Quality of life in children with
bronchial asthma
Wander A1, Bhargava S2,
Pooni P.A.3, Kakkar S 4, Arora K 5
1Dr. Arvinder Wander, Senior Resident, Department of Pediatrics, AIIMS,
New Delhi, 2Dr. Siddharth Bhargava, Assistant Professor, 3Dr. Puneet A
Pooni, Professor and Head, 4Dr. Shruti Kakkar, Assistant Professor, 5Dr. Kamaldeep Arora, Assistant Professor, above authors are affiliated
with department of Pediatrics, Dayanand Medical College and Hospital,
Ludhiana, Punjab, India
Address for
Correspondence: Dr Siddharth Bhargava, Assistant
Professor, Department of Pediatrics, Dayanand Medical College and
Hospital, Ludhiana, Punjab. Email: siddharthb27@gmail.com
Abstract
Introduction:
Bronchial asthma is one of the most common childhood diseases. It
imposes significant burden on children’s health related
quality of life despite the availability of effective and safe
treatment. So, this study was conducted to assess the quality of life
(QOL) in children with bronchial asthma and to study the impact of
various clinical and socio-demographic factors on their QOL. Methods:
Observational, hospital based study conducted in Pediatric chest clinic
of a tertiary care teaching Hospital on children between 7-17 years of
age, newly or previously diagnosed with bronchial asthma over a period
of one year. Using the Pediatric Asthma Quality of Life Questionnaire
(Standardized), (PAQLQ(S)) the quality of life was assessed in relation
to clinical and socio-demographic data among newly diagnosed and
follow-up cases of asthma. Results:
Of the 90 children enrolled, 20 were newly diagnosed and 70 were follow
up cases with male female ratio of 2.1: 1. Children reported more
impairment in PAQLQ(S) scores if the onset of symptoms was before one
year of age, in those with frequent exacerbations, poor treatment
compliance, poorly controlled symptoms and Children with history of
school absenteeism. The mean PAQLQ(S) score was lowest in emotional
function among newly diagnosed and follow up cases. Statistically
significant difference was observed between PAQLQ(S) scores of
controlled, partly controlled and uncontrolled cases of asthma. Conclusion: Although
children improved clinically with treatment, asthma had a significant
impact on emotional status of the children.
Keywords:
Limitation of activity, Asthma severity, Emotional function, Pediatric
Asthma Quality of Life Questionnaire (Standardized), PAQLQ(S), School
absenteeism
Manuscript received:
2nd June 2017, Reviewed:
11th June 2017
Author Corrected:
20th June 2017, Accepted
for Publication: 28th June 2017
Introduction
Bronchial asthma is one of the most common childhood diseases and is a
leading cause of emergency care requirements as well as a cause for
considerable morbidity, disability and occasional mortality at all
ages. While managing a patient with any disease, conventional clinical
measures usually provide valuable information about the status of the
affected organ system, but they rarely capture the functional
impairments (physical, emotional, and social) that are important to
children in their everyday lives. There is now clear evidence that the
clinical indices only weakly correlate with how the child is feeling
and how the child functions in everyday situations. To obtain a
complete picture of a child’s health status, both
conventional clinical indices and the child’s Health related
quality of life (HRQL) have to be measured. In addition, investigators
have shown that parents may not perceive their child's asthma related
quality of life accurately [1].
Very few studies have been conducted in India to measure quality of
life in children suffering from asthma. So this study was initiated to
know the quality of life in children suffering from asthma, their
problems and areas in which they lag behind their colleagues.
Methods
Design: Prospective,
observational study conducted over one year, 1st April 2013 to 31st
March 2014.
Setting: Pediatric
Chest Clinic in the Department of Pediatrics, Dayanand Medical College
and Hospital, Ludhiana.
Inclusion criteria: Children
in the age group of 7-17 years, newly or previously diagnosed with
bronchial asthma.
Exclusion criteria:
Patients who did not give consent for the study, children with other
co-existing chronic diseases, developmental retardation or inability to
answer PAQLQ(S) questionnaire.
Diagnosis and assessment of severity of bronchial asthma in the current
study was done as per "Asthma by Consensus (ABC)" guidelines of Indian
Academy of Pediatrics (IAP).[2] Grades of severity of asthma at initial
diagnosis were categorized into intermittent, mild persistent, moderate
persistent and severe persistent on the basis of day time and night
time symptoms and those who were already on treatment were categorized
into controlled, partly controlled and uncontrolled as per day time
symptoms, limitations of activities and nocturnal symptoms.
The study was approved by the Institutional Ethics Committee and
informed consent was obtained from caregivers of the enrolled children.
The enrolled Children were given Pediatric Asthma Quality of Life
Questionnaire (Standardized), PAQLQ(S). Permission was also taken for
using PAQLQ(S) from Elizabeth Juniper on behalf of QOL Technologist
Ltd. through the institution.
The PAQLQ(S) has been developed to measure the functional (physical,
emotional, occupational and social) problems that are most troublesome
to children of 7-17 years with asthma. [3] PAQLQ(S) has 23 questions in
three domains (symptoms, activity limitations and emotional function).
Children were asked to recall their experiences during the previous
week and to respond to each question on a 7-point scale (7 = no
impairment, 1 = severe impairment). Hence, a low score meant poor
'Health related quality of life'(HRQL). Individual questions were
equally weighted. The overall PAQLQ score was calculated as the mean of
the responses to each of the 23 questions. The resultant overall score
was between 1 and 7. The individual domains were analyzed in exactly
the same way. Two types of questionnaires were used - self administered
and interviewer administered. Children of age ≤ 10 year were
given interviewer administered questionnaire and children of age
> 10 years were provided self administered questionnaire.
Individual variables evaluated included clinical and socio-demographic
characteristics. Association between mean PAQLQ(S) scores and
individual variables was evaluated.
Symptom analysis (cough, wheeze etc) was done and various factors like
age of onset of symptoms, frequency of day time and night time symptoms
were asked. Details such as age at which asthma was first diagnosed,
history of exacerbations and their predisposing factors, number of OPD
visits, admissions and whether missing school because of asthma
symptoms were noted. Treatment details including compliance to
treatment were recorded. In case of non adherence, factors responsible
for non adherence were noted down.
All the factors mentioned above were considered for comparing quality
of life in children with bronchial asthma. With respect to overall mean
score as well as individual domain score mean of PAQLQ(S) comparison
for quality of life was done between different grades of severity of
asthma. Two groups were considered for comparison. First was newly
diagnosed cases (those who presented first time in OPD) and second
group comprised of follow up cases (those who were already on
treatment). No controls were taken for the study.
Statistical analysis-
Results were expressed as mean SD (Standard deviation) or number
percentage. Comparison of different parameters between groups was
performed using unpaired t-test and for more than two groups using
ANOVA. Comparison between categorical data was performed using
chi-square test and data was considered significantly if P value
0.05. Statistical analysis was performed with aid of SPSS version 17.0.
Results
A total of 90 children were enrolled in the study, out of which 20
children were newly diagnosed and 70 were follow up cases with male
female ratio of 2.1: 1. Maximum children were in the age group of 7 to
12 years (n= 67, 74.4%) followed by 13 to 17 years (n= 23, 25.6%). Of
these, 52 children (57.8%) were given interviewer administered and 38
children (42.2%) were given self administered PAQLQ(S) questionnaire.
The overall and individual domain PAQLQ scores were comparable in the
age ranges of 7 to 12 years (Mean ± 2 SD= 4.920.87) and 13
to 17 years (5.020.80);(P= 0.636).
Children were also categorized into different age groups according to
the age of onset of symptoms and its relationship to PAQLQ was studied.
Minimum mean score was recorded in those with onset of
symptoms
< 1year of age (overall mean score 4.19). There was
statistically significant adverse impact on quality of life in activity
limitation domain (p value = 0.039) and emotional function domain (p
value = 0.007) in children who had onset of symptoms during infancy.
Age of onset of symptoms <1 year was associated with maximum
impairment of quality of life (activity limitation score = 4.03,
symptom score = 4.23, emotional function score = 3.60). Emotional
function was the most impaired domain in all the age groups that were
studied.
Children who had asthma exacerbations had less overall mean score
(4.11) as compared to those who did not have exacerbations (overall
score mean = 5.08) which was statistically significant (P = 0.001).
Children who had asthma exacerbations reported more impairment in the
emotional function domain (3.831.11) than in symptoms (3.901.05) and
activity limitations (4.241.02).
About 31 Children (34%) gave history of missing school due to Asthma
symptoms. Out of these, 17 (54.8%) children belonged to moderate
persistent category and 7 (22.6%) children each were from mild
persistent and intermittent category respectively. Children who had
history of missing school because of asthma had an overall mean score
of 4.63, compared to a score of 5.11 in those who did not miss school (
P= 0.008). These Children reported significantly more impairment in the
domains of activity limitations than in symptoms and emotional function
(P = 0.001). The number of OPD visits and frequency of asthma related
admissions did not impact the PAQLQ score.
Out of the 20 newly diagnosed cases 10 (50%) were mild persistent, 7
(35%) were intermittent and 3 (15%) were moderate persistent. None of
the patients had severe persistent asthma. Overall score mean was
highest in intermittent category (overall score mean = 5.58, activity
limitations = 5.77, symptoms = 5.41, emotional function = 4.95) and was
minimum in moderate persistent category (overall score mean = 3.87,
activity limitations = 4.20, symptoms = 3.73, emotional function =
3.25). Among all categories of severity most impaired domain was
emotional function ( P= .011), followed by symptoms (P = .017) and
least impaired was activity limitations( P = .007).
Out of the 70 follow up cases, the overall score mean and individual
domain score mean was highest in controlled, followed by partly
controlled and least in uncontrolled category (Overall score mean P =
0.001, activity limitations P = 0.001, symptoms P = 0.005, emotional
function P = 0.003) .The most affected domain was emotional function
followed by symptoms and least affected was activity limitation.
Amongst the children who were categorized as Intermittent at initial
diagnoses 83.3% were controlled and 16.7% were partly controlled on
follow up. None of them was in uncontrolled category. In the mild
persistent category, 65.4% were controlled, 30.8% were partly control
and 3.8% were uncontrolled. Maximum number of poorly controlled
patients (uncontrolled 43.8% and partly controlled 40.6%) were seen in
moderate persistent category.
With regard to treatment compliance, 49% children were adherent to
treatment. Their overall score mean as well as individual score mean
was higher than those who were not adherent to treatment (Overall score
mean P < 0.001, activity limitations P = 0.001, symptoms P =
0.001, emotional function P < 0.001). The maximum score was
observed in activity limitations, which signifies that those who were
adherent had maximum improvement in activity scores and least in
emotional function.
Discussion
This observational study was aimed at assessing the factors affecting
the quality of life in children suffering from bronchial asthma.
PAQLQ(S) [Pediatric asthma quality of life questionnaire standardized]
developed by Juniper et al. formed the basis of the study [3,4]. Asthma
related Quality of Life was maximally affected in children below one
year, those who had frequent exacerbations, poor treatment compliance
and poorly controlled symptoms.
In our study, PAQLQ(s) scores of all 3 domains were lowest in children
who developed symptoms before one year of age. It could probably be
because bronchiolitis and other lower respiratory tract infections
which are more common in infancy are known to be an antecedent for
subsequent wheezing and asthma during childhood. The same was observed
in another study [5]. Severe respiratory ailments during infancy might
predispose infants to malnutrition during a crucial phase of growth and
hence adversely affect the subsequent quality of life during childhood.
In the current study, children who had exacerbations of asthma had
significantly less overall mean score as compared to those who did not
have exacerbations. Children who had asthma exacerbations reported
maximal impact on emotional functional domains and least effect on
activity limitations. The reason could probably be that hospitalization
of children because of asthma exacerbations and IV medications given
during hospital stay may cause adverse emotional impact on children.
This result is similar to another study [6]. They reported a
significant decrease (P<.001) in Mini-AQLQ domain scores with
increasing severity of asthma exacerbation. Another fact noted in our
study was that 31 children (34%) had history of missing school because
of asthma symptoms. These children had significantly lesser mean scores
compared to those who did not miss school and the maximum impact was on
activity limitation. Similarly, a western study evaluated the impact of
uncontrolled asthma on school absenteeism and health-related quality of
life (HRQL) [7]. They concluded that 70% children with uncontrolled
asthma versus 45% with controlled asthma missed school, with a median
of 6 days versus 4 days missed respectively (during the study period).
The PAQLQ score in our study was not affected by the number of OPD
visits or frequency of asthma related admissions.
Our study also demonstrated that as the grade of severity of asthma
increased, the quality of life got more impaired both in newly
diagnosed as well as follow up cases. The impairment was maximum in the
emotional domain. Moreover, patients with severe asthma reported more
limitation in their activity score as well, a finding that is similar
to results published from previous studies conducted in Serbia[8] and
Iran [9]. Yet another study found that the overall HRQL score was lower
in children with severe asthma compared to those subjects in whom
asthma was controlled (5.4 vs. 6.7, p<0.001) [10]. According to
the Serbian study, impairment in the activity limitation domain is
explained by the patient's concerns about exacerbating their asthma.[8]
It is logical that these children would avoid any activities that could
trigger an asthma attack. Similarly, in our study children with
moderate persistent asthma had more activity limitation as compared to
mild persistent and intermittent categories (P <0.007).
Similarly, another Indian study concluded that mild to moderate QOL
impairment occurred in activity domain (mean score 5.17) and emotional
domain (mean score 5.00) [11].
In the current study, among intermittent, mild persistent and moderate
persistent asthma cases most impaired domain was emotional function,
followed by symptoms and least impaired was activity limitation.
However, a study done by Farnik and Coworkers showed different results
from our study [12]. They concluded that in the children studied, the
most impaired domain was activity limitation.
The same trend was observed in patients who were already on follow up,
with the lowest PAQLQ scores in uncontrolled patients and highest
scores in the controlled group. In our study mean score among follow up
cases was maximum in activity limitation domain in all three categories
(controlled, partially controlled and uncontrolled cases) and mean
score was minimum in emotional function domain in all categories. It
was also observed that overall improvement in children's HRQOL occurred
with treatment. However, least statistically significant change
occurred in emotional function domain of PAQLQ(S) even after
improvement in asthma symptoms.
Similarly, when follow up children of each category were individually
compared for HRQL scores in relation to their initial severity at
presentation, it revealed maximum improvement in activity limitation
followed by symptoms perception and least in emotional function. It
indicates that although significant improvement was achieved in the
activity level and symptoms, these children did not recover emotionally
from the impact of the disease despite treatment. Our study results are
similar to another Indian study [13]. Statistically significant
improvement in the activity limitation and the symptom category of the
mini PAQLQ (P<0.001) after treatment was noted. There was also a
significant change in the mean grand total scores showing an overall
improvement in the child's condition with medical intervention.
However, no statistically significant change was noted in the emotional
domain of the mini PAQLQ even after medical intervention.
Another fact brought out in the study was that adherence to treatment
was associated with improved HRQOL both in the overall score and
individual domains, which was also demonstrated by studies done in
Brazil [14] and Egypt [15] respectively.
Conclusion
Thus, the study concluded that emotional function domain was most
impaired because of asthma . This could probably be because of
limitation of sports and other daily activities and because asthmatic
children tend to miss school. School absenteeism leads to poor academic
performance causing low self esteem. Frustration builds-up due to
inability to perform daily activities, in addition to dietary
restrictions imposed by the parents due to food fads. All these factors
add on to emotional deprivation which causes a major impact on quality
of life in children. It stresses the importance of providing
psychological support and counseling in the long term management of
asthma.
Funding:
Nil, Conflict of interest:
Nil
Permission from IRB:
Yes
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How to cite this article?
Wander A, Bhargava S, Pooni P.A, Kakkar S, Arora K. Quality of life in
children with bronchial asthma. J
PediatrRes.2017;4(06):382-387.doi:10.17511/ijpr.2017.06.06.