Breathlessness, coughing, wheezing, chest tightness, and chest pain are symptoms of asthma exacerbation that can lead to life-threatening condition if left untreated or unmanaged especially among children. Pediatric asthma is the most common chronic illness among children and adolescents in the Unites States estimating about six million children have asthma, and accounting for about twenty billion dollars in health care costs annually (Goff, 2022; Sullivan et al., 2018; Centers for Disease Control and Prevention [CDC], 2018). In fact, about one in six children with asthma have exacerbations that lead to emergency department (ED) visit as well as one in twenty children with asthma are hospitalized for asthma every year (CDC, 2018; Sullivan et al., 2018). Pediatric asthma can reduce physical activity and limit social interaction, and frequent exacerbations can lead more ED visits and hospitalizations that can negatively impact the overall development of younger children (Westergren et al., 2017). Although asthma can affect all ages, gender, races, and ethnic groups, children from low-socioeconomic status and minority groups have higher prevalence of asthma and asthma-related hospitalizations. Thus, this review aims to analyze the current trends of the alarming health disparities in asthma prevalence and poor outcomes among non-Hispanic Black children compared to non-Hispanic white children.
Background and Significance
Asthma is chronic illness that is cause by airway inflammation and swelling leading to symptoms of airway restriction, oftentimes due to a response to environmental triggers such as molds, pollen, or dusts (CDC, 2018; Perry et al., 2019). Currently, there are no cure for asthma but is highly manageable to improve quality of life, and exacerbations are preventable with the proper intervention, maintenance, and self- awareness (Goff, 2022). Children with poorly uncontrolled asthma and/or have frequent asthma exacerbation can lead to lung tissue remodeling of their still developing lungs that can lead to limited physical activity and decreased quality of life as they age (Westergren et al., 2017; Ferrante & La Grutta, 2018). According to Serebrisky & Wiznia (2019), current statistics shows that there is an increasing number of hospitalizations for asthma among younger children which necessitates complex and expensive healthcare cost utilization. Not only direct cost to healthcare services used such as ED visits and hospitalizations, but pediatric asthma can also have an indirect economic impact due to lost productivity from parents’ loss of workdays and intangible costs that are related to the children’s quality-of-life impairment, physical activity limitations, study performance, and psychological effects such as anxiety and depression (CDC, 2018; Ferrante & La Grutta, 2018; Perry et al., 2019).
Poor asthma outcomes have been well documented since 1980s among children of racial and ethnic minorities such as children of non-Hispanic Black descent (Volerman et al., 2017; Hughes et al., 2017; Hill et al., 2011). Factors that may contribute to the increasing number of asthma attacks in non-Hispanic Black children are attributed to increasing severity due to disease progression, poor disease management or medication adherence, access to healthcare, and low socioeconomic status (Serebrisky & Wiznia, 2019; Hill et al., 2011).
According to Hill et al. (2011), there are variability in the genetic pathways involving inflammatory response due to socioeconomic status. Overexpression of genes that regulates the inflammatory pathways such as chemokine activity, stress response, and wound response are more common in children of low socioeconomic status (Hill et al., 2011). The prevalence of asthma as well as the rate of hospitalization and ED visits due to asthma exacerbation among non-Hispanic Black children are estimated three times more likely compared to non-Hispanic white children (Goff, 2022; Volerman 2017).
Moreover, children of low socioeconomic status are constantly exposed to increased levels of pollutants such as tobacco smoke, indoor air quality, animal dander, molds, and dusts (Hill et al., 2011; Serebrisky & Wiznia, 2018). Since children almost spend all their time in confined environment, quality of air and amount of ventilation can significantly affect asthma outcome (Serebrisky & Wiznia, 2018). As a result, non-Hispanic Black children are more than seven times more likely to die from asthma compared to non-Hispanic white children (Akinbami et al., 2014; Akinbami et al., 2016).
Methods
Nationally representative data from the Healthcare Cost and Utilization Project (HCUP) online query system and CDC’s National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to calculate national estimates of asthma prevalence and outcomes (asthma exacerbation leading to ED visits or hospitalizations) among children ages 0-17 years old. The HCUP system is a free healthcare statistics analysis that provides information regarding national or regional data of participating inpatient hospital stay, emergency department visits, and ambulatory setting information that is used analyze research questions. Analysis setup chosen are both emergency department visits and inpatient stays to analyze health disparity in pediatric asthma outcome. Using the HCUPnet analysis system, the national hospitalization data are estimated using asthma diagnosis from International Classification of Diseases 9 or ICD-9 code. Diagnosis code used were 493.90 or unspecified asthma, and 493.92 or unspecified asthma with acute exacerbation. All trends were assessed in varying range between the year 1997 to 2018 across all the data sets. Racial groups were focused on non-Hispanic Black and non-Hispanic white children because other race groups are not consistently available across all the included data sets. National asthma surveillance data sets are then compared to the state of Illinois data using Illinois Department of Public Health website.
Peer reviewed articles and journals relevant to answer the pediatric asthma health disparities and poor asthma outcomes among racial groups were reviewed for this review. Databases searched include National Institute of Health, PubMed Central, MEDLINE (OVID), CINAHL (EBSCHOhost), ELSEVISIER, ResearchGate, WILEY, and Google Scholar. Articles and journals for this review were search from 2010 to present as an inclusion criteria to capture the most up-to-date information. Key phrases used to search for relevant articles were “current trend of pediatric asthma”, “pediatric asthma”, “asthma racial disparities”, “pediatric asthma outcomes”, and “role of socioeconomic status in asthma outcome”. Data used for this review is only on United States specific data, and the electronic database search was limited to articles published in English.
Results
Pediatric Asthma Prevalence
In 2020, approximately 5.8 percent of the U.S. children population ages 0-17 years old have asthma according to the 2020 National Health Interview Survey (NHIS) data, people answering “yes” to the question “have you ever been told by a doctor or other health professionals that you have asthma?” or “Do you still have asthma?” (CDC, 2021b; Pate et al., 2021). The percentages of U.S. children age groups with current asthma are provided (see Table 1).
| Table 1: Pediatric Asthma Prevalence in the United States by Age Group | ||
| Age Groups (Years) | Number with Current Asthma | Percent |
| 0-4 | 394,206 | 2.0% |
| 5-11 | 1,641,279 | 5.9% |
| 5-17 (school age) | 3,832,453 | 7.2% |
| 12-17 | 2,191,174 | 8.6% |
Illinois state data of children ages 0-17 years old who have asthma during 2011-2012, the most recent data found in Illinois Department of Public Health (IDPH) website, shows about 9 percent of Illinois children had asthma (IDPH, 2016). The percentage of Illinois children broken down in age group with current asthma are provided (see Table 2).
| Table 2: Percent of Illinois children with Asthma, 2011-2012 | |
| Age Group (Years) | Percent of children with asthma |
| 0-5 | 5% |
| 6-11 | 9% |
| 12-17 | 11% |
In 2020, the national prevalence of pediatric asthma has shown evidence of racial disparity remains. The rate of asthma prevalence among non-Hispanic Black children are double the number compared to non-Hispanic White children (CDC, 2021b; see Table 3). While Illinois state data also shows that non-Hispanic Black children have higher prevalence of asthma, having three times higher prevalence of asthma compared to non-Hispanic White children during 2011-2012 (IDPH, 2016; see Table 3).
| Table 3: Pediatric Asthma Prevalence by Race | ||
| Race | U.S. Percent in 2018-2020 | Illinois Percent in 2011-2012 |
| White | 5.5% | 6% |
| Black | 12.3% | 19% |
There were no significant differences in the prevalence of pediatric asthma between males and females in both national and Illinois state data (CDC, 2021b; IDPH, 2016; see Table 4).
| Table 4: Pediatric Asthma Prevalence by Gender | ||
| Gender | U.S. Percent in 2018-2020 | Illinois Percent in 2011-2012 |
| Boys | 5.7% | 9% |
| Girls | 6.0% | 8% |
Pediatric Asthma Healthcare Utilization
The healthcare utilization of pediatric asthma is assessed using the inpatient hospital stays information and rate of ED visits due to asthma. The national inpatient data is provided using HCUPnet hospital inpatient children only national statistics (see Table 5). Inpatient hospital stay due to asthma has shown a decrease from year 1997 to 2000 (see Table 5), but pediatric hospital stays due to asthma exacerbation significantly increased from year 2000 to 2012 (see table 6). In addition, the cost of average hospital charges due to pediatric asthma also shows an increasing trend.
| Table 5: National Hospital Inpatient Stay of Pediatric Asthma | ||
| Year | ||
| 1997 | 2000 | |
| Total number of discharge | 73,731 | 56,984 |
| Average length of stay | 2.3 | 2.2 |
| Average age | 4.84 | 4.66 |
| Average hospital charge | 4,105 | 4,443 |
| Table 6: National Hospital Inpatient Stay Due to Pediatric Asthma Exacerbation | |||||
| Year | |||||
| 2000 | 2003 | 2006 | 2009 | 2012 | |
| Total number of discharge | 14,154 | 79,931 | 68,434 | 68,477 | 58,081 |
| Average length of stay | 2.2 | 2.2 | 2.1 | 2.0 | 1.9 |
| Average age | 5.85 | 5.19 | 5.16 | 5.33 | 5.39 |
| Average cost | 4,902 | 6,556 | 7,831 | 9,644 | 11,637 |
Trend of pediatric asthma exacerbation that leads to ED visit were not able to calculate. The national asthma ED visit rate of pediatric asthma is provided instead and its break down during 2016 to 2018 (see table 7, see Appendix A).
| Table 7: National Pediatric Asthma ED Visit Rate, 2016-2018 | |
| Characteristics | Rate per 10,000 population |
| Total | 88.1 |
| Female | 72.5 |
| Male | 103.1 |
| 0-4 | 118.4 |
| 5-17 | 76.8 |
State level data of Illinois child asthma inpatient hospitalization and ED visits has no meaningful change, and the average rate is 25 percent from 2011 to 2014 (IDPH, 2016). However, breaking these rate into age groups, children under five years of age that has the highest hospitalization rate and ED visit, 46.8 percent, and 32.8 percent respectively. In addition, racial disparity in both national and state level is alarmingly significant among children who have asthma. Comparing non-Hispanic Blacks and non-Hispanic White children, the rate of hospitalization rate in children in 2016-2018 are provided (see Table 8). While Illinois state asthma hospitalization and ED visits are also showing alarming disparity among non-Hispanic Black children and non-Hispanic White children (see Table 9).
| Table 8: Hospitalization Rate per 100,000 Children Nationally | |
| Non-Hispanic Black | Non-Hispanic White |
| 297.3 | 47.9 |
| Table 9: Illinois Child Asthma Hospitalization and ED Visit | ||
| Non-Hispanic Black | Non-Hispanic White | |
| Hospitalization stays | 41.8% | 29.6% |
| ED visits | 48.6% | 27.0% |
Pediatric Healthcare Coverage
Healthcare coverage provides access to healthcare services that is essential for detection, prevention, and treatment of health conditions such as asthma. Thus, it is important to look at the healthcare coverage of children to assess their significance in the prevalence of asthma and asthma outcomes. National data are provided comparing non-Hispanic Black children and non-Hispanic White children who have asthma and those who have no asthma (CDC, 2021b; see Table 10). Illinois state data was not able to assess.
| Table 10: Healthcare Coverage Among Children | ||||||
| Children with Asthma | Children without Asthma | |||||
| Medicaid | Private | No coverage | Medicaid | Private | No coverage | |
| White | 33.5% | 62.6% | 3.8% | 22.6% | 73.4% | 3.9% |
| Black | 66.2% | 31% | 2.8% | 55.9% | 38.8% | 5.4% |
Pediatric Asthma Deaths
Deaths due to asthma is extremely rare among children but is still a major concern and a target for preventative interventions due to inflated cost of promoting quality of life among individuals who have asthma. Racial disparity in pediatric asthma death is provided (CDC, 2021b; Pate et al., 2021; see Table 11) but state data is unknown.
| Table 11: Pediatric Asthma Deaths by Demographic Characteristics, 2001-2016 | |
| Race | Death Rate per 1,000,000 |
| Non-Hispanic Black Children | 11.4 |
| Non-Hispanic White Children | 1.2 |
Discussion
The pediatric asthma prevalence briefly increased in the mid-2000 and slowly decline possibly due to the said alarming prevalence that effective interventions start to emerge and help prevent and reduce poor asthma outcomes. Among age group, children ages 12-17 years old have the highest rate of asthma prevalence. Although children under the age of five have the lowest prevalence of asthma, these children are at more risk of poorer asthma outcome such as hospitalization and ED visits. Due to underdeveloped respiratory system, these younger children will require complex and more expensive care as seen in the average age of pediatric hospitalization due to asthma and their corresponding ED visits rate. Cost of healthcare is also increasing as time goes by, thus, the use of healthcare services due to pediatric asthma exacerbation also increases. Thus, to improve pediatric asthma outcome and quality of life, these dataset can help to refocus resources such as public health services and population-based healthcare services education parents on asthma education since children under the age of five are highly dependent on their parents. This will help alleviate the excessive use of healthcare services especially ED visits rate. Medication adherence and early symptom identification are one of the few strategies to reduce asthma attacks (Sleath et al., 2012).
In this review of nationally representative dataset and state level dataset, it is profound that non-Hispanic Black children remains to have higher prevalence of asthma and poorer asthma outcome compared to non-Hispanic White children. Not only they are more likely to have asthma, but non-Hispanic Black children are also about ten time more likely to die due to asthma compared to non-Hispanic White children. Poorer asthma outcome is also seen based on hospitalization and ED visit rate on the national and Illinois state data. This could be due to socio-economic status disparities among non-Hispanic Black children and non-Hispanic White children (see Appendix B). Limitation of these datasets are that the number of actual non-Hispanic Black children who have asthma and below the poverty level is currently unavailable to assess. But non-Hispanic Black children are more likely to be covered under Medicaid or Children’s Health Insurance Program resulting in more ED visits as their primary access to healthcare services compared to non-Hispanic White children who are more privately covered (CDC, 2021b). This can help presume that non-Hispanic Black children who have asthma are more likely to be below the poverty line, and capability to maintain asthma control is poorly inadequate. Environmental, financial, and material hardships are highly associated with poorer asthma outcomes that can very well explain the racial disparity of pediatric asthma outcomes (Hughes et al., 2017). These dataset can be used by healthcare providers especially those who are in community settings and primary care settings to improve pediatric health equity and overall population health. Partnership with nationwide and local communities by healthcare providers can promote and reduce these racial disparities.
Limitations
Datasets used in this review is the most current information available both on national level and Illinois state level. The HCUP online query system is a reliable source of survey information but was not able to extract more details due to the nature of less information available for pediatrics. The datasets are then complimented with data obtained using the CDC statistics and status report that are also based on national survey. Another inquiry issue is that all the datasets regarding prevalence are highly reliant on individuals who report they have asthma or had asthma attacks. The true prevalence of pediatric asthma is not captured as those who have no healthcare coverage are reluctant to admit their medical condition. Also, this review and datasets demonstrate the pediatric asthma prevalence and their outcomes only of those non-Hispanic Black children and non-Hispanic White children. Other races and ethnicities need to be looked at to determine definitive factors that can help improve pediatric asthma outcomes.
Conclusion
Pediatric asthma is highly manageable, and attacks are preventable. These datasets demonstrate the effect of the alarming racial differences of pediatric asthma outcomes between non-Hispanic Black children and non-Hispanic White children. National and community efforts are being developed to help reduce healthcare services usage and reduce healthcare costs for pediatric patients who have asthma. Efforts to increase the surveillance and identification of these children who have asthma can have a profound effect on the promotion of their quality of life. Multimedia approach can be used as technology advances to help identify these children and reach out to their parents or guardians for available resources to help manage their children’s asthma. A good start is to partner with national and local community to create and develop web-based patient education that is user-friendly to promote patient education, as today’s trend of technology is more contactless, wireless, and mobile.
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Appendix A
(Centers for Disease Control and Prevention, 2021a)
Appendix B
