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Introduction: Asthma is the most common chronic disease among children. Asthma Action Plans (AAPs) enable asthma self-management tailored to each patient and should be updated annually. At our institution, providers face challenges in creating reliable processes to consistently complete AAPs for patients with asthma. This project's aim was to increase the percentage of patients across five hospital divisions who have an up-to-date AAP from 80% in May 2021 to 85% by October 1, 2021., Methods: We launched a quality improvement (QI) project using the Model for Improvement, focusing on improving AAP completion rates across five hospital divisions providing ambulatory care for asthma patients. The divisions (Adolescent/Young Adult Medicine, Allergy, Pulmonary, and two Primary Care sites) participated in the QI process using tools to understand the problem context. They implemented a cross-divisional AAP completion competition from June to October 2021. Each month during Action Periods, divisions trialed their interventions using Plan-Do-Study-Act cycles. We held monthly Learning Sessions for divisions to collaborate on successful intervention strategies., Results: Statistical process control chart analysis demonstrated that the overall AAP completion rate increased from a baseline of 80% to 87% with the initiation of the competition. All divisions showed improvement in AAP completion rates during the active intervention period, but sustainment varied., Conclusions: The cross-divisional competition motivated five divisions to improve processes to increase AAP completion rates. This approach effectively fostered engagement and idea sharing to boost performance, and may be considered for other QI projects., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: School classrooms, where students spend the majority of their time during the day, are the second most important indoor microenvironment for children., Objective: We investigated factors influencing classroom exposures to fine particulate matter ( PM 2.5 ), black carbon (BC), and nitrogen dioxide ( NO 2 ) in urban schools in the northeast United States., Methods: Over the period of 10 y (2008-2013; 2015-2019) measurements were conducted in 309 classrooms of 74 inner-city schools during fall, winter, and spring of the academic period. The data were analyzed using adaptive mixed-effects least absolute shrinkage and selection operator (LASSO) regression models. The LASSO variables included meteorological-, school-, and classroom-based covariates., Results: LASSO identified 10, 10, and 11 significant factors ( p < 0.05 ) that were associated with indoor PM 2.5 , BC, and NO 2 exposures, respectively. The overall variability explained by these models was R 2 = 0.679 , 0.687, and 0.621 for PM 2.5 , BC, and NO 2 , respectively. Of the model's explained variability, outdoor air pollution was the most important predictor, accounting for 53.9%, 63.4%, and 34.1% of the indoor PM 2.5 , BC, and NO 2 concentrations. School-based predictors included furnace servicing, presence of a basement, annual income, building type, building year of construction, number of classrooms, number of students, and type of ventilation that, in combination, explained 18.6%, 26.1%, and 34.2% of PM 2.5 , BC, and NO 2 levels, whereas classroom-based predictors included classroom floor level, classroom proximity to cafeteria, number of windows, frequency of cleaning, and windows facing the bus area and jointly explained 24.0%, 4.2%, and 29.3% of PM 2.5 , BC, and NO 2 concentrations, respectively., Discussion: The adaptive LASSO technique identified significant regional-, school-, and classroom-based factors influencing classroom air pollutant levels and provided robust estimates that could potentially inform targeted interventions aiming at improving children's health and well-being during their early years of development. https://doi.org/10.1289/EHP10007.

Introduction: Almost half of all school-age children with bronchopulmonary dysplasia (BPD) have asthma-like symptoms and more suffer from lung function deficits. While air pollution and indoor respiratory irritants are known to affect high-risk populations of children, few studies have objectively evaluated environmental contributions to long-term respiratory morbidity in this population. This study aimed to examine the role of indoor environmental exposures on respiratory morbidity in children with BPD., Methods and Analysis: The Air quality, Environment and Respiratory Ouctomes in BPD (AERO-BPD) study is a prospective, single-centre observational study that will enrol a unique cohort of 240 children with BPD and carefully characterise participants and their indoor home environmental exposures. Measures of indoor air quality constituents will assess the relationship of nitrogen dioxide (NO 2 ), particulate matter (PM 2.5 ), nitric oxide (NO), temperature and humidity, as well as dust concentrations of allergens, with concurrently measured respiratory symptoms and lung function.Adaptations to the research protocol due to the SARS-CoV-2 pandemic included remote home environment and participant assessments., Ethics and Dissemination: Study protocol was approved by the Boston Children's Hospital Committee on Clinical Investigation. Dissemination will be in the form of peer-reviewed publications and participant information products., Trial Registration Number: NCT04107701., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Survivors of prematurity are at risk for abnormal childhood lung function. Few studies have addressed trajectories of lung function and risk factors for abnormal growth in childhood. This study aims to describe changes in lung function in a contemporary cohort of children born preterm followed longitudinally in pulmonary clinic for post-prematurity respiratory disease and to assess maternal and neonatal risk factors associated with decreased lung function trajectories., Methods: Observational cohort of 164 children born preterm ≤ 32 weeks gestation followed in pulmonary clinic at Boston Children's Hospital with pulmonary function testing. We collected demographics and neonatal history. We used multivariable linear regression to identify the impact of neonatal and maternal risk factors on lung function trajectories in childhood., Results: We identified 264 studies from 82 subjects with acceptable longitudinal FEV 1 data and 138 studies from 47 subjects with acceptable longitudinal FVC and FEV 1 /FVC data. FEV 1 % predicted and FEV 1 /FVC were reduced compared to childhood norms. Growth in FVC outpaced FEV 1 , resulting in an FEV 1 /FVC that declined over time. In multivariable analyses, longer duration of mechanical ventilation was associated with a lower rate of rise in FEV 1 % predicted and greater decline in FEV 1 /FVC, and postnatal steroid exposure in the NICU was associated with a lower rate of rise in FEV 1 and FVC % predicted. Maternal atopy and asthma were associated with a lower rate of rise in FEV 1 % predicted., Conclusions: Children with post-prematurity respiratory disease demonstrate worsening obstruction in lung function throughout childhood. Neonatal risk factors including exposure to mechanical ventilation and postnatal steroids, as well as maternal atopy and asthma, were associated with diminished rate of rise in lung function. These results may have implications for lung function trajectories into adulthood.

Children spend over 6 h a day in schools and have higher asthma morbidity from school environmental exposures. The present study aims to determine indoor and outdoor possible sources affecting indoor PM 2.5 in classrooms. Weeklong indoor PM 2.5 samples were collected from 32 inner-city schools from a Northeastern U.S. community during three seasons (fall, winter and spring) during the years 2009 to 2013. Concurrently, daily outdoor PM 2.5 samples were taken at a central monitoring site located at a median distance of 4974 m (range 1065-11,592 m) from the schools. Classroom indoor concentrations of PM 2.5 (an average of 5.2 μg/m 3 ) were lower than outdoors (an average of 6.5 μg/m 3 ), and these averages were in the lower range compared to the findings in other schools' studies. The USEPA PMF model was applied to the PM 2.5 components measured simultaneously from classroom indoor and outdoor to estimate the source apportionment. The major sources (contributions) identified across all seasons of indoor PM 2.5 were secondary pollution (41%) and motor vehicles (17%), followed by Calcium (Ca)-rich particles (12%), biomass burning (15%), soil dust (6%), and marine aerosols (4%). Likewise, the major sources of outdoor PM 2.5 across all seasons were secondary pollution (41%) and motor vehicles (26%), followed by biomass burning (17%), soil dust (7%), road dust (3%), and marine aerosols (1%). Secondary pollution was the greatest contributor to indoor and outdoor PM 2.5 over all three seasons, with the highest contribution during spring with 53% to indoor PM 2.5 and 45% to outdoor PM 2.5 . Lower contributions of this source during fall and winter are most likely attributed to less infiltration indoors. In contrast, the indoor contribution of motor vehicles source was highest in the fall (29%) and winter (25%), which was presumably categorized by a local source. From the relationship between indoor-to-outdoor sulfur ratios and each source contribution, we also estimated the local and regional influence on indoor PM 2.5 concentration. Overall, the observed differences to indoor PM 2.5 are related to seasonality, and the distinct characteristics and behavior of each classroom/school., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Digital voice assistant technology provides unique opportunities to enhance clinical practice. We aimed to understand factors influencing pediatric providers' current and potential use of this technology in clinical practice., Methods: We surveyed pediatric providers regarding current use and interest in voice technology in the workplace. Regression analyses evaluated provider characteristics associated with voice technology use. Among respondents not interested in voice technology, we elicited individual concerns., Results: Among 114 respondents, 19 (16.7%) indicated current use of voice technology in clinical practice, and 51 (44.7%) indicated use of voice technology for nonclinical purposes. Fifty-four (47.4%) reported willingness to try digital voice assistant technology in the clinical setting. Providers who had longer clinic visits (odds ratio [OR], 3.11, 95% confidence interval [CI], 1.04, 9.33, p  = 0.04), fewer patient encounters per day ( p  = 0.02), and worked in hospital-based practices (OR, 2.95, 95% CI, 1.08, 8.07, p  = 0.03) were more likely to currently use voice technology in the office. Younger providers ( p  = 0.02) and those confident in the accuracy of voice technology (OR, 3.05, 95% CI, 1.38, 6.74, p  = 0.005) were more willing to trial digital voice assistants in the clinical setting. Among respondents unwilling or unsure about trying voice assistant technology, the most common reasons elicited were concerns related to its accuracy (35%), efficiency (33%), and privacy (28%)., Conclusion: This national survey evaluating use and attitudes toward digital voice assistant technology by pediatric providers found that while only one-eighth of pediatric providers currently use digital voice assistant technology in the clinical setting, almost half are interested in trying it in the future. Younger provider age and confidence in the accuracy of voice technology are associated with provider interest in using voice technology in the clinical setting. Future development of voice technology for clinical use will need to consider accuracy of information, efficiency of use, and patient privacy for successful integration into the workplace., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Although pre-puberty asthma is more prevalent in males, after puberty through middle-age, asthma is more prevalent in females. The surge of sex hormones with puberty might explain this gender switch., Methods: To examine the effects of sex hormones on lung function and symptoms with puberty, Tanner stage was assessed in 187 children 6-18 years of age (59% severe) enrolled in the NIH/NHLBI Severe Asthma Research Program (SARP). The effects of circulating sex hormones (n = 68; testosterone, dehydroepiandrosterone sulfate (DHEA-S), estrogen, and progesterone) on lung function and 4 week symptom control (ACQ6) in cross-section were tested by linear regression., Results: From pre-/early to late puberty, lung function did not change significantly but ACQ6 scores improved in males with severe asthma. By contrast females had lower post-BD FEV 1 % and FVC% and worse ACQ6 scores with late puberty assessed by breast development. In males log DHEA-S levels, which increased by Tanner stage, associated positively with pre- and post-BD FEV 1 %, pre-BD FVC %, and negatively (improved) with ACQ6. Patients treated with high-dose inhaled corticosteroids had similar levels of circulating DHEA-S. In females, estradiol levels increased by Tanner stage, and associated negatively with pre-BD FEV 1 % and FVC %., Conclusions: These results support beneficial effects of androgens on lung function and symptom control and weak deleterious effects of estradiol on lung function in children with asthma. Longitudinal data are necessary to confirm these cross-sectional findings and to further elucidate hormonal mechanisms informing sex differences in asthma features with puberty., Trial Registration: ClinicalTrials.gov registration number: NCT01748175 .

Outdoor air pollution penetrates buildings and contributes to total indoor exposures. We investigated the relationship of indoor to outdoor particulate matter in inner-city school classrooms. The School Inner City Asthma Study investigates the effect of classroom-based environmental exposures on students with asthma in the northeast United States. Mixed effects linear models were used to determine the relationships between indoor PM 2.5 (particulate matter) and black carbon (BC), and their corresponding outdoor concentrations, and to develop a model for predicting exposures to these pollutants. The indoor-outdoor sulfur ratio was used as an infiltration factor of outdoor fine particles. Weeklong concentrations of PM 2.5 and BC in 199 samples from 136 classrooms (30 school buildings) were compared with those measured at a central monitoring site averaged over the same timeframe. Mixed effects regression models found significant random intercept and slope effects, which indicate that: (1) there are important PM 2.5 sources in classrooms; (2) the penetration of outdoor PM 2.5 particles varies by school and (3) the site-specific outside PM 2.5 levels (inferred by the models) differ from those observed at the central monitor site. Similar results were found for BC except for lack of indoor sources. The fitted predictions from the sulfur-adjusted models were moderately predictive of observed indoor pollutant levels (out of sample correlations: PM 2.5 : r 2 =0.68, BC; r 2 =0.61). Our results suggest that PM 2.5 has important classroom sources, which vary by school. Furthermore, using these mixed effects models, classroom exposures can be accurately predicted for dates when central site measures are available but indoor measures are not available.

Rationale: Phenotypic distinctions between severe asthma (SA) and nonsevere asthma (NONSA) may be confounded by differential adherence or incorrect use of corticosteroids., Objectives: To determine if there are persistent phenotypic distinctions between SA (as defined by 2014 American Thoracic Society/European Respiratory Society guidelines) and NONSA after intramuscular triamcinolone acetonide (TA), and to identify predictors of a corticosteroid response in these populations., Methods: A total of 526 adults age 18 years and older (315 SA) and 188 children age 6 to less than 18 years (107 SA) in the NHLBI Severe Asthma Research Program III were characterized before and 3 weeks after TA. The primary outcome for corticosteroid response was defined as greater than or equal to 10-point improvement in percent predicted FEV 1 ., Measurements and Main Results: Adult asthma groups exhibited a small but significant mean FEV 1 % predicted improvement after TA (SA group mean difference, 3.4%; 95% confidence interval, 2.2-4.7%; P = 0.001), whereas children did not. Adult SA continued to manifest lower FEV 1 and worse asthma control as compared with NONSA after TA. In children, after TA only prebronchodilator FEV 1 distinguished SA from NONSA. A total of 21% of adults with SA and 20% of children with SA achieved greater than or equal to 10% improvement after TA. Baseline bronchodilator response and fractional exhaled nitric oxide had good sensitivity and specificity for predicting response in all groups except children with NONSA., Conclusions: One in five patients with SA exhibit greater than or equal to 10% improvement in FEV 1 with parenteral corticosteroid. Those likely to respond had greater bronchodilator responsiveness and fractional exhaled nitric oxide levels. In adults, differences in airflow obstruction and symptoms between SA and NONSA persist after parenteral corticosteroids, suggesting a component of corticosteroid nonresponsive pathobiology in adults with SA that may differ in children. Clinical trial registered with www.clinicaltrials.gov (NCT 01606826).

Background: In an effort to reduce barriers to screening for alcohol use in pediatric primary care, the National Institute on Alcoholism and Alcohol Abuse (NIAAA) developed a two-question Youth Alcohol Screening Tool derived from population-based survey data. It is unknown whether this screening tool, designed for use with general populations, accurately identifies risk among youth with chronic medical conditions (YCMC). This growing population, which comprises nearly one in four youth in the US, faces a unique constellation of drinking-related risks., Method: To validate the NIAAA Youth Alcohol Screening Tool in a population of YCMC, we performed a cross-sectional validation study with a sample of 388 youth ages 9-18 years presenting for routine subspecialty care at a large children's hospital for type 1 diabetes, persistent asthma, cystic fibrosis, inflammatory bowel disease, or juvenile idiopathic arthritis. Participants self-administered the NIAAA Youth Alcohol Screening Tool and the Diagnostic Interview Schedule for Children as a criterion standard measure of alcohol use disorders (AUD). Receiver operating curve analysis was used to determine cut points for identifying youth at moderate and highest risk for an AUD., Results: Nearly one third of participants (n = 118; 30.4%) reported alcohol use in the past year; 86.4% (106) of past year drinkers did not endorse any AUD criteria, 6.8% (n = 8) of drinkers endorsed a single criterion, and 6.8% of drinkers met criteria for an AUD. Using the NIAAA tool, optimal cut points found to identify youth at moderate and highest risk for an AUD were ≥ 6 and ≥12 drinking days in the past year, respectively., Conclusions: The NIAAA Youth Alcohol Screening Tool is highly efficient for detecting alcohol use and discriminating disordered use among YCMC. This brief screen appears feasible for use in specialty care to ascertain alcohol-related risk that may impact adversely on health status and disease management.

Background: Previous research has found relationships between specific indoor environmental exposures and exacerbation of asthma., Objectives: In this review we provide an updated summary of knowledge from the scientific literature on indoor exposures and exacerbation of asthma., Methods: Peer-reviewed articles published from 2000 to 2013 on indoor exposures and exacerbation of asthma were identified through PubMed, from reference lists, and from authors' files. Articles that focused on modifiable indoor exposures in relation to frequency or severity of exacerbation of asthma were selected for review. Research findings were reviewed and summarized with consideration of the strength of the evidence., Results: Sixty-nine eligible articles were included. Major changed conclusions include a causal relationship with exacerbation for indoor dampness or dampness-related agents (in children); associations with exacerbation for dampness or dampness-related agents (in adults), endotoxin, and environmental tobacco smoke (in preschool children); and limited or suggestive evidence for association with exacerbation for indoor culturable Penicillium or total fungi, nitrogen dioxide, rodents (nonoccupational), feather/down pillows (protective relative to synthetic bedding), and (regardless of specific sensitization) dust mite, cockroach, dog, and dampness-related agents., Discussion: This review, incorporating evidence reported since 2000, increases the strength of evidence linking many indoor factors to the exacerbation of asthma. Conclusions should be considered provisional until all available evidence is examined more thoroughly., Conclusion: Multiple indoor exposures, especially dampness-related agents, merit increased attention to prevent exacerbation of asthma, possibly even in nonsensitized individuals. Additional research to establish causality and evaluate interventions is needed for these and other indoor exposures.

Objective: Exposure to indoor pollutants and allergens has been speculated to cause asthma symptoms and exacerbations and influence the risk of developing asthma. The aim of this article is to review the medical literature regarding the role of the indoor environment on inner-city childhood asthma., Data Sources: A literature search was performed in PubMed. Studies focusing on inner-city indoor allergen, childhood asthma, and environmental controls were included., Results: The prevalence of asthma in children is increasing especially in inner-city area. Exposure to high levels of indoor allergens and pollutants has been related to asthma development. Studies have shown that mouse, cockroach, pets, dust mite, mold, tobacco smoke, endotoxin and nitrogen dioxide are the important exposures. Recent studies have shown that indoor environmental control is beneficial in reducing asthma morbidity and development., Conclusions: Inner-city children are exposed to various indoor allergens and pollutants that may lead to asthma development and exacerbation of existing asthma. Multifaceted environmental controls are beneficial in improving asthma symptom and maybe a viable prevention strategy. Further prospective studies of environmental intervention are needed to further identify effective strategies to improve and prevent asthma symptoms in inner-city children.