The chronic respiratory condition asthma poses unique challenges when it appears in children. Elite Sales Processing Chief Underwriting Officer Dennis Gunderson shares what every underwriter should know about the causes, symptoms, treatment and mortality risk of juvenile asthma in ON THE RISK, the Journal of The Academy of Life Underwriting.
Asthma is a chronic condition involving the inflammation of airways.
The inflammation causes swelling of the airway linings resulting in reduced airflow in the lungs. The inflammation and resulting restriction in the airways lead to difficulty in breathing and shortness in breath. While there is no cure for asthma, symptoms can be treated.
According to the National Heart, Lung, and Blood Institute, 8% or about 25 million people in the US have asthma.1 Of the 25 million asthma sufferers, 7 million are children. According to the American Lung Association, nearly 4 million of the 7 million of the children with asthma have an attack every year.2 Nearly half of the children with asthma or 3 million reports having more than one attack per year.3 Additionally, 1 in 6 children with asthma visits the emergency department and about 1 in 20 children with asthma are hospitalized. Asthma is the leading chronic illness in children with more boys affected than girls. Asthma is a primary cause of hospitalization, emergency department visits and missed school days in children under the age of 15. About 13.8 million missed school days are reported. However, there are few asthma-related deaths in children.2
The exact causes of childhood asthma are often unknown. Allergies, environmental triggers, or genetics may be causes but the exact reasons individuals develop this condition while others exposed to the same conditions do not is unknown. The common environmental triggers for adults and children include smoke, mold, air pollution, dust, animal dander, cold temperatures, stress, and exercise. Children tend to be more prone to allergen and environmental triggers than adults as their bodies and immune systems are still developing. According to the American Lung Association, secondhand smoke especially can exacerbate symptoms of childhood asthma.4
Childhood asthma is the same as adult asthma. However, children with asthma present different challenges.5 Diagnosing asthma in a child is a challenge for medical professionals. Often it is not diagnosed correctly as it may be mistaken for other childhood illnesses. To correctly diagnose asthma in a child, the healthcare provider must have a good medical history from the child’s caregiver and not just from the child. It may be asthma, if the child has a repeated history of coughing, wheezing or shortness of breath. Symptoms may be made worse due to viral infections, exposure to smoking or other irritants, exercising, changes in weather, or exposure to things the child is allergic to such as pollen. Additionally, the healthcare provider needs to understand the severity of the child’s symptoms and any exposure to triggers or aggravating factors.6 Finally, the healthcare provider needs to understand the development of the symptoms over time and the effectiveness of current treatments. Again, caregivers such as parents, guardians, and teachers are likely the major source of information depending on the child’s age and ability to articulate about their condition.
The main aspects of asthma are the airway inflammation and airway constrictions of the lungs. Airway inflammation causes swelling of the lining of the airways, reducing the amount of air taken in and exhaled. In addition, thick mucus may be produced, further obstructing the airways. Airway restriction or bronchoconstriction associated with asthma constricts or squeezes together the airway, further limiting the ability to breathe. Airway inflammation and airway constriction combine to cause wheezing, coughing, chest tightness or shortness of breath. Childhood asthma and adult asthma have the same symptoms and have like treatments. In children and adults, asthma can cause inflammation and restriction of the airways. The restricted airways result in chest tightness and shortness of breath.7 Common symptoms include wheezing, coughing, congestion, chest pain, increased mucus, pressure in the chest, shortness of breath, and difficulty sleeping.
Understanding the severity and classification of asthma is a vital part of treatment for this condition. The National Heart, Lung, and Blood Institute uses four different classifications - intermittent, mild persistent, moderate persistent, and severe persistent.1 The medical classifications are based on the following:
The number of days per week there are symtoms.
The number of nights per week one is awakened with asthma symptoms.
The number of times a rescue inhaler is used.
The degree of interference of regular activities due to asthma.
Classification of the asthma severity is key to underwriting the risk associated with asthma. The chart below is the classification and components used by the National Heart, Lung, and Blood Institute.
The classification and components used are the same for adults and children. However, the classification requires information from the patient. Adults can communicate more effectively to the medical professional about their symptoms than are children. Medical professionals rely on parents, teachers and other caregivers to the child for important information about the child’s asthma symptoms.
There is no cure for adult or juvenile asthma. Treatment for asthma focuses on treating and controlling the symptoms. Well-controlled asthma for a child involves a program that will:
Minimize or eliminate any symptoms.
Reduce or eliminate any flare-ups.
Reduce or eliminate any physical limitations.
Minimize the need for rescue inhalers.
Reduce or eliminate any side effects from medications.
Depending on the severity of the asthma symptoms, the age of the child, and the asthma triggers, treatment may include long-term control medications and quick-relief medications.8 Long-term medications are intended to reduce the inflammation of the child’s airways. In many cases, these are required every day. Some examples are inhaled corticosteroids, theophylline, or leukotriene modifiers such as Singulair.
Quick-relief medications are intended to promptly open swollen airways that are restricting breathing.
Components of Severity | Intermittent | Mild Persistent | Moderate Persistent | Severe Persistent |
|---|---|---|---|---|
Symptoms | <= 2 days/week | 2 days per week but not daily | Daily | Throughout the day |
Nighttime awakenings | 0 | 1-2 per month | 3-4 per month | 1 per week |
Symptom control with SABA | <= 2 days per week | 2 days per month but not daily | Daily | Several times per day |
Inference with normal activity | None | Minor limitation | Some limitations | Extremely limited |
Lung function FEV1/FVC | >85% | >80% | 60-80% | <60% |
Exacerbations requiring oral steroids | <= 1 per year | None or prophylactic use of steroids | 1-2 per year maximum of 2 weeks | Frequent or continuous use of steroids |
These rescue inhalers provide rapid symptom relief during an asthma attack or before strenuous activity. These are used on a short-term basis for quick relief and are not intended for long-term use. Some examples include short-acting beta agonists, Atrovent, and oral corticosteroids.
Long-term asthma medications are intended to provide day-to-day control of asthma symptoms. Asthma flare-ups may require quick-relief or rescue inhalers for prompt relief of symptoms. For a child with asthma, treatment requires a plan of action involving parental, caregiver and teacher involvement. All providers must be aware of the condition and what action is needed if flare-ups occur.
There is no cure for asthma. The key to controlling asthma symptoms in a child is to develop a plan of action including parents, caregivers, and teachers. All involved need to recognize the need for control medications, monitor how well the treatment is working, recognize the signs of a flare-up or action and know what to do, and understand when emergency help is needed.9
The primary consideration for evaluating the mortality risk of a child with asthma is to determine the severity of the symptoms. The underwriter needs to classify the severity into intermittent, mild, moderate, or severe. The factors used in making this determination include frequency of symptoms, nighttime awakening, use of “rescue” inhalers, pulmonary function test, activity limitation, and emergency department visits or hospitalizations. Additional considerations when underwriting a child with asthma include exposure to environmental triggers such as secondhand smoke, mold, air pollution, dust, animal dander, cold temperatures, or stress, as well as an understanding and acceptance of the condition by the child and parents or caregiver is an important factor to consider when accessing the mortality risk.
For children with intermittent or mild severity asthma, there is little or no adverse impact on mortality. For children with moderate severity asthma, there is an impact and would require excess mortality rates. Finally, for children with severe asthma with frequent or recent emergency department visits or hospitalizations, a postponement or decline may be warranted until the condition is stabilized.
Juvenile asthma, like adult asthma, has the same symptoms and treatments. However, juvenile asthma does present additional challenges to the healthcare provider and the underwriter. Underwriting these cases requires a focus on the severity of the symptoms. In addition, an evaluation of the acceptance by the child and caregivers as well as the exposure the child has to triggers should also be considered when evaluating the mortality risk of juvenile asthma.
Reprinted with permission of ON THE RISK, Journal of the Academy of Life Underwriting (www.ontherisk.com).