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. 2018 Sep;73(9):813-824.
doi: 10.1136/thoraxjnl-2017-210939. Epub 2018 Jun 5.

At-risk children with asthma (ARC): a systematic review

Audrey Buelo  1 , Susannah McLean  1 , Steven Julious  2 , Javier Flores-Kim  1 , Andy Bush  3 , John Henderson  4 , James Y Paton  5 , Aziz Sheikh  1 , Michael Shields  6 , Hilary Pinnock  1 ; ARC Group
Collaborators, Affiliations

At-risk children with asthma (ARC): a systematic review

Audrey Buelo et al. Thorax. 2018 Sep.

Abstract

Introduction: Asthma attacks are responsible for considerable morbidity and may be fatal. We aimed to identify and weight risk factors for asthma attacks in children (5-12 years) in order to inform and prioritise care.

Methods: We systematically searched six databases (May 2016; updated with forward citations January 2017) with no language/date restrictions. Two reviewers independently selected studies for inclusion, assessed study quality and extracted data. Heterogeneity precluded meta-analysis. Weighting was undertaken by an Expert Panel who independently assessed each variable for degree of risk and confidence in the assessment (based on study quality and size, effect sizes, biological plausibility and consistency of results) and then achieved consensus by discussion. Assessments were finally presented, discussed and agreed at a multidisciplinary workshop.

Results: From 16 109 records, we included 68 papers (28 cohort; 4 case-control; 36 cross-sectional studies). Previous asthma attacks were associated with greatly increased risk of attack (ORs between 2.0 and 4.1). Persistent symptoms (ORs between 1.4 and 7.8) and poor access to care (ORs between 1.2 and 2.3) were associated with moderately/greatly increased risk. A moderately increased risk was associated with suboptimal drug regimen, comorbid atopic/allergic disease, African-American ethnicity (USA), poverty and vitamin D deficiency. Environmental tobacco smoke exposure, younger age, obesity and low parental education were associated with slightly increased risk.

Discussion: Assessment of the clinical and demographic features identified in this review may help clinicians to focus risk reduction management on the high-risk child. Population level factors may be used by health service planners and policymakers to target healthcare initiatives.

Trial registration number: CRD42016037464.

Keywords: Paediatric asthma.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. ATS, American Thoracic Society; ERS, European Respiratory Society.
Figure 2
Figure 2
Key variables and key to Forest plots. ED, emergency department.
Figure 3
Figure 3
Greatly increased risk: evidence for risk factors and weighting decisions. Note: The scale on all the Forest plots has been curtailed at an OR of 8 to enable comparison between the plots for the different factors. If the CIs are very wide, and the upper limit extends beyond the plot this is indicated with a line with an arrow. (95% CIs are given in online supplementary table S2 if required.) ED, emergency department.
Figure 4
Figure 4
Moderately increased risk: evidence for risk factors and weighting decisions. Note: The scale on all the Forest plots has been curtailed at an OR of 8 to enable comparison between the plots for the different factors. If the CIs are very wide, and the upper limit extends beyond the plot this is indicated with a line with an arrow. (95% CIs are given in online supplementary table S2 if required.) ED, emergency department; ICS, inhaled corticosteroid; LABA, long-acting β2 agonist.
Figure 5
Figure 5
Slightly increased risk: evidence for risk factors and weighting decisions. Note: The scale on all the Forest plots has been curtailed at an OR of 8 to enable comparison between the plots for the different factors. If the CIs are very wide, and the upper limit extends beyond the plot this is indicated with a line with an arrow. (95% CIs are given in online supplementary table S2 if required.) SABA, short-acting beta2 agonist.
Figure 6
Figure 6
No increased risk, confounded and inconclusive factors: evidence for weighting decision. Note: The scale on all the Forest plots has been curtailed at an OR of 8 to enable comparison between the plots for the different factors. If the CIs are very wide, and the upper limit extends beyond the plot this is indicated with a line with an arrow. (95% CIs are given in online supplementary table S2 if required).
Figure 7
Figure 7
Summary of risk factors and weighting. ETS, environmental tobacco smoke; ICS, inhaled corticosteroid; SABA, short-acting beta2agonist.
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