The Family Health Guide


Asthma Education Leads to Improvement in Children

Managing your child's asthma should include meeting with an asthma educator a few times, according to a follow-up study. Presented at the meeting of the American Academy of Allergy, Asthma, and Immunology, the study reports that after attending an interactive training program three times patients felt less worried about their asthma and had fewer asthma-induced awakenings during the night. Both patients and their caregivers, who also took part in the program, made better decisions about asthma care.

The 30 subjects, asthmatic children ages 6–12, underwent ACE IT! (Asthma Care Education: Intensive Training), an interactive, small-group education program. The sessions included a motivational talk by a teenage athlete with asthma and a pharmacist's discussion of medications. A nurse and asthma specialist also taught the participants about the clinical nature of asthma, environmental controls, relaxation techniques, and asthma action plans.

Researchers evaluated the children at the beginning and end of the training, after six months, and again a year later. After the courses, the number of patients reporting two or more nocturnal awakenings per month dropped from 9 to 5, and the number of symptom-free days also improved, from an average of 20 days per month to over 25 days per month.
The patients were more willing to use the tools available to them, such as medications and peak flow meters, devises that asthmatics breath into to help detect airway changes. They also worked harder to avoid things that triggered their asthma, such as pets or dust.

The researchers plan to continue tracking these 30 children to study the long-term effects on quality of life, morbidity, and cost of treatment. A previous study published in the Journal of Allergy and Clinical Immunology in 2000, found that the training program was much more effective than simply handing out educational materials.

May 2002 Update

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Inhalers Lead to Hip Bone Loss

Medications commonly used for the long-term treatment of asthma may lead to hipbone loss in premenopausal women.

Researchers at Brigham and Women's Hospital in Boston found bone mass in the hip and trochanter decreased in women taking inhaled glucocorticoids, a type of steroid used for treating asthma. The rate of bone loss also increased with the rate of dosage. The three-year prospective study involved 109 women aged 18 to 45. Bone density was measured at the beginning of the study, after six months of treatment and at one, two, and three years.

Bone density was found to decline 0.00044 grams per square centimeter per puff of medicine per year of treatment. Although that's a small amount, it can be significant in the long run. If a woman with asthma is treated with six puffs of triamcinolone acetonide (the glucocorticoid studied) twice a day for 20 years, she could expect to have 0.106 grams per square centimeter less bone in her hip than she would have had without the treatment, according to this study. That degree of bone loss has been associated with a risk of hip fractures more than double that of normal women 65 and older.

Besides the hip, measurements were also taken at the spine and femoral neck, but no changes were found there. The rate of decline also varied between patients in the same dosage group and no reason for that could be found.

Though osteoporosis is a major health problem for women, the study's authors admit that inhaled glucocorticoids are among the most effective and safest medicines for asthma. They suggest doctors prescribe the lowest effective dose and patients using high doses should ask their doctors to periodically assess their bone density.
The results of previous, less extensive studies on inhaled steroids and bone density have been mixed.
October 2001 Update

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Preventing Bone Loss from Steroid Therapy

Corticosteroids are very effective in reducing inflammation. These drugs may be taken in many forms: injected directly into a shoulder to treat tendonitis, inhaled into the lungs to calm the inflammation characteristic of asthma, or as creams to treat skin rashes. The pill form (typically prednisone and Prednisolone) may be used to treat conditions such as arthritis or lupus. One of the serious side effects of these drugs when taken for long periods is loss of bone mass — essentially, osteoporosis.

Bisphosphonate drugs (used to treat osteoporosis) have been shown to prevent bone loss associated with corticosteroid therapy. A recent study confirmed that a newly developed bisphosphonate, risedronate, helped prevent bone loss associated with steroid use. While treatment with risedronate improved bone mineral density, it is too early to tell for certain if it can reduce the fracture rate for patients on steroids.

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Alendronate versus Calcitonin for Osteoporosis in Postmenopausal Women

Postmenopausal women who are unwilling to take estrogen for the treatment of osteoporosis commonly take nasal calcitonin or oral alendronate. Until now there has never been a direct comparison of the positive effects of these two drugs at their treatment doses.

In a randomized trial, researchers compared the two drugs against one another and against a placebo on 299 postmenopausal women over a period of 12 months. The researchers measured the bone mineral density of the hip, spine, and femur on each woman before starting treatment and after six and 12 months. Results showed that alendronate produced greater increases in bone mineral density at all three sites when compared to both calcitonin and the placebo. Calcitonin outperformed the placebo only in the femur. In both the spine and hip, calcitonin produced changes similar to the changes produced by the placebo. The researchers also measured markers of bone loss in serum and urine samples before and after treatment. Alendronate produced a greater decrease in these markers than calcitonin and the placebo did. The researchers could not measure the effect of the drugs on fracture risk because the study was small and over a short period.

The results of this study suggest that alendronate is more effective than calcitonin at treating osteoporosis in postmenopausal women over a period of 12 months.

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Tobacco Smoke Can Trigger Childhood Asthma

A new study further highlights the need to eliminate children's exposure to tobacco smoke. After evaluating a random sampling of about 40,000 children between the ages 6 and 7 and 13 and 14, researchers in Italy determined exposure to the secondhand smoke of at least one parent increased a child's relative risk of asthma.

The children's parents were surveyed about their smoking habits and the respiratory health of their children. Children in both age groups who were exposed to secondhand smoke from both parents were more likely to have asthma. Having a mother who smokes was a slightly stronger predictor than having a father who smokes.

These results bolster previous research that has linked exposure to secondhand smoke in the home to childhood asthma. Restricting smoking to outside the home doesn't seem to help either. A 1997 study in California found that even if their parents smoked outside, children hospitalized for acute asthma took longer to recover when discharged than children whose parents did not smoke. Tobacco smoke clings to hair and clothes fibers, so even if the activity itself takes place away from child, the child can still be exposed to secondhand smoke.

For more information about asthma, see page 505 of the Family Health Guide. For tips on how to quit smoking, see page 57.

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Breast-Feeding May Protect Against Childhood Asthma

Another vote in favor of breast-feeding! Researchers in Western Australia found that babies who are fed breast milk exclusively for their first four months are less likely to develop asthma by age 6. Asthma is the leading cause of hospital admissions for Australian youth. In the United States, it affects about 17 million Americans and about a quarter of all children under 18.

To determine whether there was a connection between asthma and breast-feeding, the researchers compared questionnaires completed by parents when their children were a year old with questionnaires completed when the children were 6. The surveys asked about breathing problems, feeding (length and exclusivity of breast-feeding), smoking in the home, and daycare (to evaluate exposure to respiratory infections).

The age at which a child was fed soy or cow's milk was more positively associated with asthma and wheezing. Introduction of milk other than breast milk before four months was a significant risk factor for the development of asthma by age 6. According to the Food and Drug Administration, babies who are breast-fed have lower rates of hospital admissions, ear infections, diarrhea, rashes, allergies, and other medical problems than bottle-fed babies. Because human milk contains cells that kill bacteria, fungi, and viruses, breast-fed babies are protected from a number of illnesses. To learn more about breast-feeding, see page 951 of the Family Health Guide. If you are unable to breast-feed, see page 505 for more information about other ways to prevent childhood asthma. Controllable risk factors include the presence of house dust and tobacco smoke.

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Inhaled Corticosteroids Affect Bone-Mineral Density

While inhaled corticosteroids are effective in controlling asthma, a recent study suggests that long-term use of higher doses of inhaled steroids may predispose both men and women to osteoporosis.

Researchers studied a group of men and women between the ages of 20 and 40 year olds. All had mild asthma and had been using a steroid inhaler for an average of six years. Because the study did not include patients with severe asthma, decreased growth and physical activity in childhood would most likely not be a contributing factor to patients' decrease in bone-mineral density. In addition, fewer than 10% of the participants had used a steroid inhaler before the age of 15. Most participants (80%) had been using beclometasone dipropionate, though the results for participants using budesonide and fluticasone propionate were the same.

What researchers found was that long-term exposure to high doses of an inhaled corticosteroid produces a significant decrease in bone-mineral density at the spine and femur. Such a decrease in bone-mineral density is associated with a doubling of the risk for fracture. Researchers also discovered that the length of time a patient used a steroid inhaler was similar to the patient's cumulative dose in its effect on the patient's bone-mineral density. Researchers also concluded that participants who had taken inhaled steroids long term and in high doses would enter their 50s and 60s with lower bone-mineral densities than those participants who had taken an inhaled corticosteroid in low doses.

People with asthma who need to use a high-dose steroid inhaler over an extended period of time should consult their doctor about the best measures they can take to prevent osteoporosis.
October 2000 Update

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