Exercise and children with asthma.

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Preference for the no-stirrup method

I

am a little behind in reading Canadian Family Physician and have just now seen the item by Dr Michelle Greiver¹ about doing pelvic examinations without using stirrups. It is great that Dr Greiver has articulated a method that I’m sure someone other than her and I has employed. I agree entirely with her comments on this topic.

I began doing pelvic examinations without stirrups about 15 years ago.

I did, and periodically still do, (non- scientifically) survey my patients, asking them to state their preference.

Without exception, my patients prefer the no-stirrup method, and therefore I continue to use it. I use the traditional method only for such procedures as inserting intrauterine contraceptive devices and doing endometrial biop- sies.

I, too, would be interested to hear whether other physicians have come to employ a similar technique.

—Don Klassen, MD, CCFP, FCFP

Winkler, Man by e-mail Reference

1. Greiver M. No stirrups? [Practice Tips]. Can Fam Physician 2001;47:1979.

Exercise and children with asthma

I

n the November 2001 issue of Canadian Family Physician, an item¹ in the “Briefing” section states that

between 10% and 18% of Canadian chil- dren have asthma. This statistic means there are a lot of children who have to understand what happens to their asthma with exercise. It is important that family practitioners encourage their asthmatic pediatric patients to engage in regular physical activity, especially in light of the articles in the January 2002 issue of Canadian Family Physician promoting physical activity.

Parents play a vital role in educating themselves and their children about exercising with asthma. Children with asthma should live a very active life.

More than 90% of asthmatics have exercise-induced asthma. With some simple information, exercising with asthma can be very comfortable.

Children with asthma should be aware of how cold weather, allergies, and

respiratory illness can make exercise difficult. A warm-up period before exercise is essential to help promote a refractory period and ease symptoms.

For cold weather, a face mask can help keep the air more humid and warm.

The use of a short-acting β-agonist, such as salbutamol, 10 to 15 minutes before activity results in less coughing and wheezing. Long-acting bronchodi- lators, such as salmeterol, are gaining in popularity, as they provide relief from exercise-induced bronchospasm for up to 9 hours. Patients need to be reminded that these medications do not replace corticosteroid therapies.

Because obesity rates are increas- ing in children, we should encourage children with asthma to maintain healthy weights and not to be inactive due to fear of possible asthma symp- toms. A handful of studies have looked at the relationship between asthma and obesity. It is unclear whether obe- sity leads to asthma in childhood, but there is the suggestion that obesity is associated with increased asthma mor- bidity in children. Belamarich et al² found that obese, inner-city children with asthma use more asthma medica- tion and wheeze more than non-obese children with asthma.

Regardless of the unanswered research questions surrounding asthma and obesity, it is important that family physicians encourage obese asthmatic children to reduce their weight to help prevent development of other chronic diseases, such as type 2 diabetes and heart disease.

Research and clinical guidelines have been focused on asthma symp- toms that can worsen with exercise.

More recently, a shift has occurred to look at the possible benefits of exer- cise on the status of childhood asthma.

Make your views known!

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A study by Nystad and colleagues³ compared bronchial responsiveness using a methacholine challenge test in children with asthma who exercised and did not exercise.

The authors also compared these results with children who did not have asthma. Their results showed that inac- tive children with asthma had increased levels of bronchial responsiveness.

Although this study cannot make causal conclusions because it was a cross-sectional study, it raises an inter- esting discussion regarding our current thinking about asthma and exercise in children. In the future, will fam- ily practitioners be able to tell their pediatric asthmatic patients to exercise to improve their asthma?

—Maureen F. Kennedy, MD, CCFP, MSC, DIPSPORTMED

Sport and Exercise Physician Director, Fitness MD Calgary, Alta by e-mail References

1. Childhood asthma costly [Briefing]. Can Fam Physician 2001;47:2421.

2. Belamarich PF, Luder E, Kattan M, Mitchell H, Islam S, Lynn H, et al. Do obese inner-city children with asthma have more symptoms than nonobese children with asthma? Pediatrics 2000;106(6):1436-41.

3. Nystad W, Stigum H, Carlsen KH. Increased level of bronchial responsiveness in inactive children with asthma. Respir Med 2001;95(10):806-10.

Nicotine patches and pregnancy

I

read with interest your Motherisk Update ar ticle,

“Nicotine replacement therapy in pregnancy,”¹ which appeared in the October 2001 issue. Dr Koren’s discus- sion revolved around the study by Wisborg et al.² The nicotine patches that were used in this study contained only a very low dose of nicotine (only 15 + 10 mg), and were used for only very short courses (3 weeks each), and for only 16 hours daily! I am unhappy that this article was cited as evidence against the efficacy of nicotine replacement therapy for these reasons: the generalizability of this study is highly questionable, and this point should have been expressed more clearly in your article.

Despite my negative comment, I urge you to continue your excellent work, which has helped me so much in the past.

—Stephen DiTommaso, MD, CCFP, FCFP

Montreal, Que CLSC des Faubourgs University of Montreal Centre de recherche et aide aux narcomanes (CRAN, methadone clinic) by e-mail References

1. Koren G. Nicotine replacement therapy during pregnancy [Motherisk Update]. Can Fam Physician 2001;47:1971-2.

2. Wisborg K, Henriksen TB, Jespersen LB, Secher NJ. Nicotine patches for pregnant smokers: a randomized controlled study. Obstet Gynecol 2000;96:

967-71.

Response

I

wish to thank Dr DiTommaso for his interest and kind words. I concur that the dose of nicotine in the patch used in the Danish study was too low. In my Update, I explicitly say “Perhaps these women need more intense therapy than the therapy used in the Danish study.… It is possible that, because they are rapid metabolizers of nicotine, pregnant women need higher doses of nicotine in the patch than those given to non-pregnant women.”

The main outstanding issue is, of course, the safety of the patch during pregnancy. Until better data on fetal safety of the low dose are available, it will be difficult to justify increased doses of nicotine.

—Gideon Koren, MD, FRCPC

Director, The Motherisk Program