Pediatric Asthma

Air pollution levels linked to 16% of pediatric asthma cases globally

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Combustion-related nitrogen dioxide pollution appeared to significantly contribute to pediatric asthma incidence globally, particularly in urban areas, according to data published in The Lancet Planetary Health.

“Decades of research provide strong evidence that air pollution is bad for cardiovascular and respiratory health, but little information exists about the pollution levels and associated health consequences that cities around the world are experiencing,” Susan C. Anenberg, PhD, associate professor of environmental and occupational health and of global health at George Washington University, told Healio. “Because most cities globally lack air quality monitoring, our study is the first time that many cities have access to information about their air pollution levels and what they mean for children’s health.”

Smoke coming out of smokestacks
Source: Adobe Stock

Anenberg and colleagues evaluated the long-term trends of annual average nitrogen dioxide (NO2) concentrations and how they correlated with pediatric asthma burdens in 13,189 urban areas globally from 2000 to 2019.

The researchers utilized an existing annual average NO2 concentration dataset for 2010 to 2012 from a land use regression model — based on 5,220 NO2 monitors in 58 countries and land use variables — to model additional years using NO2 column densities from satellite and reanalysis datasets. These concentrations were then applied in an epidemiologically derived concentration-response function with population and baseline asthma rates to estimate pediatric asthma incidence attributable to NO2.

Anenberg and colleagues estimated that, in 2019, 1.85 million (95% uncertainty interval [UI], 0.93-2.8) new pediatric asthma cases were attributable to NO2 globally, with two-thirds of those cases occurring in urban areas (1.22 million cases; 95% UI, 0.6-1.8).

“We found that over three-quarters of cities globally have nitrogen dioxide levels that exceed World Health Organization guidelines. As a result, we estimated that in 2019 about 16% of new cases of asthma among kids in urban areas were from breathing nitrogen dioxide. Globally, that’s down from about 20% in 2000, but the trend differs by world region,” Anenberg told Healio.

That 16% figure equated to 1.24 million pediatric asthma cases attributable to NO2 out of 7.73 million total cases in 2019.

Urban attributable fractions rose between 2000 and 2019 in south Asia (+23%), sub-Saharan Africa (+11%) and north Africa and the Middle East (+5%). However, they decreased in “high-income” countries, including those in Australasia, high-income Asia Pacific, high-income North America, Southern Latin America and Western Europe (–41%); Latin America and the Caribbean (–16%); central Europe, eastern Europe and central Asia (–13%); and southeast Asia, east Asia and Oceania (–6%).

Researchers noted that the contribution of NO2 concentrations, pediatric population size and asthma incidence rates to the change in NO2-attributable pediatric asthma incidence varied regionally.

“Our study shows the importance of considering demographic changes over time for understanding air pollution health risks,” the researchers wrote. “Improved and more widely accessible information about disease rates, and capturing population distribution and movement, will enable more accurate and highly resolved air pollution health impact assessments.”

Pediatric Asthma Admission Is Less Likely with Early Steroid Administration.

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Every 30-minute delay in steroid treatment increased odds of admission.

In a prospective observational study, researchers assessed whether early administration of corticosteroids reduces hospital admission in children (age range, 2–17 years) with moderate to severe asthma exacerbations (Pediatric Respiratory Assessment Measure score 5 to 12). Of 406 children (median age, 4 years) who presented to a single pediatric emergency department (ED) in Montreal during a 3-month period, 50% received corticosteroids early (within 75 minutes of triage), 33% received corticosteroids late (>75 minutes), and 17% did not receive corticosteroids. The ED’s clinical pathway recommended systemic prednisone or prednisolone (1mg/kg; maximum, 50 mg) administered within 60 minutes of triage.

Overall, 36% of patients were admitted or had prolonged ED length of stay (>6 hours), and 6% relapsed within 72 hours of ED discharge. Patients who received corticosteroids early were less likely than those who received corticosteroids late or not at all to be admitted or have prolonged ED stay (odds ratio, 0.07). For every 30-minute delay in corticosteroid administration, active ED treatment time increased by 60 minutes and odds of admission increased by 1.23. Delays were less likely in patients with severe asthma exacerbations (Pediatric Respiratory Assessment Measure score 8; OR, 0.17). Compared to patients who received delayed treatment, those who did not receive corticosteroids had lower admission rates and shorter active ED treatment time (OR, 0.1 and –2.2, respectively). Factors associated with not receiving corticosteroids included preschool patient age (OR, 2.50), lower triage priority (OR, 11.26), physician graduation more than 20 years prior (OR, 3.32), and nonpediatric emergency medicine specialty or general practitioner (OR, 3.33 and 4.82, respectively, compared to pediatric emergency specialty).

Comment: Although children who did not receive corticosteroids had less severe asthma, steroids would still be indicated for them. The finding that provider characteristics were associated with no corticosteroid administration indicates a need for education and implementation of evidence-based treatment pathways. As previously shown, triage administration of steroids for asthma is feasible and effective for preventing unnecessary admissions (JW Emerg Med Apr 13 2012).

Source: Journal Watch Emergency Medicine.