Discussion
Allergic rhinitis (AR) and asthma are among the most common diseases globally and they usually persist throughout life. There has been a visible spike in the rate at which people are contracting respiratory allergies across the world, of which allergic rhinitis and asthma are the most prominent; the former accounts for 20-30 % cases of respiratory allergies while the latter affect around 15 % of the population2,14. These allergies, with increase in severity, have a debilitating effect on the productive, social, and emotional aspects of patients, disrupting their and their caregiver’s daily lives15. Despite such significant effects, respiratory allergies are generally underestimated.
Furthermore, there is no unanimity among studies of childhood asthma and allergic rhinitis highlighting the connection between the severity of the disease and child’s quality of life. Some studies report that severe or poorly managed asthma cause impairment of social, physical, and academic lives of paediatric patients, whereas several other studies disregard it(7,16). The paucity of studies conducted in India especially in paediatric patients for measurement of QOL of patients and caregivers made us conduct this study using mPAQLQ and PACQLQ questionnaires in our population, where children were suffering from asthma and/or rhinitis.
Approximately 70% of subjects of our study were in the 7-12 years age group whereas only 30 % were adolescents. Similar distribution was seen in previous study also. 66% out of 69 patients were in the age group of 7-12 years and 33 % in 13- 17 years age group12. This could be either because respiratory allergies affect more in lower age group or adolescent age group patients get distributed among Pediatric and adult physicians.
Boys (60.6%) outnumbered girls (39.4%) in the study cohort. The trend was similar to other diseases over past few years. The study done by Scala et al in 56 Brazilian children showed female predominance in the study population17. A study done in Indian Population by Singh and associates in 20 children showing quality of life score in Indian asthmatic children receiving inhaled corticosteroid therapy also showed higher male proportion (male=55%)18. The male preponderance may be explained by preferential sex selection either by disease or by society for seeking medical help in developing countries.
Out of 246 children, 8% were suffering from AR and 27% from Asthma alone whereas two-third (65%) had both symptoms. A multicenter study done in India, by Jaggi V et al among 1161 adult asthmatic patient showed the prevalence of co-existing AR in asthma patients to be 65.24%19. In western population, prevalence of AR with Asthma was about 50-100% as reported by Gaugris et al20. Our study findings of combined involvement of nose and airways highlights the concept of ‘united airway disease’.
Out of 69 asthmatic patients, Nair et al in their study had 74% patients of moderate severe asthma whereas mild variety were only 26 %12. Boran P et al conducted study in 305 Turkish children suffering from asthma. Among them, 82% of children had intermittent asthma and 18% had persistent asthma. Sixty-four percent of asthmatics also had allergic rhinitis21.In our study, mild (56%) and persistent (78%) grade of asthma were more than the moderate- severe or intermittent type. This could be possibly because moderate severe cases used to get admitted earlier and report less in OPD. More people presented with persistent disease rather than being affected intermittently for 3-4 days many times in a year. This can be explained by possible poor compliance with medications or incorrect inhaler techniques.
When compared with the education of the caregiver, the severity or chronicity of disease (AR/Asthma), there was no significant difference seen (p = 0.422) as per the education of caregiver. This could possibly be because the study was done in urban population, 90% of whom had attained a bachelor’s degree so had better understanding of disease process and accessibility to healthcare was easy for them. Additionally, a rare possibility could be their ignorance and hence difficulty to perceive the difference in QOL of themselves as well as their children. A study conducted by Walker J et al involving subjects from 201 rural families reached to a conclusion that perception about the quality of life in subjects depends upon how well the asthma in children was controlled rather than their education level. For instance, it was observed during the course of study that in cases where asthma severity in children aggravated, not only such children missed school their parents had had to take their days off from work to look after their wards, resulting in a diminished sense of quality of life22. Juniper et al reported that there are significant changes in QOL as the severity of Asthma increases (p=<0.001). On the other hand, Annett et al and Montalto et al found no difference in QOL based on the severity of asthma13,15,23,24. A systematic review with meta-analysis on asthma control in the quality of life levels of asthmatic patients’ caregivers highlighted that asthma control levels can influence the total HRQOL scores of parents or relatives of children and adolescents with asthma25.
The result in emotional domain in children showed no significant difference in QOL in various grades of AR/Asthma (p=0.496) (p=0.918) and agreed with past studies. A study done among 305 Turkish children by Boran P and colleagues showed that severity of asthma and presence of allergic rhinitis were found to be significant factors associated with impaired QOL of these children in other domains except for emotional function21. Diette et al observed among 438 children and their caregivers that nighttime awakening reduced attendance of both child and their caregivers in school and at workplace, respectively26.
It was found that activity limitation domain of children showed significant difference with the severity of asthma in many studies. Study done by Leynart in 850 French population of young adults in two centers using SF-36 questionnaire suggested that AR alone causes less impairment of physical activity than with patients of both allergic rhinitis and asthma5. Our study results were inconsistent with the others as it was seen that there is no significant difference between activity limitation with the different grades or severity of AR/Asthma (p=0.384), (p=0.561). This could be possibly because of limited sample size and because a great chunk of our sample size belonged to mild variety whose activities were less limited.
A study conducted by Callery et al in 25 British children aged from 9 to 16 years of age group along with their caregivers also reported change in QOL of parents with the severity of asthma in children27. Similarly, Juniper et al reported significant change in QOL of caregiver in both the domains (emotional and activity limitation) (p<0.0001) with disease severity13. A Saudi Arabian study by Nafeesa et al concluded that caregiver emotional status is vital for the success of asthma management among patients. In addition, effective control status is also required to ensure low levels of anxiety among patients and their caregivers28. In our study, when compared with caregiver emotional and activity limitation score for calculating QOL score there was no statistically significant difference (p value = 0.549 and 0.446 respectively).
The possible reason for no significant changes seen in PACQLQ score was that parent’s perception of QOL related to disease severity was less. Secondly, our study was single visit study. No follow up questions post treatment of AR/Asthma were asked. So, any change noted in QOL of parents could not be assessed. Thirdly, for cases below 12 years of age, it is not prudent to form an opinion about the impact of asthma severity on child’s quality of life based on parent’s reportage alone. According to research done by Callery et al, parents report was insufficient to get an understanding of the children’s quality of life as they failed to provide complete information about the disease severity29. Lastly, our small sample size could be another added reason.