THEME 1: Helping Children and Families

    • October 6, 2008

Milwaukee Mother Learns How to Control Her Son's Asthma

When 3-year-old Jimmy Townsend was diagnosed with asthma, his mother, Octavia, faced a bewildering array of medicines and delivery devices. "In the beginning, I was not comfortable" handling the medication, says Townsend, a resident of Milwaukee's north side.

Indeed, when one piece of equipment—the medicine holding chamber that fit onto Jimmy's inhaler—grew moldy, she stopped using it, relying instead on just the inhaler to get the prescribed dosage into the little boy's system. (A holding chamber, or spacer, attaches to an inhaler and captures the right amount of medication, making it easier to administer an effective dose of medicine.) Townsend did not know how to anticipate an impending asthma attack—what tell-tale signs might be a tip-off that Jimmy needed more medication or perhaps even an unscheduled trip to the doctor's office.

These are issues by no means unique to Townsend. For thousands of families across America, many of them living in urban environments conducive to pediatric asthma, controlling this chronic disease is a continual battle.

Middle-of-the-night runs to the emergency department are commonplace in this battle. Asthma, the most common chronic childhood disease in the United States, is the number-one cause of pediatric emergency department visits and preventable hospitalizations.

Fortunately, Townsend was able to get the upper hand in her struggle, thanks in large part to a coalition of agencies and individuals named Fight Asthma Milwaukee Allies, known locally as FAM Allies.

FAM Allies was part of Allies Against Asthma, a national program of the Robert Wood Johnson Foundation (RWJF). Led by Milwaukee-based Children's Hospital and Health System, FAM Allies brought together hospitals, schools, health centers, managed care organizations, grassroots groups and other organizations to form a partnership that developed a menu of interventions to help asthmatic children in Milwaukee's center-city neighborhoods.

Among the initiatives was a program of in-home education and environmental improvement. Twice a week at first, then weekly and later monthly, Laurie Smrz, RN, asthma program coordinator at the Children's Hospital of Wisconsin (part of the Children's Hospital and Health System), visited the Townsend home to assess and address the family's situation.

One of Smrz's lessons—and, for Townsend, perhaps the most valuable—was the importance of using a holding chamber (or spacer, as the device is also known) in tandem with an inhaler to get the medicine effectively into her child's airways.

Delivered by an inhaler alone, most of the medicine was going merely into Jimmy's mouth and throat and ending up in his stomach, Townsend recalls Smrz telling her. Smrz also explained warning signs of an impending attack, such as wheezing with a high-pitched whistling sound, or gasping for air.

Meanwhile, personnel from the Milwaukee Health Department also arrived at Townsend's front door to look for allergens that could be exacerbating her son's condition.

These visitors swabbed the carpet, window sills and other nooks and crannies to collect dust mite samples for analysis—detective work that can have surprisingly helpful results.

John Meurer, MD, MBA, director of the FAM Allies coalition, tells of another boy whose asthma was severe enough to send him frequently to the hospital. The outreach nurse suspected the culprit was mouse allergen—a common asthma trigger—but could find no sign of rodents in the boy's home. Triggers are environmental exposures that can set off an asthma attack, causing airways to become inflamed, swollen and clogged. Common triggers include secondhand tobacco smoke, dust mites, cockroaches, mold, family pets and outdoor air pollution.

However, Meurer explains, "the environmental inspector looked very closely and found a small crack in the wall. And sure enough, there were a dozen mice in there. And they [the family] didn't even know it."

The inspector also discovered that the boy was sleeping on a sofa that doubled as a playground for the four-legged guests, judging by the large amount of mice fur and dander found in the fabric.

In short order, on suggestion of the health department, the family got rid of both the mice and the sofa, and subsequently the boy's need for hospital services declined, according to Meurer, who is chief of general and community pediatrics and an associate professor of pediatrics and population health at the Medical College of Wisconsin.

At the Townsend household, the results of FAM Allies' work were equally beneficial. Jimmy, now age 7, takes a long-term control medication, or controller such as inhaled corticosteroids, each day to reduce the frequency and severity of attacks and a quick-relief medicine, also known as relievers and rescue medicines, as needed to respond to wheezing or other symptoms. "He's under control now," says his mother.

Other sites that RWJF supported through Allies Against Asthma had similar experiences.

Long Beach, Calif., Grandmother Learns How to Create a Healthy Home
In Long Beach, Calif., 7-year-old Zell seemed to be getting little benefit from the asthma-control medication prescribed by his new pediatrician. Flare-ups were keeping him home from school two to three times a month and on occasion required emergency care.

Each episode left him physically and emotionally drained, recalls Alyce Tyler, his grandmother and frequent caregiver: "He's like a rag doll. His mood swings were over the top. You just hate to see your kid go through that."

Concerned about the frequency of Zell's attacks, the pediatrician referred the family to the Long Beach Alliance for Children with Asthma, a program of the community started with support from RWJF's Allies Against Asthma.

Among its activities, the alliance sends community health workers to visit the homes of Long Beach children with asthma. These are individuals from the communities in which they work and, consequently, they understand living conditions and relate easily to the families and their concerns. For Tyler, the arrival of her in-home visitor, Delores Simms, was a red-letter day. "I'm telling you: wonderful, wonderful," she says of Simms.

One of the key lessons Tyler learned was that she should be giving her grandson the prescribed medication daily and not—as she had been doing—just when he was experiencing difficulty breathing.

Simms also gave instruction in cleaning-both what to clean (window screens, air conditioning filters and other dust collectors that so easily escape notice) and how to clean (with vinegar, baking soda and water, not the highly fragrant commercial cleaners sold on TV).

"They have really taught me ways to keep the house allergen free. The key is maintenance. You don't get that from a doctor," says Tyler.

In the six months following Simms's initial visit, Zell had only a couple of episodes—and both were early on, according to Tyler. "He is happier, and we are, too," she says—the "we" including Zell's working parents.

Philadelphia Family Gets Their Lives Back on Track
In Philadelphia, Ms. S., and her 7-year-old asthmatic son had moved recently from a suburb to the city's southwest side. The family had health care coverage through a Medicaid managed care plan but since the move had not selected a primary care provider.

As a result, Ms. S. was taking her son repeatedly to the emergency room at the Children's Hospital of Philadelphia for treatment of wheezing, shortness of breath and coughing—symptoms that regularly were keeping him home from school. He had a rescue medicine (also called a reliever), inhaler and spacer, but nothing seemed to work.

The hospital emergency room staff referred the family to the Child Asthma Link Line—a telephone-based service that assesses the needs of Philadelphia families with asthmatic children and links them to an array of resources.

The Link Line is an initiative of Philadelphia Allies Against Asthma, a coalition of local health care organizations, community groups and the public schools. Created with support from RWJF's Allies Against Asthma program, Philadelphia Allies focuses on poor, African-American neighborhoods on the city's north and west sides.

For Ms. S., the voice on the other end of the toll-free Link Line (1-866-610-6000) belonged to Barbara Washington, one of two full-time asthma care coordinators who operate the service. Washington learned the boy's asthma was out of control and assessed the possible contributing factors: The family had no primary care physician and no asthma action plan (a plan developed by the health care provide to help parents manage their child's asthma), the child's nebulizer was broken and the boy's stepfather was a smoker.

Ms. S. gave assurance that the stepfather never smoked inside the house—a familiar claim about which Washington always has her doubts. "I tell families, 'I'm not condemning you for smoking, but you do know cigarette smoke is trigger number one?'

Washington herself knows all too well about the ordeal of asthma. Her daughter, now 30, suffered from it throughout her youth; the two logged many hours together in emergency rooms.

Now, as a veteran of Link Line and other asthma-assistance services and on her way to certification as an asthma educator, Washington knows a lot about managing the disease.

To help Ms. S. and her son get their lives back on track, Washington called on that experience—and on members of the Philadelphia coalition. She:

  • Contacted the asthma care manager at the family's managed care plan to help Ms. S. find a new primary care provider and arrange for a replacement nebulizer.
  • Scheduled an appointment for the family with an asthma nurse at a neighborhood health center that is part of the coalition and a participant in the family's Medicaid plan.
  • Referred the family to Asthma Safe Kids, an in-home education and assessment program of the National Nursing Centers Consortium in Philadelphia. Washington also referred the family to a toll-free number that provides advice on smoking cessation.
  • Urged Ms. S. to have the family's new primary care doctor complete an asthma action plan for her son. Washington mailed the family a packet of information on asthma triggers and management measures, including a blank asthma action plan form.

The telephone assistance was productive. Ms. S. received a new nebulizer for her son and the family enrolled in the neighborhood health center.