By developing an asthma education program in day care centers, providers are able to increase their knowledge on how to offer better care for asthmatic children.

Asthma is a chronic inflammatory disorder of the airways, characterized by intermittent, recurrent episodes of wheezing, breathlessness, chest tightness, and cough. In the United States more than 17 million people have asthma.1 It is the most common chronic disease of childhood, affecting almost 5 million children. One out of five children are born with a genetic tendency toward asthma.

Acute asthma episodes are among the most frequent causes of hospital admissions, costing an estimated $9.8 billion per year in direct medical expenditures and $2.8 billion per year for indirect costs such as parents’ absenteeism from work; they are the number one reason for school-aged children’s absenteeism.2

In the United States, the incidence of asthma has risen steadily during the past decade, with the most substantial increase occurring among children up to 4 years old.3,4 Asthma hospitalization rates are the highest among blacks and children. Collectively, people with asthma have more than 100 million days of restricted activity, 470,000 hospitalizations, and 5,000 deaths annually. However, asthma morbidity and mortality are largely preventable with improved patient education regarding the factors associated with asthma and medical management of asthma. The key is early recognition of signs and symptoms of asthma, environmental controls, combined with patient education and aggressive therapy.

According to the National Asthma Education and Prevention Program (NAEPP),5 effective asthma management includes pharmacologic therapy, objective measures of lung function, environmental control, and patient education. NAEPP encourages asthma awareness in all schools to help teachers and children learn about asthma. However, programs for day care providers are not mandatory or easily accessible. Many of the nearly 5 million children with asthma will spend time in the day care environment daily, in some cases 8 hours or more a day. Therefore, it is important that all day care providers develop skills in the management of the asthmatic child.

Survey of Day Care Providers
In May 1999, the American Lung Association of Kentucky (ALA of KY) funded a “mini-grant” designed to define and address asthma education among day care providers in the northern Kentucky area. The project called for a survey of the 126 state-licensed day care providers in the northern Kentucky counties of Boone, Bracken, Campbell, Gallatin, Grant, Kenton, Owen, and Pendleton (Figure 1). According to the ALA of KY, almost 70,000 children in Kentucky have asthma; this figure includes nearly 6,200 children in the counties covered by this project.

The asthma survey questionnaire sent to the licensed day care centers included true/false and yes/no questions regarding the day care providers’ experience with asthmatic children. A total of 148 questionnaires were returned from 54 day care centers, for a respond rate of 43% of all licensed centers. All of the responding centers accepted or would accept a child with a history of asthma; however, only 26% of the respondents had received some form of asthma education.

Twenty percent of the respondents acknowledged that they had been involved in the treatment of a child with asthma while at day care on more than one occasion in the last 6 months, with 14% of these respondents stating that they had been involved in the care of an asthmatic child more than 11 times in the last 6 months. It suggested that some day care centers had children with uncontrolled asthma who required frequent treatment from staff members.

When asked on the survey to select five common symptoms of asthma, the respondents chose the following responses: wheezing (98%); breathlessness (98%); cough (87%); cough on exertion (58%) and chest pain (58%); difficulty sleeping (47%); nausea (3%); vomiting (3%); and fever (2%). This suggested that the respondents could identify an asthma attack if a child were to have one while under their care.

However, when they were asked a series of true/false questions regarding the severity of an asthma attack, 64% of respondents were unsure of how to recognize the severity of an attack. One-third of the respondents were unfamiliar with peak flow meters and spacers, and were not routinely using them to enhance medication delivery or assess asthma symptoms; 58% said they did not know enough about asthma to ensure the safety of the child in their care if he or she were to suffer an asthma attack under their supervision. When asked about restricting a child’s activity, no one responded that they would restrict the physical activity of a child just because of a history of asthma and/or would premedicate the child if there were written directions.

The survey results supported the original hypothesis that many area day care centers accept children with asthma, but they are unfamiliar with the disease and how it is treated, or what can trigger an asthma attack.

“A” is for Asthma Workshop
After analyzing the survey results, an asthma education workshop was developed to address the specific needs of day care providers in the northern Kentucky area. In Kentucky, licensed day care providers are required to participate in at least 12 clock hours of child development training each year for continued licensing. The asthma workshop developed was approved for 3 clock hour credits by the Cabinet for Health Services of the Commonwealth of Kentucky and offered free as an incentive to attract workshop participants. Upon completion, providers received a certificate verifying their participation. Workshop leaders were a registered respiratory therapist and four second-year respiratory care students. The workshop was offered on three different occasions, for a combined draw of 106 day care providers.

The overall goal of the “A” Is for Asthma Workshop for Day Care Providers was to improve asthma education among providers, especially in the areas of asthma signs and symptoms, medications and delivery methods, and peak flow meters. This goal was congruent with the ALA of KY mission to fight lung disease. The theme for the workshop came from an asthma education kit produced by the ALA along with the Children’s Television Network called “A” Is for Asthma. This is an educational program in English and Spanish designed for child care professionals. The kit contains a 7-minute video about a young child with asthma named Dani. With the use of characters from Sesame Street, children learn about asthma, some common asthma triggers, and how to help a young friend experiencing trouble breathing. The kit also contains posters emphasizing the important points of the video. At the conclusion of the workshop, a representative from each day care center received one of these kits.

The 3-hour program included basic background information on asthma and allergies, medications used to treat asthma, asthma warning signs and symptoms, and hands-on demonstration of nebulizers, metered-dose inhalers with spacers, and peak flow meters. The content of the program is at a level that non-health care professionals can understand. At the beginning of the workshop, each individual received a folder of asthma information. In the folder was placed a vocabulary list of terms used frequently to describe asthma and asthma management such as allergen, asthma, asthma management, controller medications, environmental control, metered-dose inhaler, trigger, and wheezing. The list defined the terms in a precise, clear, and understandable fashion. The workshop format included the use of standardized slides, scripts, as well as handouts for participants to take back to the workplace for references. All of these materials comply with the 1997 NAEPP Expert Panel Report 2 guidelines.

The slides covered the basic anatomy and physiology of the respiratory system, pathophysiology of airway narrowing, signs and symptoms of asthma, allergy symptoms, environmental control methods that help reduce asthma episodes, and how to properly use medications and tools for asthma management such as inhalers and peak flow meters. Hands-on demonstrations covered medications and equipment and were led by the second-year respiratory care students.

A large poster was created, which demonstrated the correct use of a metered-dose inhaler with a spacer. The poster included step-by step instructions along with visual aids. Individuals were encouraged to take as many posters as were necessary for their centers to serve as reinforcement aids and to assist providers who were not in attendance at the workshops.

Each participant also received an asthma action plan worksheet. The instructor recommends that the day care provider have an action plan for each child who has asthma. The child’s physician completes the asthma action plan. It tells the provider what medications the child is taking, what the child’s personal best peak flow is, and any other pertinent history. The plan contains an algorithm for the management of an asthma exacerbation, giving the provider directions in the management of an acute attack.

Workshop evaluations included a pre-test and post-test on basic asthma information at the beginning and end of the workshop. The average pre-test score was 50% and average post-test score was 86%, suggesting that indeed participants did increase their knowledge on basic asthma information and how to provide better care for asthmatic children.

Workshop attendees also completed a program evaluation. Overall, the evaluations were positive, stating that the program was informative, interactive, and very beneficial. One comment stated that this workshop contained much needed information and was a worthwhile program for all day care providers.

What RTs Can Do
When asthma happens to children, they are unaware of the dangers, warning signs, or consequences. They trust their parents and other providers to take care of them. By helping day care providers learn the child’s early warning signs and how to respond to them, respiratory therapists can make a difference. During the asthma workshop, common asthma triggers such as infection, dust, mold, colds, pets, exercise, and tobacco smoke should be reviewed as well as how to institute environmental control measures.

Child care providers should not be alarmed when they notice signs of an impending asthma episode, but should take the appropriate action based on the asthma care plan provided by the physician and parents. Once the diagnosis of asthma is made, parents should obtain a specific plan from the child’s physician for daytime care and share this information with the child’s daytime provider. By reviewing common asthma signs and symptoms during an asthma education program, respiratory therapists can play a vital role in ensuring the special needs of an asthmatic child are met while the child is not in the home environment.

Resources
Currently, there are several resources available to therapists and other health care professionals interested in being involved in asthma education programs. The NAEPP has developed documents that RCPs and parents can use to introduce the concept of indoor air quality and its impact on asthma to school personnel called “How Asthma-Friendly Is Your School?” While designed for the school environment, the seven-question checklist or questionnaire can easily be adapted to the day care environment. Copies of both the questionnaire and checklist can be downloaded from the National Heart, Lung, and Blood Institute Web site at www.nhlbi.nih.gov/health/public/lung/asthma/friendhi.htm.

For those looking for a more thorough program, the Environmental Protection Agency (EPA) has an initiative called “Indoor Air Quality (IAQ) Tools for Schools.” While this comprehensive program is designed for schools, the kit contains a quick checklist that can help day care centers identify whether they have a problem with indoor air quality. The entire kit can be downloaded for free from the EPA’s Web site at www.epa.gov/iaq/schools.

The Allergy and Asthma Network Mothers of Asthmatics Inc (AAN-MA) has developed a booklet called “Breathing Easy With Daycare.” This booklet is targeted for parents and child care providers and serves as a guide about asthma and allergies.

The American Association for Respiratory Care (AARC) program “Peak Performance USA” uses RTs who volunteer their time to go into local schools to teach school nurses how to care for their asthmatic students. More information on this program can be obtained by contacting the AARC at (972) 243-2272 or www.aarc.org.

This year the Asthma and Allergy Foundation of American (AAFA) is launching a course called Asthma and Allergy Essentials for Child Care Providers on a national level. More information can be found at the AAFA Web site at www.aafa.org.

Conclusion
Day care providers have a role to play in asthma management in young children for whom asthma is not always managed optimally. The results of this survey of day care providers showed that many had experience in managing asthma attacks for children in their care, yet the vast majority of day care providers have no formal training in asthma management. Therefore, it is important that an asthma management plan be in place at day care centers to help ensure the children’s health and safety.

The findings of this limited survey indicated a need for asthma education among day care providers. By developing an asthma education program, participants in the program were able to increase their knowledge on how to provide better care for asthmatic children in their day care centers.

Debra K. Kasel, MEd, RRT, is assistant professor and clinical coordinator for the respiratory care program at Northern Kentucky University, Highland Heights.

References
1. US Centers for Disease Control and Prevention. Surveillance for asthma—United States 1960-1995. MMWR. 1998;47:1-27.
2. Trends in asthma morbidity and mortality. American Lung Association Epidemiology and Statistics Unit. November 1998.
3. US Centers for Disease Control and Prevention. Asthma mortality and hospitalization among children and young adults—United States, 1990-1993. MMWR. 1996;45:350-353.
4. US Centers for Disease Control and Prevention. Asthma—United States 1989-1992. MMWR. 1995;43:952-955.
5. National Asthma Education and Prevention Program; National Institutes of Health; National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report 2. United States Department of Health and Human Services; 1997. NIH Publication 97-4051. Bethesda, Md.