 23F on IVIG and 4, 9N, 12F, and 23F on SCIG. Our data demonstrated that serotypes 1, 3, 4, 9N, 12F, and 23F exhibited the lowest random IgG means while on IVIG, which was comparable to other published studies that looked at the mean IgG levels. In addition, our retrospective chart review demonstrated a greater number of therapeutic pneumococcal titers with SCIG in comparison to IVIG.
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http://dx.doi.org/10.1177/2333794X16689639DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5347419PMC
February 2017

Deficit of Anterior Pituitary Function and Variable Immune Deficiency Syndrome: A Novel Mutation.

Glob Pediatr Health 2017 27;4:2333794X16686870. Epub 2017 Jan 27.

Children's Hospital of Michigan, Detroit, MI, USA; Wayne State University, Detroit, MI, USA.

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http://dx.doi.org/10.1177/2333794X16686870DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5308421PMC
January 2017

Naturalistically observed conflict and youth asthma symptoms.

Health Psychol 2015 Jun 15;34(6):622-31. Epub 2014 Sep 15.

Department of Psychology, Wayne State University.

Objective: To investigate the links between naturalistically observed conflict, self-reported caregiver-youth conflict, and youth asthma symptoms.

Method: Fifty-four youth with asthma (age range: 10-17 years) wore the Electronically Activated Recorder (EAR) for a 4-day period to assess interpersonal conflict and caregiver-youth conflict as they occur in daily life. Conflict also was assessed with baseline self-report questionnaires and daily diaries completed by youth participants and their caregivers. Asthma symptoms were assessed using daily diaries, baseline self-reports, and wheezing, as coded from the EAR.

Results: EAR-observed measures of conflict were strongly associated with self-reported asthma symptoms (both baseline and daily diaries) and wheezing coded from the EAR. Further, when entered together in regression analyses, youth daily reports of negative caregiver-youth interactions and EAR-observed conflict uniquely predicted asthma symptoms; only EAR-observed conflict was associated with EAR-observed wheezing.

Conclusion: These findings demonstrate the potential impact of daily conflict on youth asthma symptoms and the importance of assessing conflict as it occurs in everyday life. More broadly, they point to the importance of formulating a clear picture of family interactions outside of the lab, which is essential for understanding how family relationships "get under the skin" to affect youth health.
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http://dx.doi.org/10.1037/hea0000138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4362935PMC
June 2015

Vitamin D Insufficiency/Deficiency in HIV-Infected Inner City Youth.

J Int Assoc Provid AIDS Care 2014 Sep-Oct;13(5):438-42. Epub 2013 Jul 23.

Division of Allergy/Immunology, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA.

Background: High prevalence of vitamin D deficiency among HIV-infected individuals has been reported in many studies. Increasing evidence for vitamin D's role in innate and cell-mediated immunity suggests that vitamin D insufficiency or deficiency is worrisome particularly for HIV-infected individuals who are already at increased risk of infection. It is unknown whether vitamin D deficiency and supplementation will have any effects on HIV infection, including CD4 counts/CD4% and HIV plasma RNA.

Method: Serum vitamin D levels, 25-hydroxyvitamin D (25-(OH)D), were obtained from 160 HIV-infected youth, aged 2 to 26 years as part of routine care. The HIV plasma RNA and CD4 counts were compared between patients with normal vitamin D and vitamin D insufficiency/deficiency. Individuals whose vitamin D level was ≤35 ng/mL received vitamin D3 supplementation. We compared the HIV plasma RNA, absolute CD4 counts, and CD4% in pre- and post-vitamin D supplementation. Categorical comparisons between the groups were examined using a nonparametric Fisher exact test, while continuous variables, pre- and post-vitamin D supplementation, were examined using a parametric paired samples t test.

Results: The majority (152 of 160; 95%) of our patients were African American. Only 8 (5%) of 160 had normal vitamin D. Of the 160 patients with HIV, 37 (23.1%) had vitamin D insufficiency (25-(OH)D level between 21 and 35 ng/mL) and 11 of 160 (71.9%) had vitamin D deficiency (25-(OH)D level ≤20 ng/mL). Absolute CD4 counts averaged lower in patients who have severe vitamin D deficiency (25-(OH)D ≤10 ng/mL; mean 574.41 ± 306.17 cells/mm(3)) compared to those who had higher vitamin D level (mean 701.15 ± 444.19 cells/mm(3)). The CD4% were also lower (mean 25.12% ± 12.5%) in those who have severe vitamin D deficiency compared to those whose vitamin D level was ≥11 ng/mL (mean 29.47% ± 11.62%). The HIV plasma RNA was similar in all the groups. Our patients who were prescribed tenofovir (TDF) and/or efavirenz (EFV) did not have different vitamin D levels than patients who were prescribed other antiretroviral (ARV) medications. Only 60 (39.5%) of the 152 patients who received vitamin D supplement showed improvement in vitamin D level. Of the 60 patients, 10 (16.7%) had normalized vitamin D level (25-(OH)D level > 35 ng/mL). We did not see any significant change in the absolute CD4 counts or CD4%.

Conclusions: A higher prevalence of vitamin D insufficiency/deficiency was found in our study compared to the previous large cohorts. However, patients who were prescribed TDF/EFV did not have lower vitamin D levels. Inadequate sunlight exposure in temperate latitudes and the cloud effect of the Great Lakes as well as large number of African American participants who live in the inner city area with poverty and poor diet may combine to explain these results. The effect of ARV medications on vitamin D may be washed out by the numerous other factors affecting vitamin D in our patients. Severe vitamin D deficiency seemed to be related to lower CD4 counts and CD4% but not related to HIV plasma RNA. Vitamin D supplementation did not increase CD4 counts/CD4% in our study.
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http://dx.doi.org/10.1177/2325957413495566DOI Listing
January 2018

Asthma consultations with specialists: what do the pediatricians seek?

Allergy Asthma Proc 2011 Jul-Aug;32(4):307-12

The Carman and Ann Adams, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, USA.

"Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma" includes guidelines for referral to an asthma specialist. Because most cases of asthma are managed by primary care physicians, we intended to explore the referral practices of pediatricians managing childhood asthma. This study was designed to identify important considerations by pediatricians while referring a child to an asthma specialist. An electronic survey was sent to 1200 graduated pediatricians enlisted in the Michigan Chapter, American Academy of Pediatrics directory. The questions explored asthma disease characteristics, physician preferences when referring children with asthma, and reasons and barriers for asthma consultations. All responses were collected anonymously. We received 240/1200 (20%) questionnaires. The majority of pediatricians considered referral to a specialist if a child had severe persistent asthma (201/236 [85.2%]) or had a single life-threatening asthma event (188/229 [82.1%]). The top two likely reasons of referral included poor asthma control (200/224 [89.3%]) and unclear diagnosis (139/224 [62.1%]). We found 74/219 (33.8%) preferred consultation to a pediatric pulmonologist when compared with 93/219 (42.5%) allergists. We found the minority of pediatricians "always" recommended referral to a specialist for the following reasons: allergy skin testing (30/222 [13.5%]), possible allergen immunotherapy (54/223 [24.2%]), and spirometry (26/221 [11.8%]). The major barrier for childhood asthma specialist consultations was issues with medical insurance coverage (137/205 [66.8%]). Allergists have to educate primary care providers about the importance of allergen control, role of allergen immunotherapy, and updating current asthma treatment guidelines when treating a child with allergic asthma.
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http://dx.doi.org/10.2500/aap.2011.32.3445DOI Listing
November 2011
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