Prescribing Knowledge for Kids' Asthma By MATTHEW COREY
Karen Warman, a pediatrician with Montefiore Medical Center's east Bronx Comprehensive Family Care Center, published the article in the journal's February issue. Warman, a SUNY-Syracuse medical school graduate, has had an interest in children's public health since she served in Sudan, east Africa, in 1985 at the height of the Ethiopian famine. With colleagues Ellen Johnson Silver, Mary P. McDouert and Ruth E. K. Stein, Warman questioned 220 caregivers (92 percent were mothers) of children who had been admitted to Pelham Parkway's Jacobi Medical Center at least once for asthma. Warman says the families were from all over the borough, and their makeup reflects the Bronx's ethnic diversity. Almost three-fifths were Puerto Rican and other Latinos, another quarter African-American, eight percent Afro-Caribbean, and eight percent of other ethnic backgrounds. Asthma afflicts some 4.8 million children nationwide. In the Bronx, however, the illness strikes at a rate twice as high as the national average. A 1990 study in the Journal of the American Medical Association estimated that 8.6 percent of kids in the borough have asthma. Among chronic medical conditions, asthma is the most common cause of school absences and even hospitalization for children. A disease of the respiratory system, asthma shows itself in persistent wheezing and coughing. Science is still struggling to understand what causes the illness in children, but opinion is now falling on the side of environmental "triggers," especially air pollution, dust, cockroaches, and adults who smoke in the home. "Asthma is a chronic, inflammatory disorder, where there is mucous plugging, inflammation, and bronchial constriction," Warman says. If untreated, she says, asthma can be fatal. But while there is no cure, pediatric asthma can be controlled, and there is no reason children who are getting treatment should avoid sports and normal play. Parents, whom the researchers credit as "the front line" of managing asthma, can assemble inexpensive equipment in the home -- most of which is covered by Medicaid or other insurance -- that will allow them to judge the intensity of an asthma attack and treat minor flare-ups themselves. What to do There are four major things parents should have in the home for asthmatic children: a peak flow meter to check the child's lung capacity mid-attack, an inhaler or nebulizer to deliver medicine to the lungs, a written plan to follow in crisis, and the number of a family doctor who can oversee treatment over the phone, and, in unusually bad cases, advise the parent to bring the boy or girl to the emergency room. In her examination room, Warman demonstrates the peak flow meter, a tool shaped like a phaser from Star Trek. She takes a heaving breath and blows into it, making the needle jump up like the strength-testing bell at a carnival. If the needle jumps above a green arrow, the child is breathing normally. If it lands between the green and red arrows, the patient is having an asthma attack and the parent should work through the at-home treatment plan. If the needle does not make it to the red arrow, the child is sick enough to go immediately to the emergency room. Most at-home treatment involves an inhaler with aerosol holding chamber. The patient shouldn't put the inhaler directly in his mouth, Warman says, "because it will just sit on the tongue like a Binaca blast." Instead, the inhaler pumps the medicine into a plastic chamber, where it mixes with air. The child inhales the medicating mist through a kid-size breathing mask. Following the rules is second nature for some parents of her own patients, Warman says. "The phone could ring in here any minute," she says, laughing. "Somehow, they know how to find me." Others find the guidelines more confusing and don't keep Warman informed. "The mother will say, 'Oh, by the way, he was in the emergency room last month,'" she says. The Pediatrics survey found that, in the Bronx, awareness of how to take these precautions correctly is quite low. Only 30 percent of families in the sample had a peak flow meter in the house, and only one of the 220 caretakers questioned knew to use it as the first step in case of an attack. While 51 percent reported having a written plan to follow in case of an attack, none of the caretakers said they actually referred to it. "In the inner city, implementation of the guidelines is particularly difficult," the study says. "Asthma teaching takes time and is difficult to accomplish in a busy clinic setting." A recent Family Health Day held at the Mosholu
Montefiore Community Center in Norwood is one innovation
used by Montefiore and other area medical providers to
educate area parents outside the hectic doctor's office.
Parent participants expressed an eagerness to learn more
about treating asthma correctly in the home. "The peak-flow meter, which I know my older daughter's not using," said Kathryn Tracey, who has asthma herself, when asked what she had learned from a demonstration by Dr. Scott Schroeder. "It sounds like she probably should be using it." "I learned new things," said mom Valentine Sanchez. "Better ways to take care of your own children, and prevent [them] from having an asthma attack." In response to the perceived lapse in the facts, Warman and her colleagues are testing a new educational brochure, the Asthma Passport Program, which is based on the same intuitive red-light, green-light idea as the peak flow meter. "It's already reducing hospitalizations for children, increasing use of equipment, and increasing [parents'] partnerships with doctors," Warman says. Jules Rubenstein contributed to this story.
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Every day, Bronx parents
wake up to their asthmatic children's wheezing and
scramble to make it better. A new study in the journal Pediatrics,
conducted on families of children with asthma from all
over the Bronx, shows that many parents are unaware of
the steps they can take in the home to alleviate asthma
attacks. 
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