Associated Press Photo/Courtesy of Cardon Children's Medical Center, Brad Armstrong
In this Sept. 1, 2010 photo provided by Cardon Children's Medical Center, Cardon Children's asthma educator Kim Reiners, right, a registered nurse, administers a breathing treatment to Kymbrea Valrey, 12, who has chronic asthma, in Mesa, Ariz. For those with medical conditions — from asthma to food allergies to diabetes and celiac disease — it may mean providing the school with medications, equipment and, as in Emmy's case, training.

Most parents and other caregivers who control how children take asthma medication administer it wrong, according to a new study from the Children's Hospital at Montefiore in New York City. That means many kids don't receive the right dose of medication and may suffer adverse outcomes.

As many as 7 million American children have asthma. Often, parents and caregivers are responsible for helping the child take the medication, which is typically inhaled. Delivery often involves a chamber called a spacer that is placed between the inhaler and the child's mouth to make it easier to be sure that the child gets the medicine in the right dose.

It's critical that parents, while most of the time are the caregivers responsible, do it properly, said Dr. Marina Reznik, pediatrician and lead author from the Children’s Hospital. She is also an assistant professor of pediatrics at Albert Einstein College of Medicine. The study appears in the Journal of Asthma.

Reznik said she was caught off-guard by how few parents in the study knew how to administer the medication. In critical cases, asthma can be life-threatening.

The researchers found that less than 1 percent of the caregivers among the 169 they studied performed correctly each of 10 steps involved in administering a metered albuterol dose using a spacer did so correctly, while less than 4 percent were able to complete the five "essential steps" involved, Reznik said.

"We expected to find many more parents who would know how to use it correctly. If they are not using it correctly, it could potentially affect asthma control," leading to more symptoms, more hospitalizations, higher cost and other issues. They worried as well that parents who used the drug incorrectly would think it was ineffective and stop using it. That could impact not just current but future use of a medication that should help.

Parents puzzled

News that so few parents knew how to use the inhaler and spacer does not particularly surprise Misti Timpson, a Sandy, Utah, mom who has two children who use inhalers. When Melia, now 8, was diagnosed with reactive airway disorder six years ago, Timpson listened to the health care provider and then went home and looked up how to use the device online. She does it by guess and by Google, she admits.

"I don't know for sure if we're doing it right or not," says Timpson, whose son Mason, 5, also has asthma, though not as severely as his sister. She has to supervise how he uses his inhaler, too.

"I am concerned we could be doing it better."

Besides wanting her children to be healthy, she said the medications are expensive and it would be a shame to waste them. "I don't want to buy it and then do it haphazardly, half-heartedly," Timpson says.

Nuts and bolts

Using caregiver reports and the guidelines from the National Heart, Lung and Blood Institute, the researchers categorized how well-controlled the asthma symptoms were for each child and found of the 169 caregivers (95 percent were moms), 87 percent had children whose asthma was "not well controlled" or "very poorly controlled."

Then they turned to the question of technique. The institute's guidelines include 10 steps for accurate use of a metered-dose inhaler with spacer (MDI-spacer) to help administer asthma medication. Five of those steps are considered essential, including shaking the inhaler before use for at least three seconds, forming a seal for delivery of the medication, pressing the pump once, taking at least six slow and deep breaths and timing the second puff by waiting at least 30 seconds before repeating the medication's application.

Anyone performing seven or more of the 10 steps correctly was deemed to have used the spacer correctly. There were very few who hit that benchmark.

The study emphasized that not only do parents and other caregivers need to be asked to demonstrate how they use the inhalers and spacers on a regular basis, but health care providers need to have their skills checked, too.

"Targeted educational interventions for both caregivers and health care providers, coupled with regular evaluation of caregiver inhalation technique are needed to optimize medication delivery in children with persistent asthma," the study authors wrote.

The children who had crisis asthma-control issues in the last 12 months had the highest likelihood their caregivers knew the proper technique, honed as a result of hospitalizations and increased training.

Parents want their children to be healthy and health care providers want to provide effective care, Reznik said. But asthma control is an area where there are real questions about whether that's occurring.

"It has to start with the physician, who is the first to see the patient, to diagnose or prescribe," said Reznik. "We need to make sure physicians know how to use these correctly as well."

They need to know the equipment, but also know how to explain it and parents have to be asked to demonstrate it back, she said. It's important for a provider to say, "Show me how you actually do it."

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