Five Questions With: Dr. Robyn Wing

Dr. Robyn Wing is an emergency medicine physician at Hasbro Children’s Hospital. She is also a fellow in pediatric emergency medicine at the Alpert Medical School at Brown University. Wing recently led a study that found that children exposed to an adverse childhood experience were significantly more likely to develop asthma. Published in Annals of Allergy, Asthma & Immunology, the study suggests that psychosocial factors may play a causative role in pediatric asthma.

PBN: How powerful of a factor is a child’s social environment in the development of asthma?
WING:
This is an area of ongoing research. In short, a child’s social environment is likely more than powerful in the development of asthma than we ever thought. I was interested in exploring the relationship between childhood exposure to Adverse Childhood Experiences (ACE’s) and pediatric asthma. ACE’s include exposure to a parent or guardian who died, was divorced/separated, served time in jail, had a problem with alcohol or drugs, was mentally ill or suicidal, or had witnessed domestic violence. In our study, after controlling for many other potential confounders, we found a significant association between reported lifetime asthma and the number of ACEs to which a child was exposed. Children exposed to even just one ACE had a 28% increased odds of reported lifetime asthma compared to those with no ACEs.

PBN: What physical processes are set in motion by stress that end up leading to asthma in some cases?
WING:
Psychosocial stressors are known to activate the sympathetic nervous system, which controls our “fight or flight” responses when we experience stressful situations. Increased activity of this system releases cortisol, a stress hormone, which has been shown to affect the activity of many immune cells. Transient increases in these hormones are protective, but excessively high or prolonged exposures, such as those experienced by children exposed to ACEs, can be harmful. A normally balanced system can get very dysregulated. Stress has been shown to lead to a shift in the immune response, leading to subsequent recruitment of inflammatory cells that can initiate or worsen inflammation in the airways characteristic of asthma.

PBN: Can a child’s environment being made less stressful lead to a diminishment in asthma symptoms or severity – or is that something for another study?
WING:
These results beg the question: Is stress a potentially modifiable risk factor for asthma development and severity? Such a possibility is exciting, as this would give clinicians yet another avenue through which to help children and adults afflicted with this disease. There have been small case reports of the use of individual and family therapy in children with asthma, demonstrating a decrease in asthma symptoms. However, extensive research in this area remains to be done. At the very least, clinicians can make parents aware that ACEs can effect their child’s asthma and perhaps be one more motivating factor to remove or shield a child from a stressful home situation. There is much more research to be done to explore these possibilities.

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PBN: How close is medicine to including questions about the home situation to every case of asthma being treated? Is that years away? And are there obstructions or objections among some physicians to such discussions being in the mix?
WING:
We are very close to having “social history” questioning become a part of the standard of care in asthmatics. In fact, many physicians are already asking these questions. With such robust research in this field, it is hard to deny the clear association. To my knowledge, there are no objections to this very important patient-provider conversation.

PBN: What first led to the idea that stress and social environment might be playing a role in the development of asthma?
WING:
Great question! I can only imagine that it was provider observation. The term “psychogenic asthma” has been around for quite some time – meaning asthma exacerbations triggered by emotional or psychological stress. Studies have now demonstrated that stress has been shown to predict the onset of asthma in children who are genetically at risk. Many studies have focused on neighborhood and urban-related stressors, such as family poverty, poor quality housing, inadequate environmental control (e.g., exposure to household allergens), and access to community resources.

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