Only 3 in 10 schools were equipped to manage a child’s asthma symptoms, a new study in Pediatrics reported.

The findings suggest that better, proactive models are needed to coordinate school asthma care, according to investigators led by Chén C. Kenyon, MD, MSPH, a pediatric hospitalist and assistant professor of pediatrics at Children’s Hospital of Philadelphia (CHOP) in Philadelphia.

Interestingly, having more in-school asthma exacerbations in the preceding year was associated with greater school readiness. A chief factor in preparedness was the presence of an asthma-aware school nurse.

The authors concluded that school children could benefit from a more proactive approach to asthma care regardless of asthma exacerbation history. “ The ultimate goal is to strengthen coordination between health systems and schools to make sure children’s schools have the information and medications to manage asthma symptoms,” Kenyon told Medscape Medical News. Partnerships might include automated data-sharing, community health workers bridging the clinic-school settings, school-based asthma therapy programs, and school-stocked albuterol.

Asthma affects 7% of US children and is a leading cause of healthcare disparities, disproportionally affecting low-income children living in urban environments.

The CHOP group’s findings aligned with studies from other large US cities. Communication between our healthcare and education systems requires privacy information releases on both sides and delivery of forms and medications by hand between clinic and school. “It’s a lot for doctors, parents/caregivers, and educators to coordinate.”

Study Details

The current paper is a retrospective, nested cohort subanalysis of the larger randomized West Philadelphia Asthma Care Implementation study.

It assessed the baseline proportion of children whose schools had elements of necessary asthma care, including documented awareness of asthma diagnoses, non-expired rescue medication, and an up-to-date care plan. The investigators formulated a “school asthma readiness” composite and used ordinal logistic regression to model the association between number of asthma exacerbations in the past year and the composite, accounting for demographic, clinical, and school characteristics.

Of 202 eligible participants aged 5-13 years, most identified as Black (95%) and non-Hispanic (98%). Most children were younger than 12 years (87%) and had public health insurance (91%).

Clinically, 46% of participants had a BMI at or above the 85th percentile, 48% had poor baseline asthma control according to the asthma control questionnaire, 73% had visited the emergency department, and 34% had been hospitalized overnight for asthma in the 12 months before enrollment.

The majority (64%) attended public schools with a median enrollment of 538 students. Although 79% of schools were aware of a child’s asthma diagnosis, only 31% possessed reliever medications and valved holding chambers and just 7% had asthma care plans.

Contrary to the authors’ working hypothesis, asthma exacerbations in the previous year were associated with significantly higher, not lower, school readiness in bivariate and multivariable analyses: odds ratio (OR), 1.44 (95% CI, 1.14-1.82; P = .002) and OR, 1.31 (95% CI, 1.02-1.7; P = .037), respectively.

Additionally, schools with larger enrollments were less likely to be asthma-ready, perhaps suggesting a less favorable ratio of trained asthma managers and nurses to students.

Socioeconomic factors also came into play, with most children coming from low-income households. The burden is placed on parents and caregivers to ensure that the necessary forms and medications are on hand at school.

Even if their children have access to asthma medications and devices at home, how should these mostly low-income parents ensure that other systems are prepared? “It’s a lot to ask of families who are dealing with a heavy set of daily burdens. Healthcare and education systems can help ease this burden,” Kenyon said.

But with so many information resources available to produce asthma-friendly schools, why is readiness not closer to 100%? This question was posed by epidemiologist Wendy M. Brunner, PhD, and pediatrician Chris L. Kjolhede, MD, MPH, of the Bassett Research Institute in Cooperstown, New York, in a related editorial.

Barriers to readiness, the commentators suggested, may include school nurse shortages, inadequate training for staff, lack of family-supplied medication stored at school, and families’ failure to deliver action plans to healthcare providers.

While adequate access to school nurses is a major advantage, Brunner and Kjolhede suggested that models such as school-based health centers (SBHCs), separate from but coordinating with the nurses’ office, may be another viable avenue for improving students’ asthma care.

Staffed by advanced care clinicians, SBHCs can work with families to create asthma action plans, share them with school nurses, and even prescribe medication. “SBHCs can address acute asthma issues while the student is at school…[and] may also be able to provide students with direct access to asthma specialists via telehealth,” they wrote.

They also noted that asthma preparedness ideally goes beyond medical supplies, training, and school nurses and may include in-school air filtration and mitigation of exposure to outdoor asthma triggers like diesel exhaust and other outdoor air pollutants.

For Kenyon, the major priority is seamless systems of communication and information sharing between health systems and schools. His group is working on streamlining consent waivers, allowing school nurses to access children’s health records, medication delivery to schools, and healthcare or community navigators as intermediaries between clinics and schools.

This study was supported by the National Heart, Lung, and Blood Institute. Kenyon had no conflicts of interest. Brunner reported being supported by the National Institutes of Health.

The editorial commentators had no conflicts of interest.