What can be learnt from the deaths of children due to asthma?

The Child Death and Serious Injury Review Committee has reviewed the deaths of 14 children and young people since 2005, resulting from asthma.

The Committee found that improvements in asthma care could be made.

Recognition of poorly controlled asthma

Health services can help families and service providers caring for children with asthma to recognise extended periods of poorly controlled asthma through:

  • Education of families about the importance of regular reviews by a paediatric respiratory specialist.
  • Training programs for general practitioners and paediatricians about recognition of, and action during extended periods of poorly controlled asthma.

Hospital admission or emergency presentation as a trigger for medical review

The Australian Asthma Handbook1 recommends that admission to a hospital or presentation to an emergency department with asthma-related diagnoses should trigger a medical review of a child’s asthma within 2-4 weeks.

Health services can improve the quality of their care to children with asthma by:

  • Monitoring the medical follow-up of all children discharged from high dependency or intensive care units by a paediatric respiratory specialist.
  • Monitoring the medical follow-up of children within 2-4 weeks of admission to hospital or presentation at an emergency department by a primary medical practitioner (general practitioner, paediatrician or paediatric respiratory specialist).
  • Assertive follow-up of children from vulnerable families who were admitted to hospital or presented to an emergency department with asthma.

Specialist care of children with poorly controlled, severe or unstable asthma

Health services can assist children to get the care they need by ensuring all children with poorly controlled, severe or unstable asthma are under the long-term care of a paediatric respiratory specialist. This may include the use of telehealth services in rural settings.

Ambulance attendance

The National Asthma Council of Australia recommends that an ambulance be called for a child having an asthma attack2. Ambulance services can assist families by:

  • Establishing free ambulance services for families that qualify for pension concessions.
  • Making available to families information about agencies that might reimburse fees for ambulance attendance.

Who is involved in caring for children with asthma?

  • Children and young people with asthma
  • Families and carers
  • Paediatric respiratory specialists
  • General practitioners
  • South Australian health services
  • South Australian education services
  • South Australian ambulance services
  • South Australian child protection services
  • Peak bodies including the Royal Australian College of General Practitioners and Asthma SA

Facts about asthma

Australia has one of the highest rates of asthma in the world3. Global mortality due to asthma fell by 57% from 1993 to 2006 in 3-34 year olds, but has plateaued since that time4. The fall in asthma mortality around the turn of the millennium is attributed to:

  • A change in medical management of asthma
  • Restriction in the use of particular reliever medications (high-dose, poorly selective β2-agonists)
  • The availability of ongoing preventative treatment (inhaled corticosteroids)5.

Asthma is a chronic inflammatory disorder of the airways. People with asthma experience episodes of wheezing, breathlessness and chest tightness due to widespread narrowing of the airways6.

Asthma symptoms including wheeze, persistent cough, and breathing difficulty that are frequent, persistent or severe may indicate poorly controlled, severe or unstable asthma. Symptoms are interpreted differently according to the age of the child.

There has been a decrease in admissions to hospital between 2005 and 2016 for asthma-related diagnoses (Figure 1).

Figure 1:  Separations from hospital for asthma

Source: Integrated South Australian Activity Collection (ISAAC), SA Health

The number of separations from intensive care for children with an asthma-related diagnosis decreased between 2009 and 2016 (Figure 2).

Figure 2:  Separations from intensive care for asthma


Source: Integrated South Australian Activity Collection (ISAAC), SA Health

Useful asthma care websites

The National Asthma Council Australia – https://www.nationalasthma.org.au/

The Australian Asthma Handbook – https://www.asthmahandbook.org.au/

Asthma Australia – https://www.asthmaaustralia.org.au/national/home

AIHW Asthma snapshot – https://www.aihw.gov.au/reports/chronic-respiratory-conditions/asthma/contents/asthma

United Kingdom Royal College of Physicians. Why asthma still kills. The National Review of Asthma Deaths. 2014. Healthcare Quality Improvement Partnership – https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills

Geographic Disparities in Child Death

Over the last 13 years, the Child Death and Serious Injury Review Committee has documented the higher death rates for children living in more remote regions of the State. The death rate for children living in different parts of South Australia can be seen in more detail in the interactive visualisation below. This map includes all deaths of children who were residents of South Australia and who died in South Australia between 2005 and 2016 inclusive.

This higher rate of death in more remote regions of South Australia is evident across all categories of death. For instance, children outside of metropolitan Adelaide are three times more likely than children in metropolitan Adelaide to die in a transport crash. This example illustrates some of the challenges of providing services to remote areas. Even if roads in remote areas were of comparable safety to roads in metropolitan Adelaide, children in remote areas may spend more time in vehicles accessing services than their metropolitan counterparts, which may expose them to greater risk of dying in a transport crash. The figure below illustrates these differences across major categories of death.

The World Health Organization states that equity is ‘the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically.’ The geographic disparity between metropolitan and non-metropolitan areas of South Australia is a remediable difference. The continued disparity in death rates across the regions of this State is contrary to the view that all children in South Australia should have equal rights.

Go to the Committee’s latest Annual Report to learn more about how it defines both remoteness and these categories of death as well as what the Committee has recommended to address issues arising from the deaths of children in South Australia.

Suicide Prevention and Child Death Review

To create a comprehensive set of suicide prevention strategies for young people, many different avenues of intervention need to be considered.

The Child Death and Serious Injury Review Committee carefully reviews all information available to it to determine if a young person has suicided. The Committee uses this information to build ‘life charts’. These charts help to identify common themes in the lives of young people who have suicided.

The Committee has determined that 49 young people have suicided since 2005; 3.4% of the total number of children who have died in South Australia since that time. Deaths in transport crashes and from illness or disease are the two most common causes of death among 15-17 year olds in South Australia. Suicide is the third most common cause of death in this age group.

The Committee has reviewed 41 deaths using the life chart methodology[1]. Four sub-groups of commonly occurring life chart themes have been identified and intervention and prevention strategies that are needed to address these themes developed.

The different kinds of prevention and intervention strategies needed to develop a comprehensive suicide prevention plan for young people are summarised here and discussed in further detail below.

Group 1
Intervention and prevention strategies need to begin early in life for young people who have disengaged from home, school, community and other forms of support.

Group 2
Youth-oriented mental health services are needed by young people who experience anxiety, depression and other emerging mental health issues in their teenage years.

Group 3
Readily available support and information services are needed by young people who have no identifiable risk factors, and are not involved with support services.

Group 4
The Committee does not have enough information about the three young people in Group 4 to determine common themes in their lives. More analysis may be possible in time, should further cases be added to this grouping.

[1] Fortune, S, Stewart, A, Yadav, K, and Hawton, K (2007), Suicide in adolescents: using life charts to understand the suicidal process. J of Aff Disorders, 100, 199-220.


Group 1

Intervention and prevention strategies recommended to address the themes identified in this sub-group should begin early in life and include:

  • Strengthening parenting capacity within families during the child’s very early years.
  • Addressing learning and behavioural problems, as they are identified in early childhood.
  • Ensuring that ongoing problems with learning and social skills are addressed, with every effort made to keep the young person engaged in education, especially in the transition to secondary school and throughout adolescence.
  • Promoting engagement through youth-specific programs in the community, with a focus on building resilience and restoring self-esteem.
  • Ensuring integrated service delivery – juvenile justice, drug and alcohol services, mental health services and alternative education options.

The intervention and prevention strategies for this sub-group can be missed by suicide prevention plans focused on risk factors, tipping points and imminent harm.

The Committee’s intervention and prevention strategies for this sub-group are based on findings regarding the similarities in the life circumstances of 13 young people which included:

  • Multiple and complex problems starting very early in life, including significant family upheaval often resulting in homelessness.
  • Learning and behavioural problems which often started at kindergarten.
  • Exacerbation of these problems in adolescence, including problems making and keeping friends – leading to social and educational disengagement.
  • Involvement of educational support services, child protection, juvenile justice, adolescent mental health, housing, and drug and alcohol services.
Group 2

Intervention and prevention strategies recommended to address the themes identified in this sub-group include:

  • Provision of youth-oriented mental health services with an emphasis on assertive outreach and follow-up, and the capacity to support the young person’s family.
  • Co-ordination between mental health services and school support services.
  • Youth-specific services with the capacity to explore issues relating to romantic and sexual relationships.

The Committee’s intervention and prevention strategies for this sub-group are based on findings regarding the similarities in the life circumstances of 20 young people which included:

  • The presence of a supportive family or family member.
  • Engagement with family, school and friends until the emergence of challenges to their mental health, eg depression and/or anxiety, which often occurred after their transition to secondary school.
  • Seeking help from adolescent mental health services (government or private), and requiring assertive outreach.
  • History of deliberate self-harm and/or previous suicide attempts.
  • Challenges in social, romantic or sexual relationships in the year/months proximal to their death.
Group 3

Intervention and prevention strategies recommended to address the themes identified in this sub-group include:

  • Readily available and accessible support and information sources – through school, workplace and/or community as well as ‘crisis’ support, especially access to help for young people during the critical hours when they appear to decide to suicide.
  • Population-based prevention programs that emphasise the role that friends/peers play in helping those who are contemplating suicide.

The Committee’s intervention and prevention strategies for this sub-group are based on findings regarding the similarities in the life circumstances of five young people which included:

  • Stability at home, in friendships and at school.
  • ‘Positive’ approaches to life.
  • Exposure to suicide through school connections.
  • No contact with support services.
  • Challenges in romantic/sexual or social relationships immediately proximal to their death.

More information about deaths attributed to suicide, and life chart review can be found in the Committee’s annual reports.

Safe Sleeping of Infants

The South Australian Safe Infant Sleeping Standards are a comprehensive set of standards for placing infants less than 12 months old to sleep. These standards were developed to help reduce the occurrence of sudden unexpected deaths of infants during sleep. Several factors occur frequently in the circumstances of these deaths. These factors are not causes of death in their own right.  Rather, they increase the risk of infants dying after being placed to sleep. The Standards provide a consistent suite of messages that health professionals can use to guide the decisions families make about safe infant sleeping.

 

Through the careful work of South Australia police, a great deal of information about the circumstances of sudden unexpected infant deaths is recorded that can help prevent these deaths from happening. Between 2005 and 2016 in South Australia, there were 128 cases where an infant died after being placed to sleep, where no apparent cause could be found for the death. The Child Death and Serious Injury Review Committee has analysed data about the factors that occurred in the circumstances of these deaths. The interactive visualisation allows you to investigate these factors and see how they co-occur. Some important intersections include:

  1. The infant not being placed to sleep in an approved bed is the factor that most frequently occurs together with a number of other factors.
  2. In more than half the cases in which the factor was breast-feeding, a parent also smoked.

These data have driven the recommendations by the Child Death and Serious Injury Review Committee in 2006 and 2016 that all families be provided with an approved bed for their infant to sleep in, along with information about safe infant sleeping. This is particularly true for families living in the most disadvantaged areas of South Australia. As shown in the Committee’s last quarterly blog post, sudden unexpected infant deaths occur more frequently in the State’s most disadvantaged areas.

Death and Disadvantage

More children die in areas of South Australia where there are greater levels of social disadvantage. The Committee has documented this association over the past 12 years and published data showing this relationship in its 2016-17 Annual Report.

In countries like Australia, this relationship between child death and social disadvantage is well known:

‘Relative poverty is highlighted as the most important social determinant for child deaths in high-income countries. The authors identify a persistent – across all causes and in time – inverse association between socioeconomic status and child mortality in high-income countries.’ The Lancet V p830. Child deaths: inequity and inequality in high-income countries.

The relationship between South Australian child deaths and disadvantage, across different categories of death, can be explored in more detail in this interactive visualisation. This includes all deaths of children in the listed categories that occurred in South Australia between 2005 and 2016 inclusive.


The Committee’s analysis shows that, between 2005 and 2016 and across all categories of death:

  • There is a broad pattern of increasing deaths with increasing levels of disadvantage across all age groups.
  • A consistent pattern of low numbers of deaths in the age range 5 to 14 years, and two peaks, one in the youngest age group and one in the oldest.
  • An increase in the number of deaths at younger and older ages is greater at higher levels of socioeconomic disadvantage. The impact of this disadvantage is demonstrated by the particularly high number of deaths in children under one year of age at higher levels of SEIFA.

Some key points to notice about disadvantage and different categories of death:

  • There is a strong association between social disadvantage and children dying from natural causes and in transport crashes. But these two categories are mirror opposites with respect to age, with natural causes involving greater numbers of younger children and transport related deaths involving greater numbers of older children.
  • Fire-related deaths, drowning and deaths resulting from the deliberate act of another person all involved greater numbers of children from areas of greater social disadvantage.
  • The distribution of deaths in these three categories also highlights the vulnerability of toddler and pre-school aged children since they had more deaths in the 1 to 4 age range than any other age.
  • Suicide deaths stand out because there is the least evident effect of social disadvantage.

Go to the Committee’s latest Annual Report to learn more about how the Committee defines ‘disadvantage’ and ‘categories of death’ and what the Committee is doing to address issues arising from the deaths of children in South Australia.