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To quantify the prevalence and impact of chronic respiratory symptoms among predominantly Alaska Native (AN)/American Indian (AI) middle school students.School-based prevalence assessment using the International Study of Asthma and Allergy in Children survey, with supplemental video material and added questions about productive cough, exposure to tobacco smoke, and the functional impact of symptoms.The Yukon-Kuskokwim delta region of western Alaska.A total of 466 children in the sixth to ninth grades, 81% of whom are AN/AI (377 children).No study intervention.Among the 377 AN/AI children, 40% reported one of the following three categories of chronic respiratory disease: physician-diagnosed asthma, 7.4%; asthma-like symptoms (ALS) without an asthma diagnosis, 11.4%; and chronic productive cough (CPC) without asthma diagnosis or symptoms, 21.5%. Symptom prevalence differed substantially between the largest town in the region and rural villages. After an adjustment for demographic factors, exposure to environmental tobacco smoke, active tobacco smoking, and self-report of atopy, village residents were 63% less likely to have ALS (p = 0.009), and had a twofold greater risk of CPC (p0.001) compared to children living in the town. Children with respiratory symptoms experienced sleep disturbances and accessed clinic visits for respiratory problems more often than did asymptomatic children.Chronic respiratory symptoms are very common among AN children. CPC is an important nonasthmatic respiratory condition in this population. The differing patterns of respiratory illness within this region may help to elucidate the specific risk factors for asthma and chronic bronchitis in children.

Bronchiectasis among children living in developing regions is associated with respiratory infections during early childhood, but specific risk factors that precede childhood bronchiectasis are not fully characterized. We hypothesized that severe respiratory syncytial viral (RSV) infection in infancy would increase the risk of bronchiectasis among Alaska Native children in rural Alaska. This was a follow-up cohort study of a 1993-1996 case-control study of RSV-hospitalized case patients and their controls. For each 5-8-year-old former case-patient and control subject, we reviewed medical records, interviewed parents, performed physical examinations and spirometry, collected sera, and analyzed all historical chest radiographs. Ten (11%) RSV cases and 10 (9%) controls had radiographic evidence of bronchiectasis. The mean age at radiographic diagnosis of bronchiectasis was 3.3 years (range, 1.2-6.1 years). Children were more likely to develop bronchiectasis if their chest radiographs, when they were 6 months' duration (RR = 3.0, P = 0.02), or infiltrates on multiple episodes (test for trend, P = 0.003). Radiographic features of hyperinflation and atelectasis among children < 2 years old were not associated with eventual bronchiectasis. A single severe infection with RSV alone did not predispose Alaska Native infants to bronchiectasis. Childhood bronchiectasis was associated with lung and hence airway injury, manifested on radiographs by parenchymal densities or "pneumonia" rather than by hyperinflation or atelectasis.

Background Advances in medical technology may be increasing the population of children who are technology-dependent (TD). We assessed the proportion of children discharged from a children's hospital who are judged to be TD, and determined the most common devices and number of prescription medications at the time of discharge. Methods Chart review of 100 randomly selected patients from all services discharged from a children's hospital during the year 2000. Data were reviewed independently by 4 investigators who classified the cases as TD if the failure or withdrawal of the technology would likely have adverse health consequences sufficient to require hospitalization. Only those cases where 3 or 4 raters agreed were classified as TD. Results Among the 100 randomly sampled patients, the median age was 7 years (range: 1 day to 24 years old), 52% were male, 86% primarily spoke English, and 54% were privately insured. The median length of stay was 3 days (range: 1 to 103 days). No diagnosis accounted for more than 5% of cases. 41% were deemed to be technology dependent, with 20% dependent upon devices, 32% dependent upon medications, and 11% dependent upon both devices and medications. Devices at the time of discharge included gastrostomy and jejeunostomy tubes (10%), central venous catheters (7%), and tracheotomies (1%). The median number of prescription medications was 2 (range: 0–13), with 12% of cases having 5 or more medications. Home care services were planned for 7% of cases. Conclusion Technology-dependency is common among children discharged from a children's hospital.

Bronchiectasis among children living in developing regions is associated with respiratory infections during early childhood, but specific risk factors that precede childhood bronchiectasis are not fully characterized. We hypothesized that severe respiratory syncytial viral (RSV) infection in infancy would increase the risk of bronchiectasis among Alaska Native children in rural Alaska. This was a follow-up cohort study of a 1993-1996 case-control study of RSV-hospitalized case patients and their controls. For each 5-8-year-old former case-patient and control subject, we reviewed medical records, interviewed parents, performed physical examinations and spirometry, collected sera, and analyzed all historical chest radiographs. Ten (11%) RSV cases and 10 (9%) controls had radiographic evidence of bronchiectasis. The mean age at radiographic diagnosis of bronchiectasis was 3.3 years (range, 1.2-6.1 years). Children were more likely to develop bronchiectasis if their chest radiographs, when they were2 years of age, showed lung parenchymal densities (RR = 3.9, P0.013), persistent parenchymal densities6 months' duration (RR = 3.0, P = 0.02), or infiltrates on multiple episodes (test for trend, P = 0.003). Radiographic features of hyperinflation and atelectasis among children2 years old were not associated with eventual bronchiectasis. A single severe infection with RSV alone did not predispose Alaska Native infants to bronchiectasis. Childhood bronchiectasis was associated with lung and hence airway injury, manifested on radiographs by parenchymal densities or "pneumonia" rather than by hyperinflation or atelectasis.

Objective. In 1993–1996, we conducted a nested case-control study to determine risk factors for hospitalization with respiratory syncytial virus (RSV) infection among Alaska Native infants and young children. In the current study, we returned to former RSV case-patients and their control subjects during 1999–2001 to determine whether children who are hospitalized with RSV at Methods. For each former RSV case-patient and control subject from remote villages in southwest Alaska, we reviewed medical records, interviewed parents, performed physical examinations and spirometry, collected sera, and analyzed chest radiographs. Case-patients were identified through surveillance for RSV hospitalization, and matched control subjects without lower respiratory infection (LRI)-related hospitalization were identified. Results. Hospitalization for RSV infection was associated with a significant increase in wheezing, LRIs, and asthma diagnosis during the first 4 years of life. The association decreased with age and was no longer significant by 5 years of age. However, hospitalization for RSV infection was associated with increased respiratory symptoms and increased chronic productive cough at 5 to 8 years of age. Children who were hospitalized with RSV were not more likely at follow-up to have allergies, eczema, or a positive family history of asthma. Conclusions. Severe RSV infection in infancy may produce airway injury, which is manifested in chronic productive cough with or without wheezing and recurrent LRIs. Although the association of RSV infection with wheezing seems to be transient, children remain at higher risk for chronic productive cough at 5 to 8 years of age. RSV prevention modalities may prevent sequelae that occur early and later in childhood.

The impact of asthma and asthma-like illness was measured in a population of 5–9-year-old Seattle public school children. Child health information was obtained from a survey of 1665 parents of first and second grade students to assess medical services use and impaired physical functioning among diagnosed asthmatics and those with current wheezing, defined as wheezing in the past 12 months without a diagnosis of asthma, relative to an asymptomatic population with neither condition. Relative to the asymptomatic population, the prevalence of respiratory-related activity limitation, and perception of poorer child health was larger among diagnosed asthmatics than children with current wheezing. However, the prevalence of sleep disturbances, school absences, medical services use, and parental concern over their child’s health was similar for both the asthmatic and wheezing groups relative to the asymptomatic group. Also, in both symptomatic groups, a history of moderate or severe wheezing was associated with an increased prevalence of respiratory-related sleep disturbances and activity limitation. The similarity between the impact of diagnosed asthma and undiagnosed asthma-like illness suggests that the overall social and economic burden of asthma may be higher than previously estimated.

We describe a pilot system of coordinated asthma care emphasizing home visits by a community-based lay worker collaborating with a pediatrician, pharmacist, and public health nurse. Study participants included 23 low-income children with moderate to severe asthma and their families at an inner-city pediatric clinic. This system was successfully implemented, and client satisfaction was extremely high. Utilization review showed a reduction in hospitalizations, emergency department visits, and unscheduled clinic visits, and an increase in follow-up clinic visits. This model of care may reduce unscheduled service use and deserves further study as an alternative for asthma management among similar patient populations.

To determine if children with chronic asthma hospitalized for an acute exacerbation experienced prolonged clinical recovery after hospital discharge if they returned to a home environment in which they were exposed to environmental tobacco smoke.A prospective longitudinal study.Children's Hospital and Medical Center, Seattle, Wash.Patients admitted to the emergency department of the Children's Hospital and Medical Center with the single diagnosis of asthma (International Classification of Diseases, Ninth Revision [ICD-9] code 493).Twenty-two children with acute asthma were sequentially enrolled in the study and longitudinally observed between February and -June 1994. The tobacco-smoking group (n = 11) was defined as having at least 1 smoker in the home. The nonsmoking group (n = 11) had no environmental tobacco smoke exposure at home. The 2 groups were similar in age, sex, preadmission chronic asthma severity, and immediate predischarge asthma status. Discharge medication use was similar in the 2 groups During a 1 month follow-up period, the tobacco-smoking group had a significantly greater number of symptomatic days than the nonsmoking group (P.05) Of the children in the nonsmoking group, 9 (82%) had less than 1 symptomatic day per week compared with 3 (27%) in the tobacco-smoking group. beta 2-Agonist bronchodilator use declined significantly (P.001) during follow-up in the nonsmoking group but not in the tobacco-smoking group, despite similar anti-inflammatory drug therapy in both groups.Recovery by children after hospitalization for acute asthma is impaired by environmental tobacco smoke exposure when the period of recovery is characterized by persistent respiratory symptoms and use of asthma medication for symptomatic relief. These findings underscore the need to limit environmental tobacco smoke exposure in children with asthma and argue for closer physician follow-up of those children returning to a home environment in which smokers are present.

Indoor risk factors for physician-diagnosed asthma and wheezing in the past 12 months without previous asthma diagnosis were assessed in a survey of parents of 5-9-year-old Seattle primary school students. Among the 925 respondents, 106 (11%) reported a physician diagnosis of asthma, 66 (7%) had wheezing without diagnosis, and 753 (82%) were asymptomatic. After adjusting for age, sex, gender, ethnicity, medical history, socioeconomic status (SES) and parental asthma status, an increased risk of physician diagnosis of asthma was associated with household water damage, the presence of one or more household tobacco smokers, and at least occasional environmental tobacco smoke (ETS) exposure. Similarly, an increased risk of wheezing in the past 12 months among children without diagnosed asthma was associated with household water damage, presence of one or more household tobacco smokers, and occasional or more frequent ETS exposure. No increased risk of either condition was associated with gas, wood, or kerosene stove use, household mold, basement water, or wall/window dampness. Similarities in the indoor risk factors patterns between diagnosed asthma and wheezing without diagnosis suggested a similar etiology of these two conditions. The slightly higher association between ETS and asthma may indicate that parents of diagnosed asthmatics were more conscious of ETS, and were more likely to prohibit household smoking by resident smokers. Future research is needed to quantify which aspects of household water damage are related to respiratory illness.

To identify clinical features of asthma present before arrival in the emergency department, at the time of emergency department treatment, and during hospitalization that differ between children with asthma hospitalized for a prolonged period and those hospitalized for an average duration.Retrospective chart review.Hospital records of patients with asthma (International Classification of Diseases, Ninth Revision, code 493) admitted to Children's Hospital and Medical Center, Seattle, Wash, from October 1989 to September 1991.The medical records of 23 children hospitalized from October 1989 to September 1991 for more than 4 days with acute asthma were compared with those of 62 sex- and age-matched children hospitalized for 2 days. Patients in the long-stay and short-stay groups had similar histories of home medication use. The presence of asthma symptoms before arrival in the emergency department was prolonged in the long-stay group (P.001). Only one of the 23 patients in the long-stay group had augmented asthma treatment within 24 hours before hospitalization, compared with 39 of the 62 patients with short stays (P.001). During hospitalization, a greater proportion of children in the long-stay group than the short-stay group received supplemental oxygen (P.01). More children in the long-stay group than the short-stay group had residual hypoxemia (arterial oxygen saturation,94%) in room air at discharge, suggesting that hospital stay was not prolonged to reach normal oxygen saturations. None of the children were readmitted within 1 month of their index admission.Early augmentation of home therapy for acute asthma is associated with a reduced duration of hospitalization for children admitted with asthma. In addition, hypoxemia in children with acute asthma on presentation and during hospitalization is associated with prolonged hospital stay.

Rationale The prevalence of atopy among children in subarctic regions has been described in Norway, Sweden, and Russia but not among native populations. Methods We studied the prevalence of atopy and aeroallergen sensitization in 206 5-8 year old Alaska Native children, part of a 517 infant cohort enrolled in a study to assess the sequelae of severe RSV infection. History, physical findings, review of all medical records, total IgE, H. pylori IgG, Mycoplasma serology, and RAST tests to 12 aeroallergens were compiled for each child. Results 58% of all children had IgE levels >70 IU/ml; 16% had IgE levels >1000 IU/ml. 62% had positive IgG levels to H. pylori and 22% had Mycoplasma+ serology in both groups. Only 7% of children had 1 or more + RAST Class III to aeroallergens. One aeroallergen affected >5% of the children ( D. pteronyssinus ). There was no association between IgE status and family history of asthma, wheezing the past year, productive cough, serum cotinine levels, or Mycoplasma or H. pylori serology. IgE levels were associated with pooled positive RAST tests. Conclusions Elevated IgE levels are common among Alaska Native children. Sensitization to aeroallergens is uncommon. IgE levels are not associated with smoke exposure, H. pylori or Mycoplasma infections or chronic respiratory symptoms.

The prevalence of asthma among children has increased in the last decade, particularly among ethnic minorities. However, the prevalence of asthma and other respiratory conditions among Alaskan native children has not been previously reported. Children attending grades 6-9 in three villages in the Yukon-Kuskokwim delta region of Alaska were surveyed in 1997 using modified validated instruments developed by the International Studies of Asthma and Allergies in Children (ISAAC). Children were categorized as those who had received a diagnosis of asthma by a doctor, children with asthma-like symptoms without a diagnosis of asthma, children with daily sputum production without asthma-like symptoms, and normal children without respiratory symptoms. The proportions of children (as% of total children surveyed/village) in each category are depicted below. The frequency of different respiratory symptoms varies among villages. Yet, in all three sites asthma symptoms are more common than diagnosed asthma. Daily sputum production suggestive of chronic bronchitis is more common than both diagnosed and undiagnosed asthma. Remarkably, more than half of middle school children in Southwest Alaska by self-reporting have chronic respiratory symptoms. Table