CHAPTER 4 Chronic Conditions
Diabetes Mellitus: Type 1 and Type 2
Encopresis (Chronic Constipation/Retention)
Fetal Alcohol Syndrome and Effects
Hepatitis Infections A, B, C, D, E, and G
Herpes Simplex Virus Infection Type 1
Herpes Simplex Virus Infection Type 2
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
Muscular Dystrophy, Duchenne’s and Becker’s
The school-age population with chronic illness is increasing and will continue to increase as medical technology saves and extends the lives of affected students daily. The physical, emotional, intellectual, and social impact of chronic illness on children is immense, and nurses and educators contribute greatly to the goal of enabling each individual to achieve maximum potential in all areas of functioning.
AMBIGUOUS GENITALIA
A. Normal sexual differentiation occurs in utero with external and internal genitalia consistent with the sex chromosome of either 46 XX (female) or 46 XY (male). Embryos have the potential to develop as either males or females, and differentiation into one sex or the other (i.e., the development of testes or ovaries) occurs during the seventh or eighth week of gestation. Errors in embryonic sex determination and differentiation result in diverse degrees of intermediate sex, a condition known as hermaphroditism or intersexuality. The condition in which the chromosomal sex is different from the phenotype sex is often referred to as intersex or disorders of sex development (DSD).
B. Hermaphroditism suggests a discrepancy between the morphology of the gonads, ovaries/testes, and the appearance of the external genitalia.
C. True hermaphroditism presents itself with both ovarian and testicular tissue as separate organs or combined in the same organ, or ovotestis; this is an extremely rare condition (Kliegman et al, 2006). Female pseudohermaphrodites have ovaries, and male pseudohermaphrodites have testes; both have ambiguous genitalia.
D. Disorders of sex development are classified by the histological appearance of the gonads but include situations in which the chromosomal and phenotype sex are different.
E. The terms hermaphrodite and sex reversal are stigmatizing and not anatomically correct. The American Academy of Pediatrics has proposed changes in terminology, from male pseuodohermaphrodite to 46 XY DSD: from female pseudohermaphrodite to 46 XX DSD; and from true hermaphrodite to ovotesticular DSD (Lee et al, 2006).
A. May be caused by atypical differentiation of primitive gonads and differentiation and development of internal duct systems and external genitalia. Alterations in these processes may result in a defect of embryogenesis, abnormalities of chromosomal complement, and biochemical abnormalities that include androgen insensitivity, defective sex hormonal synthesis in a male, placental transfer of masculinizing agents in a female, or congenital adrenal hyperplasia (CAH), also called adrenogenital syndrome.
B. Female pseudohermaphroditism usually occurs when the female fetus is exposed to excessive androgens, and male pseudohermaphroditism usually occurs from androgen insensitivity. True hermaphroditism is not completely understood. (See “Additional Information” for other ambiguous sex conditions.)
IV. Health Concerns/Emergencies
A. An electrolyte imbalance such as CAH can be life threatening if unidentified and untreated at birth.
B. Gender assignment, when doubt exists, can be psychologically distressing to the family and the growing child and may continue throughout life.
A. Will need to make decisions about sexual identity, a developmental process that lasts through childhood, adolescence, and into adulthood.
3. Cannot understand development of sexual body parts and may have feelings of inadequacy, shame, or inferiority.
B. Be supportive, understanding, honest, and encouraging with parents. Encourage openness with their child; secrecy compounds the problem.
H. At birth, four conditions that produce ambiguous genitalia require prompt and accurate assessment: (1) female pseudohermaphroditism, (2) male pseudohermaphroditism, (3) true hermaphroditism, and (4) mixed gonadal dysgenesis.
1. Gender determination may take days or weeks; tests may include history, physical examination, chromosomal analysis, endoscopy, ultrasonography, radiographic contrast tests, biochemical tests, and laparotomy or gonad biopsy.
2. Consideration of gender assignment should include both anatomical findings and genetic sex determinations.
3. Surgery may or may not be performed, but preliminary sex assignment should be made shortly after birth. Child may later decide to change sex assignment.
1. Hermaphroditism and mixed gonadal dysgenesis: choose an appropriate gender, maximize potential for adult sexual function, and decrease psychosocial difficulties. After gender decision, surgical intervention is usually undertaken, and hormonal replacements are given at puberty.
2. Defective testosterone biosynthesis of male infant: testosterone injections in adolescence and adulthood to initiate puberty and sustain adult masculinization.
3. Controversy exists regarding treatment and surgery before the child’s participation in the decision.
4. Studies have not shown any increased rates of social ostracization or psychological illness as a result of delaying surgery until the child is older.
A. The Intersex Society of North America (ISNA) supports a paradigm for the management of disorders of sex development. They are a resource for those seeking help by offering positive advocacy, policy advice, and caring support for individuals and families dealing with DSDs.
B. Female pseudohermaphroditism: These individuals have chromatin-positive nuclei and a 46 XX chromosome constitution. This anomaly occurs when the female fetus is exposed to excessive androgens that affect the external genitalia, resulting in clitoral enlargement and labial fusion. Ovarian abnormalities do not exist, but the most common cause of this condition is increased production of androgens, which produces masculinization of the external genitalia. This varies from enlargement of the clitoris to almost masculine genitalia.
1. The most common cause of this condition is CAH. Androgenic agents administered during pregnancy may cause similar anomalies to the external genitalia. This condition may also result from benign adrenal adenoma, ovarian tumors, and the treatment for threatened abortions.
2. Untreated CAH results in early sexual maturation with development of facial, axillary, and pubic hair; acne; early sexual maturation; deepening of the voice; and a noticeable increase in musculature toward an adult male physique. The females do not develop breasts and are amenorrheic and infertile. The male testes remain small, and spermatogenesis does not occur.
C. Male pseudohermaphroditism: These individuals have chromatin negative nuclei and a 46 XY chromosome constitution. External and internal genitalia vary according to degree of development of the external genitalia and internal female organs. These anomalies are caused by defects in testicular differentiation, inadequate production of testicular hormones, or defects in androgen action.
D. Androgen insensitivity syndrome (testicular feminization): This syndrome follows X-linked recessive inheritance. In individuals with this condition, l in 20,000, appear as normal females despite the presence of testes and a 46 XY chromosome constitution. External genitalia are female, the vagina generally ends blindly, and the uterus and uterine tubes are absent or rudimentary. Normal development of breasts and female characteristics occurs during puberty; however, pubic hair is scant or absent, and menstruation does not take place. Psychosexual orientation is usually completely female, and medically, socially, and legally, these are women.
1. Testes are generally in the abdomen or inguinal canals but can descend into the labia majora. These individuals are not considered ambiguous because of normal external genitalia, even though embryologically, these females represent an extreme form of male pseudohermaphroditism.
E. Hypospadias: Hypospadias occurs in one of every 300 male infants. With this condition, the external urethral orifice is on the ventral surface of the glans of the penis or on the ventral surface of the shaft of the penis. The penis is generally underdeveloped and curved ventrally, known as chordee. There are four types of hypospadias, but glandular and penile types make up 80% of cases.
1. This condition is the result of inadequate production of androgens by the fetal testes, inadequate receptor sites for the hormones, or both. In perineal hypospadias, the labioscrotal folds fail to fuse, and the external urethral orifice is found between the unfused halves of the scrotum. Because in this severe type of hypospadias the external genitalia are ambiguous, those individuals with perineal hypospadias and cryptorchidism (undescended testes) are occasionally diagnosed as male pseudohermaphrodites.
F. Epispadias: This condition occurs in about one of every 30,000 male infants. The urethra opening is on the dorsal surface of the penis.
G. Micropenis: The penis is almost hidden, since it is so small. This abnormality results from a hormonal deficiency of the fetal testes and is often associated with hypopituitarism. A number of uterine and vaginal anomalies result from arrests of development of the uterovaginal primordium during the eighth week of gestation.
H. Double uterus: This results from a lack of fusion of the inferior parts and can be associated with a double or a single vagina. Occasionally the uterus appears normal externally but is divided internally by a thin septum. When only the superior portion of the body of the uterus is involved, the condition is called bicornuate uterus. When one duct has retarded growth and it does not fuse with the other one, a bicornuate uterus with a rudimentary horn develops.
I. Absence of vagina and uterus: This condition occurs in one of every 4000 female births. It results from failure of the sinovaginal bulbs to develop and form the vaginal plate. If the vagina is absent, then the uterus is generally absent, since the developing uterus induces the formation of the vaginal plate.
IRON DEFICIENCY ANEMIA
A. In iron deficiency anemia, the blood is deficient in erythrocytes (red blood cells [RBCs]) and hemoglobin (oxygen-carrying pigment in RBCs). This is the most common type of nutritional anemia in all age groups.
1. Inadequate iron stores at birth from prematurity, low birth weight, severe maternal iron deficiency, and fetal or maternal blood loss.
2. Insufficient daily iron intake during rapid growth in children 3 months to 6 years old, during adolescent years combined with poor eating habits, and during adolescent pregnancy.
3. Excessive milk intake (milk is extremely low in iron) delays or reduces the addition of solid food to the infant’s diet; may also cause an infant to be chubby although nutritionally deficient.
C. Fatigue and shortness of breath occur from reduced hemoglobin levels, which decrease oxygenation of tissues.
IV. Health Concerns/Emergencies
B. Liquid iron temporarily stains teeth; straw or medicine dropper placed at back of throat may be used for administration. Brushing teeth after dosage may lessen discoloration.
C. Black or dark green stools when iron preparation is given; absence of discolored stools may indicate medication is not being administered or compliance is poor.
D. Individuals with iron deficiency absorb lead more easily and are at higher risk for lead poisoning.
A. May have difficulty in academic performance because of low energy level, frequent headaches, and dizziness.
A. Avoid giving medication with meals; giving juices with vitamin C enhances absorption. Coffee, tea, bran foods, milk, and antacids impede absorption of iron. If iron supplements cause vomiting and diarrhea, give them with meals.
B. Avoid giving solid food at or near breast feedings, because it interferes with bioavailability of the small amount of iron in human milk.
E. Assist family in meal planning; provide list of foods high in iron; educate family regarding disease, medication, and dietary compliance.
A. Iron medication is highly toxic and must be kept out of the reach of children. If it is in the classroom, keep it locked in a drawer or cabinet. Usual dosage is 3 to 5 mg/kg of elemental iron per day. Commonly prescribed ferrous iron is more readily absorbed than ferric iron.
B. In cultures where tea is a common beverage, advise giving iron with another beverage, since tea forms an insoluble complex with iron. Some herbal tea may have a negative effect on the absorption of iron.
C. There are various nutritional recommendations: Give infants iron-fortified formula. Give foods containing iron. The best sources are fish, poultry, and meat, especially organ meat; soybeans; dried legumes; dry enriched cereals; and whole grain breads. Other sources are egg yolks; dark green, leafy vegetables; dried fruits, apricots, peaches, prunes, and raisins; nuts and peanut butter; and molasses.
SICKLE CELL ANEMIA
A. Sickle cell disease (SCD) is the term used to describe a number of diseases called hemoglobinopathies, of which sickle cell anemia is the most common. It is a severe, chronic, incurable, anemia characterized by sickle-shaped red blood cells, and it results in acute and chronic organ damage. RBCs with sickle-cell hemoglobin (Hb S) change and become crescent-shaped with the following conditions: low oxygen tension, dehydration, and acidosis.
A. Sickle cell anemia is inherited by an autosomal recessive pattern. The abnormality occurs in the globin portion of the hemoglobin. The hemoglobins (Hb) are identified by letters. Hb A denotes normal adult hemoglobin, Hb AS refers to sickle cell trait (carrier state of one normal hemoglobin gene and one sickle hemoglobin gene), and Hb SS designates sickle cell anemia. Those with SCD have parents who both have the trait. It is one of the most common genetic disorders affecting persons of African descent. The gene is also found in ethnic groups from sections of Turkey, the Middle East, India, the Mediterranean, and the Caribbean. Those with Hb AS demonstrate a mutation with the ability to resist malarial parasites.
B. In the United States, 8% of African-Americans are carriers of the sickle cell trait, and 1 in 500 manifests the disease (NIH, 2005).
C. Most states now perform newborn screening for sickle cell anemia with Hb electrophoresis (Robertson and Shilkofski, 2005).
B. Dactylitis occurs; it is characterized by painful, nonpitting edema of hands and feet and is often accompanied by a fever as high as 103° F (39.4° C); it most frequently occurs from 6 months to 4 years of age.
C. Enlarged spleen in early childhood because of its function in removing sickle cells from circulation; functional activity is generally lost during first few years of life.
D. From approximately 6 to 8 years, spleen decreases in size from repeated infarcts and is replaced by fibrous mass.
E. Splenic sequestration crisis, a sudden pooling of blood in the spleen, generally occurs between 4 months and 3 years of age.
F. Bacterial infections from functional asplenia are a major cause of death in all age groups. Infective organisms: Haemophilus influenzae, Streptococcus pneumoniae, and Neisseria meningitis.
G. Aplastic anemia crisis, which is caused by a decrease in RBC production secondary to an infection.
H. Painful vasoocclusive crisis, in which sickle cells obstruct blood vessels: causes occlusion, ischemia, and possible necrosis, and can potentially affect every organ. In older children, there is pain and tenderness in bones, back, and joints of extremities from infarctions.
I. Central nervous system (CNS) infarction or stroke may appear at any age and can cause paralysis or death.
K. Older children may have cardiomegaly, symptomatic gallstone formation, and damage of the liver, pancreas, and heart from the increased iron absorption.
M. Other possible clinical manifestations are growth retardation, underweight, delayed sexual maturation, frontal protuberance, retinopathy, sensorineural hearing loss, priapism (abnormal, constant, painful penile erection), urinary retention, leg ulcers, and renal complications.
IV. Health Concerns/Emergencies
A. Young children with fever, nonproductive cough, pain, or respiratory distress may have acute chest syndrome (ACS), a life-threatening pulmonary complication. ACS is the second most common condition requiring hospitalization.
B. Aphasia, seizures, visual disturbances, headache, or any other neurologic symptoms may indicate cerebral insult.
D. Spleen sequestration often follows an acute febrile illness, requiring immediate hospitalization. It is one of the most life-threatening complications and is responsible for the highest incidence of death in the young child; symptoms of fever, headache, and nausea may be present.
E. Eleven percent of children have strokes that can lead to lifelong disabilities. The highest risk is between 2 and 5 years of age.
F. Routine blood transfusions seem to decrease the risk for a stroke, based on research using brain ultrasound data. Transfusions pose another risk by increasing iron in the body, which can damage the heart and other vital organs, unless steps are taken to reduce iron levels.
B. Misses school frequently; grades, along with motivation, may drop. Pain may interfere with concentration.
C. Child may not want to spend the night at a friend’s house, because bed wetting is common in some children with sickle cell anemia. Using Depends or similar diapering product may be a solution if done in privacy.
B. Febrile infants with SCD should be seen immediately because of risk of bacterial and subsequent secondary infection.
C. Daily antibiotic (penicillin) treatment beginning at 2 months and continuing to age 5 or 6 can reduce serious infections by about 85%.
D. Review for or vaccinate with H. influenzae type B (HIB) vaccine at age 2 months to protect against life-threatening bacterial infections. Other vaccinations that prevent respiratory complications are advised (National Institutes of Health [NIH], 2002).
E. Encourage fluid intake because of need to maintain hemodilution; dehydration increases the sickling process; 150 ml/kg/day (Nettina, 2006).
G. Routine visual screening up to age 10 and annual retinal examination for sickle retinopathy thereafter. Referral to ophthalmologist in the event of any eye trauma.
H. Routine audiological assessments, because individual is at high risk for sensorineural hearing loss in the high-frequency range due to reduced circulation in the inner ear (vasoocclusive episodes).
J. Educate teachers and other school staff regarding basic concerns during school day, field trips, sports, and other physical activities; have water available for hydration; avoid temperature extremes, stress, overexertion, and fatigue.
K. Be aware of symptoms that require urgent medical care: fever, shortness of breath, chest pain, progressive fatigue, atypical headache, abrupt visual changes, sudden loss of sensation or weakness, unrelieved pain, priapism, and abdominal distention.
A. Prenatal diagnosis for known carriers of hemoglobinopathies is available by chorionic villi sampling (CVS) during the first trimester. Amniocentesis can be done in the second trimester. A simple hemoglobin electrophoresis test can determine if someone is a carrier of the sickle cell trait.
B. If both parents possess the trait, there is a 25% chance that a child will have Hb S. There is also a 25% chance that the child will have neither the trait nor the disease, and there is a 50% chance that the child will have the trait, like both the parents, but not the disease.
C. The drug hydroxyurea reduces the number of pain crises in about 50% of severely affected adults and is also being used in children (NIH, 2002). Bone marrow transplant has been successful in some severely affected children, whereas about 5% to 8% with severe hemoglobin disorders die. Hematopoietic stem cell transplantation has been successful in curing many children. Gene therapy approaches continue to be researched.
D. Vasoocclusive episodes are caused by sickling that is precipitated by a variety of factors (e.g., weather changes, stress, menstruation). A physiological process causes the accompanying pain and is associated with a psychosocial component based on the individual’s tolerance and reaction to pain and family beliefs and interpretations.
JUVENILE ARTHRITIS
A. Juvenile arthritis (JA) is an inflammatory disease of children. There are three main forms of the disease: (1) monoarticular (involving one joint) or pauciarticular (involving four or fewer joints), (2) polyarticular (involving five or more joints), and (3) Still’s disease (systemic onset). JA diagnosis is given when onset is before age 16, and duration lasts longer than 6 weeks without other known cause. The term juvenile arthritis is becoming popular to distinguish more clearly between JA and adult rheumatoid arthritis. JA was previously known as Juvenile Rheumatoid Arthritis (JRA) but JRA applies to a small percentage of children. The newer, broader term is Juvenile Idiopathic Arthritis (JIA).
A. The cause of JA is unknown; present theories include infections, autoimmunity, and genetic predisposition. Approximately 1 in 1000 children has JA (Haftel, 2006).
3. Probable duration of disease, degree of disability, and eventual functional ability are based on onset, type, extent of joint involvement, and extent of systemic involvement. Long-term prognosis is good; about 75% enter long remissions without significant impairment.
4. Early in the disease process, a child may exhibit irritability, fatigue, poor appetite, poor weight gain, growth delay, early morning joint stiffness, and walking with knees flexed to protect inflamed joints and avoid pain.
5. Most common handicapping complications are hip disease or loss of vision because of iridocyclitis (inflammation of iris and ciliary body).
1. Monoarticular and pauciarticular arthritis:
e. Commonly seen in ankle, wrist, hip, cervical spine, and proximal interphalangeal joints, but knee joint is most commonly involved.
f. May not complain of pain; however, can be listless and have difficulty getting up in the morning.
2. Polyarticular arthritis:
c. Seen at any age, but there is a peak in early childhood and again in adolescence with a positive rheumatoid factor.
h. High incidence of involvement of temporomandibular joint (TMJ), causing a receding chin; also involves hips, wrist carpal bones, and cervical spine.
3. Systemic-onset juvenile arthritis:
d. Salmon-colored macular rash frequently comes and goes with fever or may be brought on by hot shower or trauma; appears over trunk or extremities and is nonpruritic.
e. Joint symptoms generally do not appear for several weeks or months and at first are only subjective; warmth, swelling, and tenderness may be observed later.
B. Work with staff to accommodate student’s inability to be punctual because of morning stiffness and pain; allow rest time at school, and have extra sets of text books available, because heavy loads can increase pain. May need shortened day to decrease fatigue.
C. Promote independence in activities of daily living whenever possible, and make adaptive devices available (e.g., railing in bathrooms, elevated commodes).
D. Monitor weight; decreased physical activity may lead to excessive weight gain, causing increased strain on inflamed joints of lower extremities; may be secondary to decreased physical activity. Weight loss can indicate arthritis of TMJ, which causes pain while chewing, malnutrition, poor disease management, and anorexia.
E. Discuss interactions of oral contraceptives with medications, effects of arthritis medications on fetal development, and delayed sexual maturation.
A. Pain and physical limitations may interfere with daily activities and self-care and may contribute to weight gain.
B. Academic performance can suffer from frequent absences from school or inability to concentrate because of discomfort.
C. There may be social isolation from inability to participate in many activities with peers or failure of peers to accept the child who is “different.”
G. May constantly depend on others if limitations prevent the child from doing even simple tasks, such as turning on a faucet, opening a door, or cutting meat.
I. Susceptible to increased dental caries secondary to painful TMJ and poor oral hygiene because of limited use of upper extremities.
A. At risk for chronic iridocyclitis, also called uveitis or iritis. Presence of positive antinuclear antibody (ANA) indicates child—girls especially—at high risk for chronic uveitis, which is the primary treatable cause of blindness in children (Haftel, 2006). Sometimes asymptomatic, but can be detected by a special slit-lamp examination. Need annual ophthalmologic exam.
C. Consult with physical therapist regarding classroom activities, exercises, and positioning that might help preserve function and prevent deformities.
D. Occupational therapists provide information and design therapy for fine motor movements, ADLs, and when TMJ is involved.
F. Splints, braces, and casts are used to immobilize the joints in a neutral position and prevent contractures. Passive, active, and resistive exercises are a daily routine to maintain range of motion and muscle strength. Swimming is an excellent activity.
G. Unconventional therapies introduced by family may interfere with prescribed medical treatment, such as dietary regimens and supplements.
H. Use of surgery is limited but may be performed to relieve pain, correct deformities, or restore range of motion (e.g., soft tissue releases, tendon lengthening, and joint replacements).
I. Medication:
2. The primary drugs for alleviating pain and inhibiting inflammation are nonsteroidal antiinflammatory drugs (NSAIDs), which include naproxen (Naprosyn), tolmetin (Tolectin), indomethacin (Indocin), and ibuprofen (Advil or Motrin). May take up to 8 to 12 weeks to observe improvement. Most common side effect for this group of medications is GI irritation, which may be avoided if NSAIDs are taken with food. Other side effects that may interfere with school include dizziness, headache, and drowsiness.
3. Second-line drugs include disease modifying antiinflammatory drugs (DMARDS), which include gold compound (Solganal), penicillamina (DePen), and hydroxychloroquine (Plaquenil). These are added to the medication schedule when NSAIDs are not effective.
4. Corticosteroids are very strong antiinflammatory drugs used when life-threatening events occur (e.g., pericarditis), when systemic disease does not respond to NSAIDs, and for iridocyclitis.
5. Cytotoxic drugs are prescribed for severe debilitating disease and those not responding to NSAIDs or DMARDS. These are antineoplastics or immunosuppressants, such as cyclophosphamide (Cytoxan) and azathioprine (Imuran).
A. The arthritic process (Figure 4-1) begins with inflammation of the synovial membrane (synovitis) and joint capsule, which increases fluid in the joint (joint effusion), making it feel swollen and boggy. Chronic synovitis may lead to erosion of joint structure and loss of joint space. Immobilization of the joints (ankylosis), bone deformity, and subluxation (partial dislocation) occur over time. These inflammation processes can extend to other systems, causing pericarditis, pneumonia, uveitis, or organomegaly.
B. JA may last as little as several months to a year or may go away indefinitely. Most children have exacerbations and remissions for many years, but the exacerbations tend to diminish over time.
C. Remission is defined as being symptom-free for 6 months after stopping medication. Inflammation has a unique effect on the growing child. Severe arthritis can slow growth (e.g., knee inflammation may inhibit growth compared with an uninflamed knee). May resume normal growth patterns when arthritis is in remission. If the premature epiphyseal fusion has not occurred, the normal height curve will resume within 2 to 3 years.
ASTHMA
A. Asthma is a chronic inflammatory disorder of the airways characterized by airflow obstruction, which is usually reversible either spontaneously or by treatment, and bronchial hyperresponsiveness to a variety of stimuli.
A. The inherited tendency to develop an immunoglobulin E (IgE) mediated response to allergens, known as atopy, is the strongest predisposing factor for developing asthma. Environmental causes include viruses, allergens, or anything that irritates and impacts the respiratory tract. Respiratory syncytial virus (RSV) is one of the viral infections, and exposure early in life can increase the risk of developing asthma. The allergic triggers are generally those carried in the air, such as plant pollens, molds, animal dander, and dust mites. In some instances, no allergic process can be detected. Secondhand smoke, an irritant, can trigger asthma attacks and increase severity of an episode. It is more of a concern in younger children due to their rapid breathing rate. Asthma is a complex disorder in which biochemical, immunological, endocrine, infectious, and psychological factors are involved to varying degrees in different people.
B. In the United States in 2005, 6.5 million children under the age of 18 had asthma, suggesting around 9% of children were affected (CDC, 2006a). Asthma is the number one cause of school absenteeism and is responsible for 12.8 million days of school missed in 2003. It is the most prevalent cause of chronic illness and a leading cause of pediatric hospital admissions (Hall and DeFrances, 2003).
C. Asthma is more common in African-Americans. At a ratio of 2:1, it is more common in boys until adolescence. After puberty prevalence is higher in girls. Childhood asthma is not usually outgrown. Adolescents or young adults may experience relief, but symptoms usually return later.
A. Diagnosis generally occurs between 3 and 8 years of age, and many have symptoms during the first year of life; however, approximately 80% of children with asthma develop symptoms before age 5 (Bloom, Dey, and Freeman, 2006).
B. Diagnosis is based on individual’s health history; family history of asthma, allergy, rhinitis, or sinusitis; spirometry and challenge tests (e.g., histamine, methacholine, cold air); as well as response to appropriate therapy.
1. Plant pollens, molds, dust mites, cockroach droppings, animal dander or secretory products, and air pollutants, especially secondhand smoke.
2. Viral respiratory infections and weather changes (e.g., excessively cold, wet, or humid conditions).
3. Physical exercise or strong emotional expressions (e.g., fear, frustration, or hard laughing or crying).
4. Medications (e.g., aspirin, NSAIDs, β-blockers, eye drops); sensitivity increases with age and severity of asthma; aspirin is in many over-the-counter (OTC) medications, including Pepto-Bismol; these drugs may precipitate a severe or fatal exacerbation in a small percentage of people.
F. Exacerbations are caused by edema or inflammation in the bronchial wall and constriction of the small and large airways in the lungs, which results from bronchial smooth muscle spasm and excessive production of mucus.
G. Children younger than age 5 may experience more airway obstruction than do older children, perhaps because they have smaller airways.
I. Most children with asthma have allergies in the form of rhinitis or atopic dermatitis (Liu, Spahn and Leung, 2004).
J. Mild intermittent asthma is treated with a bronchodilator as needed and does not require daily medication. A child who usually meets the criteria for mild intermittent asthma may have exacerbations during a cold that increase the requirement for rescue medication. The illness may actually require a daily medication for a short period because of the possibility of damage and the ongoing repair process associated with chronic inflammation that could lead to permanent airway damage, called remodeling, which is not responsive to treatment.
K. Mild, moderate, and severe persistent asthma are treated with daily preventive and acute inflammation treatments. Use of inhaled corticosteroids is frequently the recommended treatment (see Box 4-1).
IV. Health Concerns/Emergencies
A. Status asthmaticus, a long lasting or severe asthma episode that does not respond to treatment, can lead to respiratory failure and death.
B. Acute, prolonged asthmatic attack may result in reduced oxygenation. Symptoms of status asthmaticus include restlessness, increased anxiety, and heavy sweating.
C. Silent chest may indicate severe spasm or obstruction with no movement of air and therefore no breath sounds; this condition requires immediate emergency treatment.
1. Difficulty walking or talking (e.g., unable to speak in complete sentences, using phrases or single words).
4. Perioral or nail bed cyanosis are both extremely serious signs that indicate impending respiratory arrest.
C. May be self-conscious about need for medication or monitoring, and may avoid going to health office for assessment or treatment. Some students may carry their own medications.
E. May experience delay in puberty and growth because of disease and corticosteroid use; maximal height usually possible through appropriate disease management.
F. May be negatively affected by the impact this chronic illness has on family routines, economic resources, activities, and dynamics.
G. Increasing control of the treatment plan and self-management by the student, especially in adolescence, improves compliance, diminishes exacerbation, and promotes self-empowerment.
2. Develop IHCP in consultation with parents and HCP; student should have written plans for both school and home care.
1. Student may need 504 plan developed to attain success in school (see Special Education,Chapter 9).
Box 4-1 Classifications of Asthma
Individuals at any level can experience mild, moderate, or severe exacerbations.
Modified from the National Asthma Education and Prevention Program: Expert panel report 2: guidelines for the diagnosis and management of asthma (NIH Pub No 97-4051), Bethesda, Md, 1997, National Heart, Lung, and Blood Institute.
Box 4-2 Sample Questions for the Initial Assessment of Asthma
A “yes” answer to any question* suggests that an asthma condition is likely.
1. Have you had a sudden severe episode or recurrent episodes of coughing, wheezing (high-pitched whistling sounds when breathing out), or shortness of breath?
3. Have you had coughing, wheezing, or shortness of breath during a particular season or time of the year?
4. Have you had coughing, wheezing, or shortness of breath in certain places or when exposed to certain things (e.g., animals, tobacco smoke, perfumes)?
In the past 4 weeks, have you had coughing, wheezing, or shortness of breath:
From the National Asthma Education and Prevention Program: Expert panel report 2: guidelines for the diagnosis and management of asthma (NIH Pub No 97-4051), Bethesda, Md, 1997, National Heart, Lung, and Blood Institute.
NOTE: Most states have laws allowing students to carry medication for asthma and anaphylaxis. Self-administration of medication is allowed when determined appropriate by school nurse, parent, and HCP, and management procedures are in place when necessary. Be knowledgeable about the Nurse Practice Act and state and school district policies and guidelines. The National Association of School Nurses (NASN) has a position statement on asthma.
1. Do breathing exercises and physical training to strengthen respiratory muscles, improve breathing patterns, prevent overinflation, improve cough for clearing the airway, and provide physical and mental relaxation.
1. Use a daily check-off list of factors: respiratory status, medications used, PEFR, adherence to treatment plan, inhaler technique, amount of prn medications needed, side effects of medications, and sleep disturbances. Provide verification of effective protocol or need for change and monitor growth, especially when on long-term inhaled steroids. Avoid obesity; kids usually experience catch-up growth. (see Table 4-1 and Table 4-2).
2. Screen for glaucoma or cataracts when on daily high-dose systemic corticosteroids; otherwise, routine vision screening is acceptable.
1. Controlled breathing, including pursed lips with expiration, may calm a student in respiratory distress, but it does not improve lung function.
4. Consider allergen immunotherapy when individual is sensitive, unable to avoid allergens, medications are not controlling symptoms, and reactions are noted most of the year.
4. Treatment of acute asthmatic episode and correct use of devices (e.g., metered-dose and dry-powder inhalers, nebulizers, space holding chambers).
A. Pregnancy poses risks for the asthmatic, and good asthma control is needed to avoid perinatal mortality, premature delivery, and low birth weight. Most of the medications used for asthma pose little risk to the fetus. Pregnant women generally use Sudafed and antitussives, which are typically not problemlematic during pregnancy.
B. Physical activity is generally not limited; there are Olympic medalists who are asthmatics, including 40 gold medal winners. EIB is associated with hyperventilation of cold, dry air. Thus running, ice skating, and cross-country skiing are difficult, but swimming is an excellent exercise, because it builds up lung capacity without compromising the airway.
1. EIB is caused by pulmonary loss of water and heat when hyperventilation occurs in air that is drier and cooler than the air in the lungs. EIB may be the only symptom of asthma for some students, but the condition should be evaluated to make certain symptoms are under control as much as possible. Symptoms of EIB usually occur during or a few minutes after vigorous exercise; they are generally at their worst 5 to 10 minutes after stopping exercise, and should resolve within a half hour.
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