Threatening Factor Exposure Triggers Recurrence of Asthma in

Children

Sandi Alfa Wiga Arsa

, Tintin Sukartini

and Sri Utami

Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

Politeknik Kesehatan Kementrian Kesehatan,Surabaya, Indonesia

Keywords: Childhood Asthma, Relapse, Trigger Factor.

Abstract: Asthma is an important health problem because of the high recurrence rate in children, if not handled

properly, asthma can reduce the quality of life of children, interfere with growth, limit daily activities,

interfere with sleep, increase school attendance, and lead to academic achievement in school decreased. The

threat of trigger factors for recurrence is overwhelming and varies in every child. Usually, there are one or

more factors of some dominant factors, so that efforts to educate health better focus on the factors that

threaten the recurrence. This study aims to identify the factors of the threat of exposure to asthma triggers in

children. The design of this research is analytical descriptive with the cross-sectional design. The number of

respondents was 53 children with asthma. Bivariate analysis showed that the trigger factors associated with

the occurrence of recurrence of asthma were allergen exposure (p = 0.177), physical activity (p = 0.69),

foods (0.036) and weather (0.192). The result of the multivariate analysis showed the strength of the

strongest relationship until weakest relapse of asthma in children was the activity (OR = 0,241) and allergen

(OR = 0,05). It is expected that management of asthma through education in children or parents can be more

focused on avoiding the threat factors of exposure trigger recurrence.

1 BACKGROUND

Asthma in children continues to be one of the most

common chronic diseases in childhood. This is a

common disease in children). Most asthma-related

deaths occur in low- and middle-income countries

(WHO, 2017). Although not occupying the top spot

as a cause of morbidity or mortality in children, if

not handled properly, asthma can reduce the quality

of life of children, interfere with growth, limit daily

activities, interfere with sleep, increase school

attendance, and lead to academic achievement in

school decreased (National Heart Lung and Blood

Institute, 2007). The results of the survey using the

International Study on Asthma and Allergy in

Childhood (ISAAC, 2013) have been conducted in

155 centers of asthma in 56 countries, one of which

is Indonesia aimed at the age group of 6-7 years and

13-14 shows the results varies in some countries

with asthma prevalence between 2.1 - 32.2% (IDAI,

2016). Asthma is an important health problem

because of the high recurrence rate in children, in

2013, 3.4 million (school-aged children) SAC

experienced asthma exacerbations, SAC with asthma

and exacerbations had 18.9 times more visits to

emergency departments (Sullivan et al., 2017). The

threats to the occurrence of recurrence are exercise,

exposure to allergens or irritants, weather changes,

or viral respiratory infections (Page et al., 2017).

The exact mechanisms for the cause of asthma are

not known exactly but there are several factors that

trigger an asthma attack. The term trigger factor or

current precipitating factor is more commonly used

which includes allergens, exercise, air pollution,

occupational factors, respiratory infections, nasal

and sinus problems, sensitive to drugs and food,

gastroesophageal reflux disease (Gastroesophageal

Reflux Disease / GERD) and psychological factors

(emotional stress) (Lewis, Bucher, Heitkemper, &

Dirksen, 2013). Asthma control in children is very

difficult to achieve because children are still

dependent on their parents or caregivers to make

decisions about their health (Conn, Halterman,

Lynch, & Cabana, 2007). Recurrence of asthma in

children often occurs due to the threat of trigger

recurrence has not been identified by nurses, health

workers or parents. Parents are aware of the

symptoms of asthma that worsen, they are not

302

Arsa, S., Sukartini, T. and Utami, S.

Threatening Factor Exposure Triggers Recurrence of Asthma in Children.

DOI: 10.5220/0008324303020308

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 302-308

ISBN: 978-989-758-336-0

always clear what triggers relapse (Searle, Jago,

Henderson, & Turner, 2017). The threat of trigger

factors for recurrence is overwhelming and varies in

every child, usually, there are one or more factors of

some dominant factors, so that efforts to educate

health better focus on the factors that threaten the

recurrence. It is, therefore, the purpose of this study

to explore the threat factors of the trigger for

childhood asthma relapse.

2 METHODS

2.1 Participants

Children aged 6 - 11 with diagnoses of asthma by

doctors at Pediatric Department in Mardi Waluyo

Hospital Blitar, Indonesia. Children who come to a

child health center, with parents between January

and February 2018 to complete the contents of the

questionnaire provided by the researcher. Questions

in the questionnaire involve parents and children in

filling in. The inclusion criteria in this study were 1)

parents with asthma children aged 6-11 years 2)

parents who can communicate orally and written

well 3) parents with children with asthma without

any other illness that aggravate the condition of

children such as tuberculosis, sepsis, typhoid fever,

bronchitis, and pneumonia. The exclusion criteria in

this study were 1) the child suffered the severe

attack and the threat of stop breathing 2) the elderly

with hearing, psychiatric disorder. Determination of

sample size in this study using software G Power

(Buchner, 2010) with the statistical test: Logistic

regression. Using 1% error rate and 95% power.

Determination of the value with the lowest and

highest value p value refers to the previous research

(Brigham, Goldenberg, Stolfi, Mueller, & Forbis,

2016) p the lowest value of 0.675 and the highest of

0.001 to obtain the number of samples of 53

participants. Sampling in this research is done by

probability sampling method through simple random

sampling.

2.2 Measurement

Measurement of recurrence of asthma using

questions addressed to parents in the questionnaire

Childhood Asthma Control Test for children 4 to 11

years (asthma.com, 2017) and open-ended questions

about specific symptoms of childhood asthma

relapse in the last 2 weeks such as: cough especially

at night or early morning, shortness of breath,

difficulty of sputum, breath sounds (wheeze) that

sounds if the child exhales, the weight on the chest

(National Heart Lung and Blood Institute, 2007).

Through the assessment found that asthma children

in the last 2 weeks relapse or not relapse.

Measurements for the threat factor variables of

asthma relapse were adapted from (Lewis et al.,

2013) compiled into questionnaires used by (Putu,

2012), which were then modified according to the

needs of this study. The threat factors for relapse are

as follows: 1) allergens 2) physical activity 3) air

and environmental pollution 4) respiratory infections

5) drug and food sensitivity 6) psychological

condition 7) emotional stress condition 8) air

condition/weather, with each -the threat factor of the

relapse trigger is categorized by x > median

(exposed), x < median (not exposed).

2.3 Statistical Analysis

2.3.1 Univariate

Univariate analysis was conducted to describe the

characteristics of each of the variables studied.

Univariate analyzes for categorical data such as

recurrence, child sex, long-suffering from asthma,

and trigger threat factors are presented in the form of

frequency distribution using percentages or

proportions. In numerical data such as the child's age

is described as the mean, median, maximum-

maximum and standard deviations. All data were

analyzed at the 95% significance level (α = 0,05).

2.3.2 Bivariate

Bivariate analysis to analyze the relationship of the

categoric variable with categoric variable was done

by using chi-square statistic test. The chi-square

statistical test aims to examine the difference in

proportion. If the bivariate test results have p <0.25

then the variable can be entered in the multivariate

model. However, if p value> 0.25 then still put into

multivariate if the variable is substantially important.

2.3.3 Multivariate

Multivariate analysis in this study to perform

multivariate analysis, used multiple logistic

regression analysis because it has the categorical

dependent variable. The important variables

included in the multivariate model are those with p-

value <0.05. The variables affect the dependent

variable is known from the value of each p-value.

The relationship strength sequence of the variables

affects the dependent variable. In the logistic

Threatening Factor Exposure Triggers Recurrence of Asthma in Children

303

regression, the order of strength of the relationship is

known from the value of the Odd Ratio (OR).

3 RESULTS

Table 1 shows the number of respondents obtained

is 53 children with diagnosis of asthma, the majority

of them, male gender as much as 31 respondents

(58.5%), as many of 35 respondents (66%) have

suffered from asthma for more than 2 years and the

majority of children experienced a recurrence in the

last 2 weeks by 34 respondents (64.2%)

Table 2 Discussion of the respondents in this

study was 8.25 + 1.592 years with the age range of

6-11 years.

Table 3 presents the distribution of respondents

based on the exposure of the threatening factors of

relapse, of all the factors of the majority of

respondents exposed to these threat factors, allergen

38 respondents (71.7%), severe physical activity 27

respondents (50.9%), air pollution around the

environment 32 respondents (60.4 %), respiratory

infection 27 respondents (50.9%), food 31

respondents (58.5%), psychological 48 respondents

(90.6%), emotional stress 30 respondents (56.6%),

weather 30 respondents (56.6%). This table also

shows of bivariate selection, not all variables show

p-value <0.25 as a requirement to enter into

multivariate test. Variables that will be included into

the logistic regression analysis is a variable that in

bivariate analysis has a value of p <0.25. The

variables were allergen (p = 0.177), activity (p =

0.069), foods (p = 0.036), and weather (p = 0.192).

Table 4 above gives value Nagelkerke R square of

0.474 which means that contribution of four variable

that is allergens, activities, eating, and weatherable

explain accuracy by 47% and 34% others explained

by other factors.

Table 5 shows the chi-square test of Hosmer and

Lemeshow test with p-value of significance of 0.775

(p > 0.05), then H0 is accepted that the model has

sufficient to explain the data (goodness of fit)

Table 6 shows that accuracy prediction in this

reasearch is 77.4 %

Table 8 shows the results of variables that affect

the recurrence of asthma in children are allergens,

physical activity, food and weather. The strength of

the relationship can be seen from the value of OR

(EXP (B)). The strength of the largest and smallest

relation is activity (OR = 0,241) and allergen (OR =

0,057). Testing on alone evidently allergen (p =

0.018), food (p = 0.008), weather (p = 0.026) has a

significance value <0.05 while activity (p = 0.056)

has sig value > 0,05 me aning on alone allergens,

food, and weather have a significant influence

to relaps, and activities have no effect on recurrence

but in a manner at the same time all four variables

have an effect on recurrence with a value of p =

0.007. Thus, it can be we conclude that the equation

obtained is : g(x) = (constant = 6.130) + (-2.856

(allergen)) + (-1.421 (activity)) + (-2.006 (food)) + (-

2.914 (weather)). Value of free variable: 1 if

exposed and 0 if not exposed

4 DISCUSSION

This study shows that the majority of children with

58.5% of asthma have an average age of 6-11, an

average score of 8.25 years, 66% of children have

had asthma for more than 2 years, and 64% of them

have relapsed in the last 2 weeks. From the results of

the survey conducted (Zahran, Bailey, Damon,

Garbe, & Breysse, 2018) in the United States, the

number of boys is 51% more than women with 5-11

age range of 39%, this indicates that at this age

group is a condition where children are more

frequently exposed to the risk factors for recurrence.

There were 8 recurrence threat factors which were

assessed in this study. The majority of respondents

received the exposure, namely: allergen (71%),

physical activity (50.9%), pollution (60%),

respiratory infections (50.9%), food (58%) ,

psychological (90%), emotion (56%), and weather

(56.6%). Only 4 factors had a requirement to pass a

multivariate assay suspected to be associated with

recurrence experienced by a child with asthma (see

Table 4). This shows that asthma is a unique chronic

respiratory disease, not all children have the same

Table 1: Respondent demographic.

Variables

Gender

Man

58.5

Women

41.5

Long-time suffering from

asthma

> 2 years

<2 years

Recurrence in the last 2 weeks

Relapse

64.2

No relapse

35.8

Table 2: Distribution of respondents by age.

Variables

Mean

Median

Min-

Max

Age

8.25

1.592

6-11

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

304

triggering factor of recurrence, asthma in children

becomes a very interesting material to do research to

get the best formulation for each place in providing

preventive measures in lowering the number

recurrence in children. It is explained in Table 5 that

the four variables are able to explain the accuracy of

47% and the other 34% explained by other factors.

Table 7 shows that the prediction accuracy in this

study is 77.4%. the strength of the relationship of

each variable can be seen through indigo Odd Ratio

(OR), which sequentially from the strongest

relationship to the weakest is the activity (OR =

0241), allergen (OR = 0.057), food (OR = 0.050),

weather (OR- 0.004) Here's a discussion on 4 factors

that are suspected to have an effect on recurrence in

this study.

4.1 The Association of Allergen with

Recurrence of Asthma in Children

The result of univariate analysis showed that the

average of allergen exposure was 7.34 with a

minimum value of 4-10. Exposure to allergens in

this study includes exposure to allergens indoors or

outdoors consisting of mites, room dust, outdoor

dust, foul odour and animal dander. The result of

bivariate analysis showed that allergen variable was

eligible for multivariate test with p = 0.177 (p

<0.25). In multivariate test alone allergen variables

have significant effect on recurrence with value p =

0.018 where p <0.05. The results of this study are in

line with several research results that have been

done with different environmental conditions. It has

been 50 years since dust mites were first appreciated

to be the main source of allergens in house dust, and

by extension into the main trigger of respiratory

illness due to allergies. Dust mites are a major

contributor to asthma in many parts of the world and

well-defined first-line allergens that cannot be

visually identified (Wilson & Platts-Mills, 2018).

The most predictive triggers of asthma exacerbations

are dust allergens predicted as a trigger for asthma

relapse in children (OR, 1.65, 95% CI, 1.13-2.43, P

= 0.01) (Chipps et al., 2018). This proves that

allergens should be avoided in order not to recur

asthma in children. Efforts to avoid allergens by

modifying the home environment are important in

the effort to reduce the rate of childhood asthma

relapse, some avoiding dust mites can be explained

in the review done by commonly also described in

(IDAI, 2016).

Table 3: Distribution of respondents based on exposure to threatening triggering factors of recurrence.

No.

Variables

Mean

Median

Min-

Max

Relapse

No relapse

p-value

Allergens

7.34

1.4

4-10

0.177 *)

Exposed

71.7

71.1

28.9

Not exposed

28.3

46.7

53.3

Activity

6.72

1.53

4-10

0.069*)

Exposed

50.9

77.8

22.2

Not exposed

49.1

Pollution

7.11

1.20

5-9

0.987

Exposed

60.4

62.5

37.5

Not exposed

39.6

66.7

33.3

Infection

9.55

2.53

3-13

0.918

Exposed

50.9

66.7

33.3

Not exposed

49.1

61.5

38.5

Food

14.47

2.75

8-19

0.036*)

Exposed

58.5

77.4

22.6

Not exposed

41.5

54.5

Psychological

2.47

0.85

1-4

0.774

Exposed

90.6

62.5

37.5

Not exposed

9.4

Stress

4.74

1.13

3-7

0.468

Exposed

56.6

Not exposed

43.4

56.5

43.5

Weather

2.19

0.83

1-4

0.192*)

Exposed

56.6

68.9

31.1

Not exposed

43.4

37.5

62.5

Threatening Factor Exposure Triggers Recurrence of Asthma in Children

305

4.2 The Association of Food and Drug

with Recurrence of Asthma in

Children

The result of the univariate analysis shows that the

average of exposure is 14.47 with minimum-

maximum value 8-19. The food in this study was

food exposure containing preservatives, dyes and

flavoring, consumption of animal protein, vegetable,

while medicines were the consumption of febrifuge,

antibiotics, prescription drugs, and drugs that may

have been consumed in the last 2 weeks. The result

of the bivariate analysis showed that the variable of

food was eligible for the multivariate test with p =

0.036 (p <0.25). In multivariate test alone food

variables have a significant effect on recurrence with

value p = 0.008 where p <0.05. Study of the results

of the III Phase III Asthma and Allergies in

Childhood (ISAAC) questionnaire, with more

specifically collected data on the association of risk

of asthma incidence with the diet consumed.

Vegetable intake is negatively associated with the

risk of symptoms in children 6-7, but this association

is attenuated in the 13-14 age group. Fastfood /

burger intake is positively associated with all three

results in older children. Higher intake of fruits and

vegetables is associated with a lower prevalence of

allergy symptoms in Latin American children. In

contrast, fast-food intake was positively associated

with the prevalence of wheeze in adolescent age

(Cepeda et al., 2017). Research conducted by

(Singh, Jindal, & Goyal, 2017) for children with

asthma showed that family history of asthma,

passive smoking, and food allergies were

significantly associated with asthma, food allergies

had a value of p <0.001 OR 3.03 (95% CI: 2.25-4.0).

In this study, the factors of consumption of drugs

and foods became the trigger factor for recurrence,

but most of the children cannot keep the diet

continuously, because in the age group 6-11 years is

the age of school where food and snacks in school

become a factor making them unable to adhere to the

diet. Food factors need to be wary of factors causing

recurrence in children with asthma. The choice of

schools that tighten food consumption contains

preservatives, dyes, and flavoring as an option for

the avoidance of this factor.

4.3 The Association of Weather with

Recurrence of Asthma in Children

The univariate analysis result shows that the average

of exposure is 2.19 with minimum-maximum value

1- 4. The weather in this study is exposure to high

and hot weather conditions experienced by children

during the last 2 weeks. The result of bivariate

analysis showed that the weather variable was

eligible for multivariate test with p = 0,192 (p

<0.25). In the multivariate test by itself the weather

variable had a significant effect on recurrence with

the value p = 0.026 where p <0.05. Generally asthma

attacks are caused by cold air (59.2%)

(Dharmayanti, Hapsari, & Azhar, 2013). Studies

conducted by (Hyrkäs, Ikäheimo, Jaakkola, &

Jaakkola, 2016) found that patients with less

controlled asthma were more susceptible to cold-

breathing respiratory symptoms and even worsened

asthma control increased the prevalence of

symptoms. In this study recurrence often occurs in

cold air conditions, this study was conducted in

Blitar City, East Java Indonesia, at the time of the

study, the weather in the study location was in cold

and rain conditions during January to February, the

majority of respondents complained of shortness of

breath when approaching night until late afternoon.

This is in accordance with the theory that the

assumption that asthma is defined as a condition

when there is a disturbance in the respiratory system

that causes patients experiencing wheezing,

shortness of breath, coughing, and tightness in the

chest, especially during the night or early morning

Table 4: Distribution of respondents by age.

Variables

Mean

Median

Min-Max

Age

8.25

1.592

6-11

Table 5: Negelkerke R square value.

Cox & Snell R Square

Nagelkerke R Square

0.345

0.474

Table 6: The chi-square value of the Hosmer

and Lemeshow Test.

Chi-square

Sig.

3.261

0.775

Table 7: The predicted accuracy of the study.

Observed

Predicted

Recurrence

Correct

Relapse

Recurrence

Relapse

79.4

No Relaps

73.7

Overall Percentage

77.4

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

306

(National Heart Lung and Blood Institute, 2007).

Efforts that can be done is to adjust the self-

protection against weather changes such as the use

of hats, masks, jackets or scarves when needed.

4.4 The Association of Activity with

Recurrence of Asthma in Children

The result of the univariate analysis shows that the

average of exposure is 6.72 with a minimum value

of 4-10. Activities in this study consist of cycling,

swimming, running, climbing stairs, walking fast.

The result of the bivariate analysis showed that the

activity variable was eligible for the multivariate test

with p = 0.069 (p <0.25). In the multivariate test

alone the activity variable had no significant effect

on recurrence with p-value = 0.056 where p> 0.05.

In previous studies found no association between

physical activity, asthma control levels, spirometric

measurements and quality of life (Lim, Ko, Benton,

Berge, & Mak, 2017). But in fact, there are several

studies that mention that physical activity causes the

occurrence of recurrence of asthma in children.

Exercise can trigger acute exacerbations in almost

all individuals with asthma. Heat loss, water loss,

postexertional rewarming, and the role of some

mediators have been proposed as a possible

mechanism responsible for airway obstruction

caused by exercise (Hughes, 2014). Physical training

should be part of the overall management plan for

people with asthma. In this study, physical activity

of swimming, sport, cycling, and running was most

commonly found in asthmatic children, but only a

few children had a recurrence after physical activity.

Recurrence after an activity is suspected to have 3

other factors that also affect in this study, possibly

when doing activities outside the room also exposed

to large, eat or even weather. The goal of asthma

treatment alone is to get a controlled condition, with

a minimum of recurrence rates during physical

activity. When treated correctly, individuals with

asthma should be able to participate in sports

gradually.

5 CONCLUSIONS

The threat factors of trigger recurrence of asthma in

children vary with each other, in this study obtained

4 threat factors that trigger the recurrence of children

with asthma in the Pediatric Department, Mardi

Waluyo Hospital. Sequentially from the strength of

the relationship are activity, allergen, food, weather.

From this research can be known the recurrence

characteristics of children with asthma triggered by

these 4 factors. Avoidance of these trigger factors

will have many benefits. Activity can be controlled,

quality of sleep gradually improving, children can

attend school and can achieve. Benefits that parents

get, is not the amount of time consumed to manage

the recurrence of asthma in children, the costs

incurred for treatment becomes more effective.

Therefore, nursing intervention in the form of

education, home visit, in children or parents can be

focused on these 4 factors. The hope of further

research at the same place is to provide education

formulated from this study. Will be more effective

and efficient in providing education.

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