Doctors grade asthma screening in schools

Physicians disagree about whether the focus should be on diagnosis or treatment.

By Victoria Stagg Elliott, amednews staff. Aug. 18, 2003.

School-based asthma screening tests for children are giving allergy experts hope that the problem of underdiagnosis can be addressed.

Studies published recently in the Annals of Allergy, Asthma and Immunology suggest that questionnaires conducted through schools might effectively screen for asthma and allergies in children. The tools don't actually diagnose the conditions but are designed to identify children who need follow-up.

Costly condition
Screening schoolkids
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"Schoolchildren are screened for vision problems, hearing disorders and scoliosis. There's every reason to include allergies and asthma among the screenings," said Robert M. Miles, MD, past president of the American College of Allergy, Asthma and Immunology. "The earlier allergic asthma is recognized and treated in children, the better the outcome."

Several screening tests exist, and many physicians see a need for a useful school-based screen to lower high rates of school absenteeism and sleep disturbances caused by undiagnosed allergies and asthma.

"When working with the schools to determine their biggest problems with asthma and allergies, what we got consistently was they didn't know how many sufferers they had," said Raoul Wolf, MD, lead author of one of the papers and professor of pediatrics and chief of the section of allergy and immunology at the University of Chicago. "From that, we thought that it might be a good idea to develop a tool that would be easy to use."

Worries about false-positives

Critics of the studies, however, suspect the screenings mostly will pick up very mild cases that might not require treatment. They also said the tests are not specific enough or sensitive enough to be useful. Detractors are particularly concerned about parents walking away convinced that their child does not have asthma or allergies because of a screen, when in fact they might have a false-negative.

"Missing a person on a screen delays recognition and treatment and may create a false sense of security because the child was 'screened' for asthma and allergies and none were found," said Dennis R. Ownby, MD, professor of pediatrics and medicine and chief of the section of allergy and immunology at the Medical College of Georgia in Augusta.

Critics also expressed concern about the disconnect between screening and access to diagnosis and treatment. Dr. Wolf's team, for example, attempted to provide links to follow-up care but found no takers.

"We use this questionnaire, which is really nice," said Barbara Yawn, MD, director of research at Olmsted Medical Center in Rochester, Minn. "But will it impact the outcomes?"

Given the uncertainty, many experts suggest that a more effective approach would be to get better treatment for children who are already diagnosed. The Centers for Disease Control and Prevention recently shifted its focus from prevalence rates to indicators of how well asthma is controlled. Several previous studies have tried but failed to show a connection between school-based screening and an increase in diagnosis or treatment. Another paper in the same journal suggested that screening should concentrate on finding children who are diagnosed but undertreated.

"Let's spend the resources for the kids we know have asthma," said Dr. Yawn, lead author of that paper. "Our recommendation is that you probably shouldn't use the screen for identifying new cases of asthma. Instead, it should be used to get better care for the ones we already know about."

Detractors also said questionnaires aimed at finding children with asthma might be better suited for the primary care physician's office than the school. "It would be very helpful because we can ask the questions and we can do the follow-up right there," said Dr. Yawn.

Researchers now are validating a composite of the various screens.

ADDITIONAL INFORMATION:

Costly condition

5 million: Number of people younger than 18 who have asthma.

14 million: School days lost each year because of asthma.

$3.2 billion: Yearly cost of treating asthma in those younger than 18.

266: Number of children who died from asthma in 1996, up almost threefold from 93 deaths in 1979.

Source: Centers for Disease Control and Prevention

Screening schoolkids

Objective: To develop a brief, simple screen for asthma and allergies in schoolchildren.

Method: Questions for the already validated Brief Pediatric Asthma Screen (BPAS) were expanded to include questions about allergies. The survey was distributed to elementary schools, and results were validated for 129 students by an asthma expert.

Results: Questions about wheezing, persistent cough, night cough and response to changes in air temperature were the best indications of asthma. Questions about using allergy medicine, frequent sneezing, itchy eyes and symptom seasonality were most indicative of allergies.

Conclusion: The enhanced screening provides a rapid and valid method for the detection of potential allergy and asthma in schoolchildren.

Source: Annals of Allergy, Asthma and Immunology, May 2003