Teens play basketball outside on a hot day in summer 2023 in New York City after the state issued an air quality health advisory recommending active children and those with asthma limit time outside. Experts worry that a new federal report minimizes how millions of kids in the U.S. rely on asthma medications to breathe normally. (Photo by Spencer Platt/Getty Images)
Medical experts are dismayed over a federal report’s claim that kids are overprescribed asthma medications, saying it minimizes how many lives the drugs save.
Safe treatment protocols for asthma management have been carefully studied over the years, said Dr. Perry Sheffield, a pediatrician and professor at the Icahn School of Medicine at Mount Sinai.
“The federal government actually has some really beautiful and clear guidelines and strategies, and things that are vetted by and carefully edited by many experts in the field,” said Sheffield, who co-directs a region of the federally funded Pediatric Environmental Health Specialty Units that serves New Jersey, New York, Puerto Rico and the U.S. Virgin Islands.
Asthma affects more than 4.6 million American children, according to the federal Centers for Disease Control and Prevention. It’s one of the most common long-term diseases in U.S. children.
The Make America Healthy Again Commission report released in late May, parts of which have been widely criticized, alleges that American children are on too much medication of various kinds, including asthma treatments.
Experts worry that the administration will set policy based on the assessment that would dissuade insurers from covering asthma prescriptions. They also say that the report’s assertions could worsen disparities that affect children’s access to those medications and undermine years of research around the drugs.
The MAHA commission has until August to release a strategy based on the findings in the report.
Black and Indigenous children as well as those living in inner cities or in lower-income households are among those with the highest rates of asthma. Pollution disproportionately shrouds communities of color and can be a trigger that exacerbates the disease.
The report’s message could heighten those disparities, said Dr. Elizabeth Matsui, a University of Texas at Austin professor and a past chair of the American Academy of Pediatrics’ Section on Allergy and Immunology.
“One thing that has been very clear is that kids of color are less likely to be appropriately managed in terms of their asthma medication management,” she said. “So a message of overprescription that is simply not supported by the evidence also could potentially exacerbate already-existing racial and ethnic disparities in asthma that we have really not made much headway on.”
The commission’s claims
The report touches on childhood prediabetes, obesity and mental health. However, firearm injuries — the leading cause of death for children and teens in 2020 and 2021, according to the CDC — weren’t mentioned.
The 70-page report from the commission, chaired by Secretary of Health and Human Services Robert F. Kennedy Jr., claims four main issues are the drivers behind childhood chronic disease: poor diet, aggregation of environmental chemicals, lack of physical activity and chronic stress, and “overmedicalization.”
Matsui and other experts said the report’s use of that word is “problematic.”
“The implication could be, unfortunately, that when a child has asthma — so, they have coughing, chest tightness, wheezing — that that is not really a disease,” said Matsui. “We know for a fact that that’s a disease, and we know that it is quite treatable, quite controllable, and that it has profound impacts on the child’s day-to-day life.”
Other scientists have similarly criticized the report, saying it makes sweeping and misleading generalizations about children’s health without sufficient evidence. The White House corrected the report after nonprofit news outlet NOTUS found that it cited studies that didn’t exist.
The implication could be, unfortunately, that when a child has asthma … that that is not really a disease. We know for a fact that that's a disease.
– Dr. Elizabeth Matsui, University of Texas at Austin professor
When it comes to asthma, the report says, “Asthma controller prescriptions increased 30% from 1999-2008.” That sentence originally cited a broken link to a study from 2011; the link was later replaced. Controller meds include inhalers.The MAHA report also claims that “There is evidence of overprescription of oral corticosteroids for mild cases of asthma.” The original version of the report listed estimated percentages of oral corticosteroids overuse, citing a nonexistent study. The wording was changed and the citation was later replaced with a link to a 2017 study by pediatric pulmonologist Dr. Harold Farber.
The study was not a randomized controlled trial, which increases reliability. Farber told NOTUS that the report made an “overgeneralization” of his research. Stateline also reached out to Farber, whose public relations team declined an interview request.
Oral corticosteroids are liquid or tablet medications used to reduce inflammation for conditions including allergies, asthma, arthritis and Crohn’s disease. For asthma, they’re used to treat severe flare-up episodes. The Asthma and Allergy Foundation of America says the medications have been shown to reduce emergency room visits and hospitalizations, and that while they do come with risk of side effects, they’re mostly used in acute flare-ups. And while rare, asthma-related deaths in kids do occur, and are often preventable.
“Asthma medications, including oral steroids, are lifesaving,” said Dr. Elizabeth Friedman, a pediatrician at Children’s Mercy Kansas City. “I believe that physicians, not politicians, are best equipped and most effectively trained to make the determination of whether or not these medications are needed for our patients.”
Friedman worries that federal characterizations of asthma meds will affect how state Medicaid agencies cover the drugs. When Medicaid coverage changed for a common prescribed inhaler last year, many of her Missouri Medicaid patients were suddenly without the drug. They ended up hospitalized, she said.
Friedman directs Region 7 of the Pediatric Environmental Health Specialty Units, a network of experts that works to address reproductive and children’s environmental health issues. Region 7 provides outreach and education in Iowa, Kansas, Missouri and Nebraska.
She also said she’s concerned that the report is “making a broad, sweeping statement based on one epidemiologic study from one state.”
Increased use
An increase in inhaler prescriptions is not necessarily a bad thing, experts say. It’s a sign that kids are getting their medication.
There has been an increase in inhaler prescriptions, along with a corresponding decrease in the oral corticosteroids, which is what experts would want to see, said Chelsea Langer, bureau chief of the New Mexico Department of Health’s Environmental Health Epidemiology Bureau. She said that means kids are “following their asthma action plans and taking the controller medications to prevent needing the relief or treatment [oral] meds.”
Asthma prevalence has increased over the years, meaning more people need medication, noted Dr. Alan Baptist, division head of Allergy and Clinical Immunology at Henry Ford Health in Michigan.
He said that because steroid tablets come with risk of side effects, it is best to limit them.
But for kids without access to a regular pediatric provider or to health insurance that covers an inhaler, cost can be an obstacle, he said. Fluticasone propionate, an FDA-approved medicine for people 4 and older, costs on average $200 or more for one inhaler without insurance.
“What often happens with kids, and especially kids who are in Medicaid, or who are in an underserved or disadvantaged population, they are not given appropriate asthma controller medication,” said Baptist, who helped write federal guidelines for asthma treatment best practices as part of a National Institutes of Health committee.
Baptist noted that while he was glad to see pollution mentioned in the report as a danger for kids, it’s at odds with the recent cuts to environmental health grants that aimed to address such asthma triggers.
“They’re somewhat cherry-picking some of the data that they’re putting down,” he said. “It says the U.S. government is ‘committed to fostering radical transparency and gold-standard science’ to better understand the potential cumulative impacts of environmental exposure. If that’s what they’re saying, then they should be funding even greater studies that look at the effects.”
Dr. Priya Bansal, an Illinois pediatrician and past president of the Illinois Society of Allergy, Asthma and Immunology, said she’s concerned the report doesn’t define mild, moderate or severe asthma to differentiate the different best-practice treatment plans.
Bansal also said she worries that federal officials’ characterization of an FDA-approved drug will lead to insurance companies refusing to cover inhalers or oral steroids for her patients who rely on them.
“I’m going to be worried about coverage for my asthmatics,” she said. “The question is, what’s the next move that they’re going to make? If they think that, are they going to now say, ‘Hey, we’re not going to cover inhalers for mild asthmatics’?”
This report was first published by Stateline, which like NC Newsline, is part of the national States Newsroom network. Stateline reporter Nada Hassanein can be reached at [email protected].
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