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Association of Asthma Severity and Educational Attainment at Age 6–7

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Association of Asthma Severity and Educational Attainment at Age 6–7 Asthma Thorax: first published as 10.1136/thoraxjnl-2020-215422 on 11 November 2020. Downloaded from Original research Association of asthma severity and educational attainment at age 6–7 years in a birth cohort: population- based record- linkage study Annette Evans,1 Daniel Farewell,1 Joanne Demmler,2 Amrita Bandyopadhyay,3 Colin Victor Eric Powell ,1,4 Shantini Paranjothy1,5,6 ► Additional material is ABSTRACT published online only. To view, Background There is conflicting research about the Key messages please visit the journal online (http:// dx. doi. org/ 10. 1136/ association between asthma and poor educational thoraxjnl-2020- 215422). attainment that may be due to asthma definitions. Our What is the key question? study creates seven categories of current chronic and ► Is asthma or wheeze severity during the first For numbered affiliations see acute asthma to investigate if there is an association for six years of life associated with educational end of article. poorer educational attainment at age 6–7 years, and the attainment at age 6–7 years, should we role of respiratory infections and school absence. consider the influence of respiratory infections Correspondence to and does school absence explain the Annette Evans, Division of Methods This study used a population-based electronic Population Medicine, Cardiff cross-sectional birth cohort 1998–2005, in Wales, UK, relationship? University School of Medicine, using health and education administrative datasets. What is the bottom line? Neuadd Meirionydd, Heath Park, Current asthma or wheeze categories were developed ► After multivariable adjustment, asthma severity Cardiff CF14 4XN, UK; using clinical management guidelines in general EvansA50@ cardiff. ac. uk has no association with education outcomes practice (GP) data, acute asthma was inpatient hospital at age 6–7 years, but inpatient hospital admissions and respiratory infections were the count of Received 2 June 2020 admissions for acute asthma or wheeze were Revised 1 September 2020 GP visits, from birth to age 6–7 years. We used multilevel associated with increased risk for not attaining Accepted 9 October 2020 logistic regression grouped by schools to ascertain if Published Online First the expected level of education for children. asthma or wheeze was associated with not attaining 11 November 2020 Lower respiratory tract infections were also the expected level in teacher assessment at Key Stage 1 an independent predictor for not attaining the (KS1) adjusting for sociodemographics, perinatal, other expected level in education. School absence respiratory illness and school characteristics. We tested if was found to potentially explain the association absence from school was a mediator in this relationship between acute asthma and lower educational http://thorax.bmj.com/ using the difference method. attainment. Results There were 85 906 children in this population representative cohort with 7-year follow-up . In adjusted Why read on? multilevel logistic regression, only asthma inpatient ► This is the first study to consider interactions hospital admission was associated with increased risk between asthma and respiratory infections for not attaining the expected level at KS1 (adjusted coded in general practice consultations and OR 1.14 95% CI (1.02 to 1.27)). Lower respiratory tract hospital admissions on educational attainment. infection (LRTI) GP contacts remained an independent The cohort contained 85 000 children and rich on September 24, 2021 by guest. Protected copyright. predictor for not attaining the expected level of covariate information, allowing us to adjust for education. Absence from school was a potential mediator numerous factors including sociodemographics, of the association between hospital admission and birth and school characteristics in modelling educational attainment. the association between asthma and education Conclusions Clinicians and educators need to be outcome. aware that children who have inpatient hospital admissions for asthma or wheeze, or repeated LRTI, may require additional educational support for their educational outcomes. English language centres (UK, Australia, Canada, New Zealand) and Oceania (22%).5 Healthcare and societal burden of asthma in the UK was thought to be in excess of £1.1 billion in 2011–2012.6 INTRODUCTION Clinicians mostly follow asthma management Asthma is a common childhood condition, with guidelines7 8 that advise step changes in medica- © Author(s) (or their prevalence of current asthma (symptoms within the tion or a hospital admittance by age of the child. employer(s)) 2021. Re- use last year) at age 7 years estimated to be 12% in the Decisions to step up or step down in the manage- permitted under CC BY. UK,1 similar to Australia2 and the USA.3 Cumula- ment plan are based on assessment usually after Published by BMJ. tive prevalence of wheeze was found to be between any hospital admission for acute exacerbation To cite: Evans A, Farewell D, 15% and 26% during the first 7 years of childhood and include consideration of previous hospital Demmler J, et al. Thorax in the UK,4 with current wheeze at age 6–7 years admission, Paediatric Intensive Care Unit (PICU) 2021;76:116–125. from 7% in the Indian subcontinent to 21% in admission, recent steroids, psychological and 116 Evans A, et al. Thorax 2021;76:116–125. doi:10.1136/thoraxjnl-2020-215422 Asthma Thorax: first published as 10.1136/thoraxjnl-2020-215422 on 11 November 2020. Downloaded from family issues, compliance/adherence issues, response to initial collected health and education administrative data. Data were treatment, distance from home and family preference. Chronic extracted for asthma, wheeze and other respiratory diagnosis asthma is managed using regular reviews, and guidelines differ from GP or inpatient hospital admissions data. Children were for recommendations of a step change due to frequency of exac- followed up from birth to age 6–7 years, to their first teacher- erbations either to enable no acute exacerbations or when more based educational assessment at KS1, through record linkage than two to three exacerbations occur in a year. These guide- between education and health routine datasets. lines for asthma include school attendance but do not include evidence on the impact of hospital admissions or the burden of Data sources and participants co- occurring respiratory infections on educational outcomes. We analysed deidentified data in the Secure Anonymized Infor- Asthma aetiology is multifactorial, diagnosed by a combina- mation Linkage (SAIL) databank, UK,20 21 using the Wales Elec- tion of symptoms of inflammation in the airways with revers- tronic Cohort for Children (WECC),22 developed from five ible airway narrowing and airway hyper- responsiveness. Acute health and demographic national datasets detailed in online asthma exacerbations present as the onset of wheeze and respi- supplement table S1. WECC includes all children living in Wales ratory distress. In young children, clinicians often diagnose viral- during 1990–2012 in the Wales Demographic Service (WDS), induced wheeze but do not diagnose asthma, as symptoms may from registration with a GP in the National Health Service resolve as the child grows older. Upper respiratory tract infections (NHS). We record- linked these children to the General Practice (URTIs) are also common during childhood, and found to occur Database (GPD), containing all contacts with general medical between three and eight times a year in primary or preschool practitioners (including nurse appointments), and to national children.9 10 Children with asthma may experience more severe 11 educational databases through NHS number (health datasets symptoms when they acquire a respiratory infection. only), name, date of birth, gender, and phonetic and soundex Children with asthma who suffer frequent exacerbations that version of names (online supplement table S1). may require intervention by a general practitioner or a hospital Children were excluded if they were not born in Wales (as stay may miss school days, resulting in lower educational attain- these children had high levels of missing data for birth char- ment compared with their peers, but evidence about asthma acteristics), born before 1 January 1998 (as electronic GP and between age 5 and 9 years is mixed. Two studies in the USA hospital inpatient admissions data were not available from the and UK have reported that well-managed asthma had little data sources before this date) or after 31 August 2005 (as they 12 13 impact on educational attainment or for repeating a school would not have sufficient follow- up to age 6–7 years). Further 14 15 year, although others showed those with asthma had lower exclusions were children who died or moved out of Wales before 16 17 educational attainment compared with those without. Three age 7 years, who did not attend a local education authority studies examined severity of asthma with conflicting outcomes: school, did not take KS1 at the normal age or where the child’s one study in New Zealand showed no difference in educational GP practice had not signed up to SAIL (figure 1). At the time of 17 outcomes, two studies associated higher severity with poorer data extraction, the GPD in the SAIL databank had over 40% 18 19 school readiness or educational attainment. These conflicting of the 474 practices in Wales signed up, and over 1.9 million results may be due to different definitions of asthma, reliance people. on parental reporting, inclusion of older children
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