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What is the role of healthcare providers?
The healthcare system is a natural place to respond to ACEs and promote resilience in children,
youth and families. Guidelines for well childcare are extensive in the early years – 13 visits in
the first three years of lifei --, which is a crucial period of child development. Health systems,
and in particular pediatric providers, are in a unique position to identify issues for both children
and their families that contribute to either promoting or inhibiting healthy development. The
American Association of Pediatrics (AAP) issued a policy statement in 2012 that encourages,
among other things, pediatricians to take a more proactive role in educating patients and
families about the impact of toxic stress and in advocating for the development of interventions
that mitigate its impact. ii
What is trauma-informed care?
Trauma-informed care encompasses three levels of focus from a systems level: addressing
policy and procedures, creating approaches for organizing and delivering services and providing
specific programs or interventions for families.
The federal agency Substance Abuse and Mental Health Services Administration (SAMHSA) has
outlined six principles for trauma informed care: (1) creating a culture of physical and
psychological safety for staff and the people they serve; (2) building and maintaining
trustworthiness and transparency among staff, clients and others involved with the
organization; (3) utilizing peer support to promote healing and recovery; (4) leveling the power
differences between staff and clients and among staff to foster collaboration and mutuality; (5)
cultivating a culture of empowerment, voice and choice that recognizes individual strengths,
resilience and an ability to heal from past trauma; and (6) recognizing and responding to the
cultural, historical and gender roots of trauma.
Sobieraj, Diana M., Baker, William L., Weeda, Erin R., Nguyen, Elaine, Coleman, Craig I., White, C. Michael, Lazarus, Stephen C., Blake, Kathryn V., Lang, Jason E.
Objective. To assess efficacy of intermittent inhaled corticosteroid (ICS) therapy in different populations (0 to 4 years old with recurrent wheezing, 5 years and older with persistent asthma, with or without long-acting beta agonist [LABA]), and to assess efficacy of added long-acting muscarinic antagonist (LAMA) in patients 12 years and older with uncontrolled, persistent asthma.
Data sources. MEDLINE®, Embase®, Cochrane Central, and Cochrane Database of Systematic Reviews bibliographic databases from earliest date through March 23, 2017; hand searches of references of relevant studies; www.clinicaltrials.gov and the International Controlled Trials Registry Platform.
Review methods. Two investigators screened abstracts of identified references for eligibility and subsequently reviewed full-text files. We abstracted data, performed meta-analyses when appropriate, assessed the risk of bias of each individual study, and graded the strength of evidence for each comparison and outcome. Outcomes for which data were extracted included exacerbations, mortality, asthma control composite scores, spirometry, asthma-specific quality of life, and rescue medication use.
Results. We included 56 unique studies (54 randomized controlled trials, 2 observational studies) in this review. Compared to rescue short-acting beta-agonist (SABA) use, adding intermittent ICS reduces the risk of exacerbation requiring oral steroids and improves caregiver quality of life in children less than 5 years old with recurrent wheezing in the setting of a respiratory tract infection (RTI). In patients 12 years and older with persistent asthma, differences in intermittent ICS versus controller use of ICS were not detected, although few studies provided evidence, leading to primarily low strength of evidence ratings. Using ICS and LABA as both a controller and quick relief therapy reduced the risk of exacerbations and improved symptom control in patients 12 years and older compared to ICS controller (with or without LABA). Data in patients 4 to 11 years old suggest lower risk of exacerbations with ICS and LABA controller and quick relief use, but with a lower strength of evidence than in the older population. In patients 12 years and older with uncontrolled, persistent asthma, LAMA versus placebo as add-on to ICS reduces the risk of exacerbations requiring systemic corticosteroids and improves lung function measure through spirometry. Current evidence does not suggest that a difference exists in the efficacy of LAMA versus LABA as add-on to ICS. Triple therapy of ICS, LAMA, and LABA improves lung function measured through spirometry, although the risk of exacerbation was not different versus ICS and LABA.
Conclusions. Intermittent ICS added to SABA during an RTI provides benefit to patients less than 5 years of age with recurrent wheezing. In patients 12 years and older with persistent asthma, differences in intermittent ICS versus controller use of ICS were not detected, although few studies provided evidence for this question. In patients 12 years and older with persistent asthma, using ICS and LABA as both a controller and quick relief therapy may be more effective at preventing exacerbations than ICS controller (with or without LABA). LAMA is effective in the management of uncontrolled, persistent asthma in patients 12 years of age and older, and current evidence does not suggest a difference between LAMA and LABA as add-on to ICS.
