Halloween Safety & Asthma Express – PediaCast 444

Show Notes


  • Halloween is around the corner! This week we cover safety tips for families choosing costumes, carving pumpkins and heading outdoors for tricks and treats. Fall also brings wheezing. We consider the cause, symptoms, diagnosis and treatment of asthma and explore a special program at Nationwide Children’s called Asthma Express. We hope you can join us!


  • Halloween Safety
  • Trick or Treat
  • Wheezing
  • Asthma Express




Announcer 1: This is PediaCast.


Announcer 1: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone. And welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. 

It is Episode 444 for October 23rd, 2019. We're calling this one "Halloween Safety and Asthma Express." I want to welcome all of you to the program. 

Halloween is around the corner and soon there will be a lot of little ghosts and zombies and princesses and pirates crossing streets and going door to door begging for candy, at least in my neighborhood. And I'll bet the same is true in your neighborhood as well.


And, of course, we want you and your kids to be safe this year as you prepare for the holiday, host or attend the Halloween party, and canvas the neighborhood for tricks and treats. 

It's another one of those topics we cover nearly every year. And it's important to do so because after a year of not going trick or treat, not thinking about Halloween, we often forget or overlook tips and tricks for keeping our families and those little kiddos safe.

So with help from the American Academy of Pediatrics, we will run through all the details of what all of us need to know and remember regarding Halloween safety. That will be coming up momentarily. 

And then, we're going to turn our attention to asthma and a special program here at Nationwide Children's Hospital called the Asthma Express. Asthma is a very common disorder affecting about 10% of all kids in the United States. And this is the time of year when the perfect storm occurs for worsening asthma and wheezing as kids share viruses at school, fall allergies are kicked in, and colder temperatures turn on the furnace, which dries out the air in the home and circulates indoor allergens such as pet dander and dust mites.


So we'll consider all aspects of asthma including the cause, symptoms, treatment, prevention and, of course, the Asthma Express Program here at Nationwide Children's.

To help me do that, we have a terrific panel of three guests in the studio today. Sandy Birchfield and Elizabeth Bryant are both Asthma Express nurses. They're going to tell us about the program and educate us on asthma.

And then, Kelly Kersey is a senior quality services coordinator here at Nationwide Children's. So she really oversees programs that are sort of designed to improve health outcomes, which really describes the essence of our Asthma Express Program. So she's going to talk about a little bit more from a program standpoint.


Before we get to them, I do want to answer a quick listener question that involves our last episode, PediaCast 443, where we teamed up with the Centers for Disease Control and Prevention and talked about influenza and flu shots. 

This particular question comes from Lindsey in Oklahoma. Lindsey says, "Hello, Dr. Mike. I just listened to your recent parent podcast about flu vaccines. I have a couple of questions I thought you might know the answers to, given your research of the topic. When you noted that 1 to 2 cases per 1 million vaccines given resulted in serious complications, can you define which complications you are referring to?"

That is a great question, Lindsey, because I did kind of overlooked what complications that can occur with the flu vaccine where we see 1 to 2 cases per million doses. And that number refers to Guillain-Barre Syndrome which is a life-threatening autoimmune neuromuscular condition. 


More simply put, our body's immune system makes antibodies that attacks the nerves and cause weakness, which can become life threatening. Now, it's a very rare event following certain immunizations including the flu vaccine. However, natural flu illness — so if you get the flu itself — that is also associated with Guillain-Barre Syndrome. In fact, more commonly than the flu vaccines. 

So in a sense, you're still better off with the vaccine than getting sick with the actual flu in terms of your risk of getting Guillain-Barre Syndrome.

By the way, if you'd like to learn more about that particular condition, Guillain-Barre Syndrome, we covered that in a considerable detail in PediaCast Episode 341. And I'll put a link to that in show notes for this episode, 444, over at pediacast.org if you would like to take a listen to that.


And by the way, where did those numbers come from? They really come from the CDC itself which monitors vaccine reactions. And I'll put a link to the Flu Vaccine Safety Information page at the CDC where those numbers come from. Again, I'll put that in the show notes as well.

Secondly, Lindsey asked, "Do you know of the stats cited for deaths from the flu, how many of those flu death patients were in fact vaccinated?"

Another good question, Lindsey. It really depends on the flu year in question because it does vary from one flu season to the next. But in general, and especially as we consider kids, it ends up being about 75% to 90% of pediatric flu-related deaths occur in unvaccinated children. So the vast majority, 75% to 90% of kids who died from the flu did not receive the flu vaccine. 


And I'll put a couple of links that reference those numbers in the show notes as well again over at pediacast.org, Episode 444. One from the American Academy of Pediatrics entitled "Unvaccinated Children Account for Majority of Pediatric Flu Deaths" and another from CDC, "90 Percent of Children Who Died From Flu Not Vaccinated". That references a particular year, but these are all recent years. And if you look from year to year, again, it ends up being about 75% to 90%.

So thanks for the follow-up questions, Lindsey. They were excellent. If you have not listened to my conversation with Dr. Dawood from the Centers for Disease Control and Prevention of the CDC, please consider doing so. Again, that was our last episode, 443, "Influenza and Flu Shots".

And even more importantly than listening to that program, if your family has not yet received your flu vaccines, the time to act is now. It takes a couple of weeks for you to have full benefit of your flu vaccine. So you definitely want to get it before the influenza virus invades your community, which is certainly going to happen at some point either late in the fall, during the winter, and perhaps even into early spring.


If you do have a question or a comment for the program, kind of like Lindsey did, if you need some clarification on something we're talking about, easy to get in touch, just head over to pediacast.org and click on the Contact link.

Also, I want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at pediacast.org.

So, let's take a quick break. And then, we will be back to talk about Halloween safety and Asthma Express. That's coming up right after this.



Dr. Mike Patrick: We are back and ready to talk Halloween safety, which is an important thing for all of us to keep in mind this time of the year. There's even some safety tips here if you maybe have older kids and you're not going to go around trick-or-treating but you're going to have folks come to your place doing the trick-or-treating. We have some ideas for you to keep your areas safe as other kids are kind of traipsing in and out. 

So, really things that we all need to keep in mind. And, by the way, hopefully they're of interest to you because we want to keep everyone safe over Halloween.

But if you forget what it is that we're saying and you'd like a checklist or you want to share this information with other folks in written form, I am going to provide a link for you to the American Academy of Pediatrics site that sort of goes through these Halloween safety tips, again, in written format. And I'll put a link to that in show notes for this episode, 444, over at pediacast.org.


So the first consideration really is how do we choose a costume that is safe to use? Because there's just so many options out there. 

First, you're going to want a costume that is bright and reflective since we're doing trick or treat at dusk. It's a little dim outside. People have their car lights on, so it's going to be important to be bright and reflective. 

And make sure shoes fit well and that costumes are short enough to prevent tripping, entanglement, or contact with flame. Folks may have candles and jack-o-lanterns. 

There may be other sources of open flame. You want to make sure that you don't have anything that's too flowing and could flow into the fire. 


We probably really want to keep open flames away for hosting Halloween. Better to put flashlights and other sorts of lights inside a jack-o-lantern rather than flames especially on trick-or-treat night.

Consider adding reflective tape or striping to costumes and trick-or-treat bags for even greater visibility. And because masks can limit or block eyesight, consider non-toxic makeup and decorative hats as safer alternatives. Hats should fit properly so they don't slide down over the eyes. And makeup should be tested ahead of time on a small patch of skin to make sure there is no unpleasant allergic rash surprises on the big day. 

When shopping for costumes, wigs, and accessories, look for and purchase those with a label that clearly indicates that the items are flame resistant. And if a sword or cane or stick or light saber is part of your child's costume, make sure it's not sharp or real long. A child may easily be hurt by these accessories if he or she stumbles or trips. So that's something to keep in mind. 


And then, avoid decorative contact lenses, The packaging on these things often may claim that one size fits all or there's no need to see an eye specialist. However, using decorative contact lenses without a prescription is both dangerous and may even be illegal. It can cause pain, inflammation, serious eye disorders and infections, scratches on the surface of the eye. And these things can even lead to permanent vision loss if there's delay in treatment. And so, just stay away from those. Leave those to the professionals. No decorative contact lenses.

And, of course, review with your child how to call 911 or their local emergency number if you ever have an emergency or become lost over Halloween and during trick-or-treat.


All right, let's move on to pumpkin carving. Small children should not carve pumpkins, all right? Have them draw a face with markers. And then, if you really want, the parents can do the cutting after that. Even if you're using one of the blunt, the non-sharp kind of pumpkin carving knives, if they're really small, probably, just wait till they get a little older to do that. 

Once you do get the pumpkin carved and scooped out, consider using a flashlight or glow stick instead of a candle to light your pumpkin, as I'd mentioned before. If you absolutely must use a candle, if you're like, "No, it's not Halloween without the candle," then a votive is going to be the safest. But you really do want to keep a close eye on that. 

Candle at pumpkins should be placed on a sturdy table, away from curtains and other flammable objects, and really not on the porch or any path or visitors may pass close by. Because, you know, they may be wearing those flowing costumes. And, of course, never leave an open flame including a candle-lit pumpkin unattended.


Other safety tips around the home, keep your home safe for those visiting trick-or-treaters. Really look around, remove from the porch and front yard anything that a child could trip over. That would include garden hoses, toys, bikes, lawn decorations. Really keep that zone free of objects. 

Check your outdoor lights, replace burnout bulbs. 

Any wet leaves or snow, if you already have snow in your area. Boy, that does not sound good. We don't have any here yet, thankfully, but I'm sure that some of you listening may in the upper elevations out west. Do keep wet leaves and snow swept away from sidewalks and steps. 

And restrain your pets so they do not inadvertently jump on or bite a trick-or-treater, or run away and become lost. Just keep your pets, remember to keep them away from the front door that's being opened and closed frequently.

And then, as you're going around trick-or-treating, a parent or responsible adult should accompany young children on their neighborhood rounds the entire time, stay with them.


Have flashlights with fresh batteries for all children and their escorts. If your older children are going out alone, plan and review the route that is acceptable to you and agree on a specific time when they will return home. Only go to homes with the porch light on and never enter a home or a car for a treat. Very important to review that safety tip with your kids. 

And because pedestrian injuries are the most common injuries to children on Halloween, remind your trick-or-treaters to stay in a group and communicate exactly where they are going to be going. Remember the reflective tape for costumes and trick-or-treat bags. I know I already mentioned that, but again, you just want to be really highly visible considering that pedestrian injuries are the most common ones. 

Carry a cell phone for quick communication. Remain on well-lit streets, and always use the sidewalk. If no sidewalk is available, walk at the far edge of the roadway facing traffic. But really, going to a neighborhood with sidewalks is going to be your safest bet. 

Never cut across yards or use alleys, as you may come across objects more readily that you could trip over or a car could dart out through an alley or a bicycle rider. So really watch that. 


And only cross the street as a group and establish crosswalks as recognized by local custom. Never cross between park cars or out of driveways. So wherever it is that normally during the day pedestrians would cross, that's where you should cross as well, certainly not in the middle of the street.

And don't assume that you have the right of way. Of course, you do. Pedestrians always sort of have the right of way. But don't assume that because motorists may have trouble seeing you as a trick-or-treater. And just because one car stops does not mean that others will.

So really be defensive. Watch out for cars. Let them go by. Make sure the coast is clear before you're crossing any roads or alleyways. And, of course, law enforcement authorities should be notified immediately of any suspicious or unlawful activity that you come across while you are trick-or-treating. 


We also want to think about health over Halloween, a good meal prior to parties and trick-or-treating will discourage youngsters from filling up on Halloween treats. So it's kind of like don't go to the grocery store when you're really hungry. You're going to buy a lot more. 

Same thing with trick-or-treating, don't go out hungry. Or else you're just going to eat a whole bunch of candy and then probably not feel so well afterward.

Consider purchasing non-food treats for those who visit your home such as coloring books or pens, and pencils. That always is fun when kids get home. It's not all candy in there. There's some fun stuff, too. And maybe you are the home that provides that for your trick-or-treaters. 

Wait until children are home to sort and check through the treats. So don't eat while you're on the sidewalks and going door to door. Wait till you get home and you can sort them and check them out before you eat.


Tampering is rare but still a responsible adult should closely examine all treats and throw away any spoiled, unwrapped, or suspicious items. And then, try to ration the treats for the days and weeks following the Halloween. Don't just keep the open bag for kids to grab the candy out. Really ration it. Put some away, keep a little bit out, and watch how much kids are eating.

In terms of food allergies, Halloween can be tricky for children with food allergies. So it's going to be important that parents closely examine Halloween candy to avoid a potentially life-threatening reaction. 

Always read the ingredient labels on the treats. Many popular Halloween candies contain some of the most common allergens such a peanuts, or tree nuts, milk, soy, egg, or wheat. If the ingredients are not listed, arrange a treat exchange with classmates or friends or bag up the goodies your child cannot eat — because of an allergy or because the ingredients are not listed — and leave them with a note saying the treat fairy will swap those for a prize. Have some prize ready and just let your kids know, "Hey, the ingredient's not listed," or , "You know you can't have this one. Let them out tonight and maybe the treat fairy will stop by, just like the tooth fairy, and leave you a prize instead."


Also, be aware that even if they are not listed on the ingredient label, candy is at high risk for containing trace amounts of common allergy triggers because factories often produce many different products. Also, fun size or miniature candies may have different ingredients or be made on different equipment than the regular size candies. Meaning that brands your child previously ate without a problem could potentially cause a reaction. So just beware of that.

Also, teach your child to politely turn down home-baked items such as cupcakes and brownies and never taste or share another child's food, just in case. And, of course, have those epipens or epinephrine auto injectors ready. And if your child does show any sign of anaphylaxis or a severe life-threatening allergic reaction, don't be afraid to use it. It could save their life.


Another terrific resource from the American Academy of Pediatrics, and I will put a link to this in the show notes as well, Halloween for Kids with Special Needs or Restrictions. There's actually a short podcast that the AAP put together with some tips for kids with special needs at Halloween time. Really well done. And I'll put a link to that in the show notes.

Also, all of these tips that I just went through, we'll have a link to those in the show notes. And then, a couple of blog post that I have written in the past. One, Kids Behavior and the Full Moon. Are kids' behaviors really different? Do folks act differently when there is a full moon? We look at the myths and the legends and the truth and talk about that in that blog post. So be sure to check that out.

And also one, Beware of Bats and Rabies. So a couple of Halloween-themed blog post for you from the 700 Children's Blog. And I'll put links to both of those in the show notes for this episode, again, 444, over at pediacast.org.


All right, let's take a quick break and we will get our guests settled into the studio and be back to talk about asthma and Asthma Express. That's coming up next.


Dr. Mike Patrick: Sandy Birchfield and Elizabeth Bryant are registered nurses with the Asthma Express Program at Nationwide Children's Hospital. They are experts in the treatment of pediatric asthma and prevention of wheezing and difficulty breathing in young patients. They also provide extensive education to families regarding this common disease. This makes Sandy and Elizabeth the perfect duo to have in the studio as we consider asthma and wheezing in children. Thanks to both of you for joining us today. 


Sandy Birchfield: Thank you.

Elizabeth Bryant: Thank you.

Dr. Mike Patrick: Really appreciate it. And Kelly Kersey is also in the house. Kelly is a certified professional in healthcare quality, which means you'll see the letters CPHQ after her name. She's a senior quality improvement services coordinator at Nationwide Children's Hospital, which means she works hard to improve the quality of care that we provide for children and their families, with an emphasis on improving health outcomes in a very intentional fashion.

One of the intentional programs that Kelly oversees is known as Asthma Express which we will cover in considerable detail as we move through the show today. But, for now, let's give Kelly a warm welcome. Thanks for stopping by. 

Kelly Kersey: Thank you. 

Dr. Mike Patrick: Really appreciate all of you being here. So, Sandy, I want to start with you. What is the meaning of these words that folks hear often, like wheezing and asthma? Sometimes you hear bronchiolitis, sometimes reactive airway disease. Sort of walk us through the meaning of these common terms. 

Sandy Birchfield: So bronchiolitis is swelling and some increased mucous production in the airways that's usually caused by a virus. The common virus we usually see that with is RSV, but also HNV, influenza. 


Reactive airway disease is something we hear a lot for patients who haven't yet been diagnosed with asthma. So they're having similar symptoms that asthma patients would have. Maybe that's just their first or second time and they haven't had that diagnosis yet. And then, asthma is where the airway is swelling and constricting and you also have that increased mucous production and that can be caused by… Also, caused by viruses could be a trigger, but also caused by some things in the environment and allergens. 

Dr. Mike Patrick: So air moves through our lungs, through the breathing tubes and anything that constricts that flow of air is going to create vibrations and turbulence. And so, you get some noise that's made. And that wheezing that we hear when kids breathe out is really because the air flow is not going through nice big open tubes that are smooth, right? 

There's a lot of obstruction kind of stuff, from inflammation, and as you said mucous. And when that happens recurrently, then we would start to call it asthma. 

Sandy Birchfield: Yes. 


Dr. Mike Patrick: Absolutely. It's a pretty common condition, right? About 10% of all kids in the United States have asthma. This is something that you guys, of course, being asthma nurses, you see this all the time.

Sandy Birchfield: Yes, we see it a lot. 

Dr. Mike Patrick: So you mentioned environmental factors that contribute to asthma. What are some of the environmental factors that folks need to be aware of?

Sandy Birchfield: Well, in Ohio, we have drastic changes in weather. Sometimes, daily, and that can affect people with asthma. We have a lot of different allergens in the environment, air pollution, exhaust fumes from the areas around 270. And a lot of patients that live in that area have more flare-ups than our patients in rural areas.


Dr. Mike Patrick: So stuff outside the house, inside the house, pollens. 

Sandy Birchfield: And dust and mold and…

Dr. Mike Patrick: Can really make a difference. And cigarette smoke and vaping.

Sandy Birchfield: Oh, yeah. 

Dr. Mike Patrick: We're seeing more and more of that and there's certainly irritating chemicals. Whether there's nicotine or not or whether it's flavored or not, there's still chemicals in the vape. What do you call the smoke, the vaping smoke?

Sandy Birchfield: The main vape.

Dr. Mike Patrick: Yes, yes.

Kelly Kersey: Steam?

Dr. Mike Patrick: And we're hearing in the news of these things actually causing lung damage and may be associated with chronic disease. And yet, the numbers of middle school and high school students who are vaping seems to be going up. So, it's becoming a bigger and bigger problem. With that, we need to get the word out about it, right?

Sandy Birchfield: Yes, it is. We usually talk to all of our teenage patients about vaping and smoking. 

Dr. Mike Patrick: Elizabeth, we covered what causes asthma in terms of the inflammation and the reaction to allergens and viruses and mucous and things that decrease the diameter of the airways. Besides wheezing, what other signs and symptoms go along with asthma itself? 


Elizabeth Bryant: So early signs can be similar to viral illnesses, fatigue, dark circles under the eyes. Usually, you'll see some runny nose, and you'll see the kids during what we call the asthma salute, which is a big runny salute up the nose with the hand. 

Think about when you get sick. You wake up with a sore throat. Maybe you have some sinus pressure and you're walking around drinking the juice like Sandy is. 


Elizabeth Bryant: And you're saying I'm not getting sick. Well, these kids, the same thing's going in their body. They just don't know how to describe it. So it's up to a parent to recognize, "Oh, they're fatigued. Something's going on." If you're a mom and you see your kid going through this, you know that this is happening before it's going to happen.

So it can look like that. Coughing is a big one. 


Dr. Mike Patrick: So coughing, difficulty breathing, but even behavioral changes. I love that you mentioned as a parent, if you just notice they're not acting like they usually would act, or something just seems off, your mom radar is going off. I mean, they're really having some difficulty breathing and don't know how to express that. 

Elizabeth Bryant: Right. Shortness of breath. If your kid is sitting down and resting while other kids are still playing, that's a big sign. So it's something, you need to explore that a little bit more. Did I mention coughing?

Dr. Mike Patrick: Yeah.

Elizabeth Bryant: And don't wait till coughing's a lot. One or two coughs, we cough to clear our airway. However, two or three in a row is indicative of airway constriction.

Dr. Mike Patrick: And I think it's really good point because some kids, you may not hear them wheeze. The idea that they have asthma or that their asthma is flaring up really may present as chronic coughing. 

Elizabeth Bryant: Right.

Dr. Mike Patrick: So you want to make sure you let your provider know that as well and get them help if they have known asthma and they're starting to cough more than usual.

Elizabeth Bryant: Right, yeah. I would like to tell parents if you have a diagnosis of asthma and your kid coughs three times, start the albuterol puffs with the spacer. 


Dr. Mike Patrick: So I think that leads us into the treatment of asthma very nicely. How do we treat asthma for kids, once we know that's what's going on? 

Elizabeth Bryant: So, well, usually, it will start out without the diagnosis. We talked about the reactive airway disease. So they treat it with the fast-acting bronchodilator. Once the diagnosis of asthma is made, we go ahead and start a controller medicine which is an inhaled corticosteroid. And they take two puffs in the morning, two puffs at night. 

If the asthma progresses or is not well controlled with that inhaled corticosteroid, we do a combination drug. It's an inhaled drug. It's got the inhaled corticosteroid and a long-acting bronchodilator. LABA is what we call it. We use that. 

There are other medications that we can add. Sometimes, allergy meds. Sometime, Singulair. Now, we have the ability to add biologics, which is an amazing and exciting new aspect of asthma treatment. They can look at biomarkers in the airway and in the blood and tailor-made injections for the suppression of those biomarkers.


Dr. Mike Patrick: Really interesting stuff. I want to walk back to sort of the basic treatment of wheezing and asthma. And you mentioned bronchodilators and corticosteroids. And when we think about what causes wheezing in the first place, and that is obstruction in the airways and mucous and inflammation and so the available space for air to flow is diminished, of course, the steroid medicines are going to decrease inflammation. So that you increase your airway diameter because you don't have the swelling into the airway anymore. 

And bronchodilators, those relax smooth muscle that exist on the inside of the airway. So if we relax that muscle, then that makes the diameter of the airway bigger.

If you think about it in that terms, we've sort of gotten away from using bronchodilators and tiny little babies with bronchiolitis because they don't really have much smooth muscle to relax. And those bronchodilators also have side effects to increase your heart rate, increase your respiratory rate, make you feel anxious. And so, giving little babies with bronchiolitis were again, although that's not a 100%, there are instances especially if there's a strong family history of asthma that maybe they would help a little bit. 


But the important thing to remember is that those are really going to be your rescue inhalers because they have a really quick onset to relax that muscle and make the airway bigger. Whereas, steroids take a little bit longer to reduce inflammation. And so, those are going to be more like your controller medicines. 

And if you have steroids in inhaler form, it's really important that you know the difference between which one is the rescue inhaler and which one is the maintenance inhaler, because if you start using the steroid every four hours, it's not really going to help you out as much, right?

Elizabeth Bryant: Right. We'd like to steer away from calling it the brown inhaler and the blue inhaler. I make them say the names of the medication that they are on. And I say, "Until you know it, say it every time you give it."


The albuterol, I don't like to call that a rescue med. I like to call them a symptom reliever because I don't want parents to wait until they are in a rescue mode to give it. I want to give it early, right on the onset. Keep the airway open, every four hours, as needed. And sometimes, you need it for three or four days. And that's okay to give it. 

Dr. Mike Patrick: I love that you say that. So, because I think we get in our minds and we use the same terminology over and over again, I know there's probably a lot of pediatric providers listening to this who do use the term rescue inhaler. But you're right, you don't want to wait to the point that you're needing to rescue someone. Just as soon as those symptoms start… 

Elizabeth Bryant: Space them. 

Dr. Mike Patrick: Yeah, with the bronchodilators, albuterol, Xopenex, those kind of things. 

Tell us about the importance of using a spacer and mask with these inhalers. You don't just want to put it in your mouth and spray, right?


Elizabeth Bryant: No. The particles of medication need a few inches. Otherwise, it kind of just propels to the back of the throat and we end up swallowing it. The spacer allows for the particles to be suspended so that the patient can easily breathe them in, simply put.

Dr. Mike Patrick: So those particles are suspended and then you suck them down into the lungs. Whereas, if you spray something in your mouth, it hits the back of the throat. You're going to swallow some of it and the medicine's not really getting down to where you need it. 

And you would recommend a spacer for all ages, right? 

Elizabeth Bryant: All ages.

Dr. Mike Patrick: Not just young kids. 

Elizabeth Bryant: Yeah, exactly.

Dr. Mike Patrick: Teenagers, adults with asthma really ought to be using spacer with their inhaler. 

Elizabeth Bryant: Think about the mechanism of action. If you are breathing in, you have to be able to forcefully that aerosol in, that MDI in, in order to get it into your lungs. If you are having an asthma attack, you don't have the ability first of all to blow out the air that you have and then to… 


Elizabeth Bryant: Real hard because you're constricted and swollen and it just ends up falling in your mouth, on your tongue.


Dr. Mike Patrick: Yeah, absolutely. And folks should check with their provider before following this advice because it really is tailored from person to person. But we're beginning to realize that maybe two puffs is not enough when you're having those symptoms. And you may need to ramp that up and maybe do four puffs, six puffs, eight puffs. But, obviously, talk to your provider so it's individualized for your child in terms of what you do when you have those symptoms. 

But when we consider that we're sort of transitioning more and more away from using the nebulizer where you pour the contents in and you turn the machine on and it gives you to the mist to the meter-dose inhaler. But two puffs does not equal a whole neb. 

Elizabeth Bryant: No, it doesn't. I feel like six to eight puffs to onset. But again, I'm not a physician and I wouldn't dare tell anybody that. 

Dr. Mike Patrick: You want to use the lowest dose that works. And sometimes, you're going to need to ramp that up. 


Elizabeth Bryant: And sometimes, yeah. Two does work. If you get to a position where you're doing more than two puffs every four hours, it's time to call the doctor. 

Dr. Mike Patrick: Yeah. And that's where this notion of an asthma action plan can really come into play, so that it's really more individualized. "Hey, when you start having symptoms, use this many puffs." It sort of gives you a recipe of what to do. 

Tell us, Sandy, a little about the asthma action plan and how important it is. 

Sandy Birchfield: The asthma action plan, I like to look at it as like a personalized instruction booklet for the family. It is provided by the physician and the physician orders everything that's on the asthma action plan. And it simply just tells you in the green zone — and that's at the top of the page for the family — it tells them that these are the things you need to do every day even when you're healthy and then these things are hopefully going to maintain that long health for you.

And then, of course, as all kids do, they get colds and viruses. And then, with the weather changing and trick-or-treat coming up, a lot of kids will be out in the evening and it's going to be kind of cold. So in the yellow section of the asthma action plan, it talks about what to do when you start to get cold symptoms. And we talk to families about starting that rescue inhaler, the albuterol, as soon as the onset of cold symptoms are there and not to wait for those symptoms to get worse. 


Your treatment that you have available at home is going to work much better if you're using at the moment you realize that these symptoms are starting and you don't wait for the symptoms to progress. 

And then, other symptoms like wheezing and shortness of breath and coughing are also on that yellow section. And that would be the same treatment which is usually two puffs of the albuterol every four hours. If for some reason, that isn't working, the orange section will then tell them to usually do… At this point, they may increase the amount of albuterol they're getting. So sometimes, four to six puffs. 

But at that point, we like you to call your doctor. And we'll have a phone number listed there for you to call. And then, they'll let you know what to do from there. At that point, they usually want the child seen.


Dr. Mike Patrick: And then, red section is your kid's in trouble. You need to see someone now because they're having difficulty breathing. I mean, giving the albuterol but also be arranging transport to see someone as soon as possible. 

And the nice thing with this again is when your child is having difficulty, sometimes it's hard to think clearly. And so, by having that asthma action plan, you know, "Okay, wait a minute, let's refocus. This is the symptoms we're having. This is what I need to do." And it really can help families.

If there's a babysitter that's taking care of a child, or a child at school, they ought to have the asthma action plan with the school nurse as well. So, just a good way to communicate with everyone, "Hey, if a particular child has these symptoms, this is how we're going to manage it for this child and get everybody on board." 

Sandy Birchfield: Yes.

Dr. Mike Patrick: Very, very important. 

Elizabeth, what are some complications can occur? What are some of the things that we worry about if we have poorly controlled asthma? 


Elizabeth Bryant: Well, sadly, death is a complication that we don't want to happen. A lot of kids die of asthma every year. I feel like it's something like nine kids a day in the United States die from asthma. 

Also, the lack of oxygen to the brain can cause what we call hypoxia, which if that continues for a long time can cause impairment, neurological impairment which is not desirable. It can also cause permanent lung damage, as the inflammation is pretty much constant in the lungs. We call that term remodeling. So the lungs don't function as well, it's scarred.

Also, obesity, because of increased corticosteroid oral use. Poor sleep can lead to learning impairments, behavioral issues, and the stress on the family is tremendous. 

Dr. Mike Patrick: Yeah, absolutely. And the sleep thing and if you're not getting a good night sleep, then you're not alert during the day the next day and that can cause academic problems and school problems and missed school and parents can miss work. So there's a financial burden on families as well. 


Elizabeth Bryant: Indeed, yes. 

Dr. Mike Patrick: You mentioned the corticosteroids. So if you have poorly controlled asthma and then you're getting your steroids by mouth, over time, as you do that more and more can cause a problem. But the inhaled steroids that are used as a maintenance or controller medication, those aren't necessarily associated with obesity.

Maybe there's some growth issues, but asthma itself that's uncontrolled as a chronic illness can also cause growth issues. 

Elizabeth Bryant: Right. 

Dr. Mike Patrick: So, certainly, the benefit of daily inhaled steroids outweighs any risk that you would have from it. 

Elizabeth Bryant: The risks are minimum. The linear growth I feel like, I saw a statistic one time and it was a quarter centimeter to half a centimeter of linear growth was lost over the entire growth time. 

There can be some adrenal suppression which can cause obesity. But when you're on these meds, you're seeing a doctor all the time. You as a parent realize, "Wow, he's packing on weight," and you would bring this up to a physician. And a physician would look at that and make sure maybe the steroids need to be backed off a little bit. 


I haven't seen that that much. I don't know if Sandy has. 

Dr. Mike Patrick: And diet and exercise become even more important. 

Elizabeth Bryant: And think about it, if your asthma's not controlled, you're not going to exercise as well. And they need to exercise a lot to grow. So it's a vicious circle. We want them to play outside but they need to be on these controllers as well.

Dr. Mike Patrick: Yeah, absolutely. So in that vein of wanting great control of asthma, the Asthma Express Program was sort born out of that desire. So, Kelly, tell us a little bit about what the Asthma Express Program is here at Nationwide Children's.

Kelly Kersey: So Asthma Express is a diagnosis-driven program. So what does that mean? So inside Asthma, patients can get one to three visits prescribed by their physician to the Asthma Express based on the level of persistence of their symptoms. 

So our main goal is going out and helping these patients and their caregivers and parents basically understand their symptoms and how to help them best maintain their optimal level of health and maintain like control of asthma. 


So in these nursing visits, our dynamic duo, one of them goes out to the home. And we do physical assessment. We do an environmental assessment. They review the medications that are prescribed to the patients, specifically those asthma medications like Elizabeth and Sandy were referring to earlier to make sure that they're properly administering them. Sometimes, we find out that they are not. 

The asthma action plan, while the document instructs you on what to do if things are not in the green zone, can sometimes be challenging to understand when you're in an exacerbated state. They make sure that that is easily understood by the patient and their family. 


And then, they also tend to other educational needs. Because we try to individualize this program to every patient that we provide it to. 

Dr. Mike Patrick: Yeah, so how do folks get hooked up with the Asthma Express Program? How do you become aware that this is a family that really needs our services and needs an asthma nurse to come out to the house and do an assessment and education.

Kelly Kersey: So we can do that in a variety of ways. We do have a lot of partners within the organization that are well aware of our program. And so, a lot of our referrals do come after in-patient hospitalization. But we would like to get our hands on these patients to help them maintain control and stay in the community and in their home.

So we are doing community outreach where we're reaching out to pediatricians throughout the area and going to physician conferences, putting information out that way. 


We do moms-to-be program where we're reaching out to moms that might have a new baby that are getting resources for other things, but they might have other children with them. And so, that's another avenue. 

Basically, we're trying to be a little bit more proactive as opposed to reactive to prevent those ED visits and prevent those hospitalizations.

Dr. Mike Patrick: And physicians here in the Central Ohio area, and we'll put a link in the show notes to the Asthma Express Program. We also have a phone number that folks can call to refer patients who they think may have help from this program, in terms of the education and the support and really keeping their asthma under better control and keeping them out of the emergency department, hospital, and intensive care unit sometimes by keeping that asthma under control. It's so very important.

Kelly Kersey: It is. 

Dr. Mike Patrick: For families who are involved in the Asthma Express Program, is there a charge to this? Someone's got to pay for the time of the nurses coming out and the education. Is this something that's covered by insurance?


Kelly Kersey: It is covered by insurance. Most providers do in fact cover it. Our PFK providers cover it. Most of our private insurances cover it. And we are working on ways to hopefully in the near future help our patients that do not have coverage to receive these services in the near future as well. 

Dr. Mike Patrick: From the primary care standpoint and the family standpoint, and correct me if I'm wrong about this, I would think that ability to pay shouldn't be the first consideration. It should be get that referral and then you guys can work with insurance companies and figure out how hopefully to make it happen. 

Kelly Kersey: And that's exactly what we do, but there are a lot of times where I feel that some of our families that are referred that are self-pay because they don't have insurance coverage get scared and don't understand that there's things that we can do behind the scenes to help them, and so they refuse it. And then, we end up seeing subsequent ED visit, urgent care visits, and hospitalizations as a result.


Dr. Mike Patrick: Yeah, and if they're self-pay, those are really much higher bills than the Asthma Express Program would have been. So there's some education that probably goes along with trying to explain that to folks as well. 

Kelly Kersey: Correct.

Dr. Mike Patrick: So have you seen this program make a difference? So you're a quality expert, and so one of the things you know, data and metrics. Is this something you think is making a difference in the lives of these families? 

Kelly Kersey: I get super excited to talk about stuff like this. So yes, we have seen a profound difference. Especially I think since about 2016, when we compare patients that were enrolled in Asthma Express as opposed to those who were not. It's statistically significant and it's profound. 

So we're able to measure that on a monthly basis. We only go out about three months past discharge from the Asthma Express Program. But we do compare that to see what utilization for the emergency department in the hospital is like for patients that are referred to us but do not enroll in the program. 


And so, I think that the understanding that is provided by our nurses that go along the lines with like their asthma action plan, how to properly use their medications, and how to identify and avoid or reduce exposure to their triggers are all things along the lines that have helped immensely. 

Dr. Mike Patrick: If a family, let's say they were involved in the Asthma Express Program, many months go by, their child doesn't have a flare-up of their asthma and then we all see this. And then, suddenly it's a new viral season. The new school year starts and boom it's a problem again. You forget these things.

And so, can you re-enrol a second time?

Kelly Kersey: So, kind of. We do offer kind of a subset to the program now where we… Basically, it's a refresher education. So if we see a patient that has been readmitted or gone back to the emergency department and they feel like they need a refresher. Sandy and Elizabeth both have several families that they have good rapport with as a result of this. 


We can put them through one, maybe two or three additional visits that has to come through from their physician again, but it is now another layer to the program that we offer.

Dr. Mike Patrick: We have a lot of folks in the audience who do not live in Ohio and are not in the Nationwide Children's immediate service area. I would suspect that if there are areas of the country where maybe there's not similar program and they are interested, community members, parents, physicians, pediatricians, family practice doctors who wanted to put together a similar program that will be covered by insurance in their community, I would imagine you guys will be open up to people contacting you and saying, "Hey, how did you put this together?"

Kelly Kersey: Yeah, absolutely. In fact, we did the very same thing. So the program that we run here at Nationwide Children's Hospital Home Care is not exactly the same but was created in the spirit of what was started by Boston Children's. And if you look around the country, there are other departments of health and pediatric providers that have done the same thing.


I would say that it is somewhat demographic driven and cityscapes need to be taken into account because one place might have different issues and others depending on environment and climate and how people are housed. We learned that over the course of several years.

Dr. Mike Patrick: And so, it really kind of morphs in order to benefit the people who are enrolled in the program and the unique needs of a particular community or area. So really a fantastic thing. And at the heart of it, it is really improving health outcomes and making family's lives better, keeping kids out of the hospital and in schools, and parents in work. And it's really just doing what's best for the community and changing things as you go to make that happen.

Kelly Kersey: Right.

Dr. Mike Patrick: We have a ton of asthma programs here at Nationwide Children's. I'm going to put links in the show notes to all of these things. So we have, of course, our Asthma Express Program that we've talked about. 


We have just that Comprehensive Asthma Clinic. So if your child has complex asthma and you're in our service area, make sure that you know that that's resource is available. And again, link to our Asthma Program will be in the show notes for this episode, 444, over at pediacast.org.

We have a terrific school-based asthma program. We talked about that in Episode 360. I'll put a link to that podcast. 

And then, we have a fabulous website with a ton of resources for families, patients, providers. We have teaching materials, videos, handouts, asthma action plans, and all sorts of educational stuff for patients and families. And I'll put a link to that in the show notes as well. 

Actually, last week, we did a podcast on our CME side. So PediaCast CME, it's Continuing Medical Education. And we had a program on sort of an update on managing pediatric asthma. We had a neonatologist and an allergy asthma expert here in the studio. Also, one of our homecare nurses joined us for that one.


PediaCast CME 50 for providers, you can get free Category 1 CME Credit for listening and I'll put a link in the show notes to that program as well.

Lots of other links for you. We talked about the flu and flu shot safety a little bit in the intro to the program. We'll have all of those links that we had mentioned. Also, all of the links I mentioned with our Halloween safety segment a bit earlier on. And then, of course, all of these asthma resources for you as well, including the phone number to make referrals to the Asthma Express Program here in Central Ohio. 

So once again, Sandy Birchfield and Elizabeth Bryant, Asthma Express nurses here at Nationwide Children's, and Kelly Kersey with Quality Improvement Services, really appreciate all of you stopping by today. 

Kelly Kersey: Thanks.

Elizabeth Bryant: Thank you.

Sandy Birchfield: Thanks for having us. 



Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out  of your day and making PediaCast a part of it. Really do appreciate that. 

Thanks to our guests this week, Sandy Birchfield and Elizabeth Bryant, both Asthma Express nurses and Kelly Kersey with Quality Improvement Services, all of them from Nationwide Children's Hospital. 

Don't forget, you can find PediaCast in all sorts of places. We are in the Apple Podcasts app, iTunes, Google Play, iHeart Radio, Spotify, SoundCloud and most mobile podcast app for iOS and Android.

We are also a proud member of the Parents on Demand Network, which you can find at parentsondemand.com. 


And, of course, our landing site, we have our entire archive of past programs, show notes for each of the episodes, transcripts, written transcripts for many of them, our Terms of Use Agreement, and a handy contact page if you would like to suggest a topic for a future program or have a comment or question that you would like to ask me or share with the audience. Again, that's over at pediacast.org.

Reviews are helpful wherever you listen to PediaCast. We always appreciate when you take a moment to share your thoughts about the program. 

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Don't forget to tell others about the program, not just on social media but also face to face — your family, friends, neighbors, co-workers, babysitters, daycare workers, anybody who has kids or takes care of children. And that would include your child's pediatric healthcare provider. Please let them know about the program so that they can share it with their other patients and families. 


And while you have their ear, let them know we have a podcast for them as well. It is called PediaCast CME. That stands for Continuing Medical Education. It is similar to this program. We turned up the science a couple notches and offer free Category I Continuing Medical Education Credit for those who listen. 

Shows and details are available at the landing site for that program, pediacastcme.org. And those episodes are also available in Apple Podcasts, iTunes, Google Play, iHeart Radio, Spotify, and most mobile podcast apps. Simply search for PediaCast CME.

Thanks again for stopping by. And until next time, this is Dr. Mike saying Happy Halloween, stay safe, stay healthy, and stay involved with your kids. So long, everybody.



Announcer 1: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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