Asthma is the most common chronic condition affecting children and the most common reason children are hospitalized. It is estimated that more than 15% of Canadian children have been diagnosed with asthma, nearly double the number of adults with the disease. There are excellent national guidelines on asthma in those six years of age and older (1) and a recent position paper on the diagnosis of management of asthma in preschoolers (2). Both of these guidelines emphasize the critical first step in asthma management as education, including understanding the disease, recognizing asthma symptoms, avoiding triggers, having a written self-management plan and instructions on proper inhaler with spacer technique.
All of the recommended adult asthma apps previously reviewed are relevant to adolescents and young adults with asthma and to parents and caregivers of children with asthma. While most children have access to mobile devices in their homes and are often more adept at using them than their parents, children are highly unlikely to be motivated to engage in self-monitoring and managing their symptoms unless the right incentives are involved.
We selected four apps for clinical review. Two apps focus on self-monitoring with symptom journaling and reminders to help patients remember to take their medications. One of these directly targets parents with a greater focus on education. Two of the apps target children through games.
Disclaimer: I am not a gamer. As a child of the Atari and 8-bit Nintendo era, my go-to games are Super Mario, Arkanoid and Tetris. Before Pokemon and Hatchimals there was Tamagotchi. The current repertoire of go-to games on my phone include 2048, Balls Smasher and, yes, Candy Crush.
AAP Asthma Tracker for Adolescents
This app is part of a series of condition specific apps developed by @Point of Care but re-branded by the American Academy of Pediatrics (AAP). The @Point of Care version is called Asthma Manager. The overall goal of the @Point of Care platform is to integrate patient-reported health data with the latest evidence to foster greater patient adherence and practitioner learning, practice change and provide patient-specific clinical decision support. Both versions of the app contain a journal tool to track symptoms and spirometry. Each journal entry is quite long and buggy, requiring multiple taps and extensive data entry. Both versions contain a patient education section, with the Asthma Manager version linking directly to the American Lung Association website through an internal browser that under performs. The strength of the AAP version is that the patient education section is pre-populated with pediatric relevant educational content, instructions and videos.In addition, the AAP version has a My Action Plan section where users can create a personalized asthma action plan with their provider’s help with action steps based on their daily peak flow readings. Despite these two additional features, the app is clunky to use with lots of bugs and is clearly an attempt to customize a generic patient health-tracking app for asthma. While re-branded by a reputable source, this app is mostly useful for the educational content, which could also be accessed directly on the internet.
The app has three main sections. My Medical Setting allows users to track their treatments, conditions and care team members. These sections are not intuitive and are poorly designed. Treatment type is restricted to selected asthma medications and you cannot specify doses. There is a limited set of medical conditions from which to choose, and you can only specify yes or no to having food, medication or seasonal allergy.
The My Daily Record section includes the key features of a journal and My Action Plan. These features are poorly executed. In Journal Entry, the first items you are asked to rate are your pain, mood and whether you have other symptoms today. These could be relevant to asthma, but are definitely not mandatory as presented by the app. It is difficult to tap on “Yes” for symptoms, after which you still need to tap an arrow to then select your symptoms. In multiple different sections, different warning screens with different messages pop-up prompting you to seek urgent medical attention. In My Action Plan, you are asked to re-enter medications in free-text boxes and then enter the medications again in the action plan steps. My Resources & Progress includes patient education that is populated by well-done material from healthychildren.org. The My Charts section displays charts for items without any data entered and only visualizes cough frequency from the list of asthma symptoms that could be tracked.
The only useful feature of this app is the educational material. It would not be an effective self-monitoring tool for users unless a user is highly motivated to complete extensive and redundant data entry.
The user interface is simple, clear and easy to learn, despite the dated feel. Some, but not all, of the sections are intuitive and use internally consistent gestures and controls. Data entry is inefficient and redundant, requiring duplicate entries for medications in different sections.
Privacy & Security+-
You need an email address and password to register with @Point of Care and log in to the app. There is an extensive legal disclaimer within the app that contains multiple URLs on the @Point of Care website, but not direct links. Personal information is transmitted from the app to @Point of Care, with personal information being shared directly to third party marketers for direct marketing purposes or the direct marketing purposes of other third party marketers, with de-identified aggregated data shared with third parties for commercial purposes. You can opt-out of this by emailing them, but the default is opt-in.
@Point of Care seems like a credible company, providing regular update to the app and responsive technical support. Unfortunately, most sections of the app are slow and require you to watch the progress icon for a few seconds.
The app is free and available for iPhone and iPad in the Apple App Store. The language is targeted toward adults and does not appeal to children. There could be added-value if providers routinely use the companion app, but otherwise, users are likely to download this app then not use it.
This app was published by Carolinas HealthCare System, a public, not-for-profit healthcare organization in the U.S. southeast, and Levine Children’s Hospital in Charlotte, North Carolina. The Amazings features fast-paced, runner-style gameplay to help kids recognize and avoid asthma triggers like pollen, cigarette smoke and pollution, and stay vigilant about their health. The intended audience is children with asthma aged seven to 12 years old. Compared to Wizdy Pets, this app targets a slightly older audience. As a much-older than 12-year-old, I found gameplay quite simple and addictive.
The app provides asthma education through runner-style gameplay. The overall goal of the game is to complete 16 missions – levels – and unlock all 16 secret files, for example asthma triggers. Completion of four missions also unlocks a new character and new pages of a comic. Gameplay involves a hero running forward on a three-lane road. Users move the character right or left, jump or slide to collect “orbs” that replenish health, and avoid obstacles and asthma triggers. The goal is to unlock a secret file with information — no pictures, animations, audio or video – about each asthma trigger. For example, “Secret File 001 Page 01 Smoke: Secondhand smoke hurts everyone, especially kids with asthma. Kids are growing very fast and this causes them to suffer more when exposed to cigarette smoke. Ask people not to smoke near you. This can be hard, but its important to let them know that the smoke can start your asthma.”
If the hero runs into an obstacle, gameplay restarts at the last file. If the hero runs into a trigger, then health lowers significantly and tapping on the inhaler prevents health from failing There are short useful quick tips for gameplay that pop up frequently.
Similar to Wizdy Pets, the sole focus of this app is education. It is more explicit in providing information about asthma triggers but children would still likely benefit from discussion of the information. The content seems accurate but is not directly linked to specific guidelines. The app and websites state that the “game is based on the latest research on how children can manage their asthma”.
The user interface is simple, clear and easy to learn, using familiar gestures, large icons and clear text. Navigation and gameplay is intuitive. The app only operates in portrait orientation and occasionally side swipes are mistaken for upswipes. An on-screen control pad might help. After a few minutes of playing, however, it is easy to adjust gestures to operate flawlessly. Under the settings menu there is a help section with clear instructions on controls, useful items and things that affect health.
Privacy & Security+-
The app was developed by Dreamkind and the Goodwin Design Group, both companies with websites that appear legitimate and professional. The app was released July 17, 2014 and does not appear to have been updated. It functioned well, although I did receive a warning that the app may not as it has not been updated for the latest iOS.
The recommended user age is between seven and 12 years. This seems appropriate, as the gameplay and text is a little more advanced than Wizdy Pets. The app is available free in both the Apple App Store and Google Play store for phones and tablets. A 550+ MB download, users will need access to WiFi and lots of storage space on their devices.
7 keys to manage Childhood Asthma
This app was created by Dr. Jagdish Chinnappa, Consultant Paediatrician at Child Central Clinic & Manipal Hospital in Bangalore, India, aka Silicon Valley of the East. The main goal of this app is to help parents manage their child’s asthma by providing education about important aspects of asthma care including allergen avoidance, lifestyle modification, symptom relief, controller medications, action plan and response monitoring. There are some excellent videos of cartoon characters demonstrating the proper medication administration technique for different devices.
Overall the app is an excellent mobile educational tool with some limited tracking features.
The app has seven main sections, with a major focus on asthma education including allergen avoidance, lifestyle modification, parental assessment of symptom severity, reliever and controller medications, diagnosis and management of common co-morbid conditions, and an unmodifiable/generic asthma action plan. There are some excellent videos of cartoon characters demonstrating the proper medication administration technique for different devices. The Monitor Response section allows users to track symptoms in a simple diary and record peak flow, height and weight. This data can be tracked on a calendar with a pdf report generated to share with your doctor.
Education is the first and most important aspect of asthma self-management and this is very well done in this app. The content seems accurate, but is not directly linked to specific guidelines. Some of the information provided may be irrelevant to the Canadian setting, for example, “dry pillows and mattresses regularly in the sun to avoid house dust mites”.
The user interface is simple, clear and easy to learn but does have a dated feel. Navigation between sections and within each section is smooth and intuitive. The layout of each section is consistent and easy to read. For example, each allergen section starts with a few common pictures, description, symptoms and action to be taken. Similarly each medication has a description, ways it can be administered and dosage.
Privacy & Security+-
According to the various websites linking to this app, Dr. Chinnappa seems to be a credible, experienced and respected physician. The app was last updated in May 2016. It functioned well without stalling or crashing. The app was developed by chain-sys.com, an enterprise resource planning and computing software company in India.
The app is available in a lite and paid ($3.99) version in both the Apple Store and Google Play store. The lite version includes the allergen avoidance and medication sections; the other sections require payment. The language is targeted toward parents, but contains simple, concise and easily understood bullets. There are plenty of images to appeal to children and the cartoon videos are well done and easy to follow. The app could use some text editing for grammar. The app may have additional appeal to ethnic minorities as some of the images and animations feature people of South East Asian descent.
Wizdy Games is a health-oriented gaming start-up promoting patient self-management through engaging mobile games. Wizdy Pets features a fire-breathing dragon who educates children about asthma through games. In one mini-game, children lead the dragon through the steps of taking an inhaler. In another, Trigger Ninja, children need to slash asthma triggers but not inhalers. Completing missions and mini-games earns badges, coins to buy items and fire-breathing power to fight the smog monster. By playing this game, children will learn to identify asthma triggers, how to take inhalers, the difference between controller and reliever medicines and the importance of taking regular controller medicine. My favourite feature is the dragon who gets hungry and needs healthy food to increase its lifeline. The purchase of unhealthy food items actually decreases the lifeline.
Overall, this is an excellent game for children with asthma. Its interface is simple and features colourful cartoon animations.
The app targets asthma education via gaming, interactive features and engaging activities. The games provide a simple interface with colourful cartoons like many popular games. They mimic real life, for example how to take inhalers, and provide reminders like “Don’t forget to take your everyday inhaler every morning and night”.
While education is the first and most important aspect of asthma self-management, children may need some coaching/discussion, for example, what is pollen, why is it bad if you have asthma, how to avoid it. Although the content seems accurate, it is not directly linked to specific guidelines.
The user interface is simple, clear and easy to learn, as it uses familiar gestures. Navigation and gameplay is intuitive but gesture controls are not as smooth and responsive as they could be. Further, some aspects of gameplay were frustrating. For example, coins are earned by playing mini-games and can be used to purchase food. However, if you have no coins, you cannot purchase food and if the dragon is hungry it is too tired to play games. Eventually, the dragon gets really sick and goes to the hospital to regain health. It would be useful to have hints that popped up more often or a help, FAQ, instructions or set-up section.
Privacy & Security+-
The Wizdy Games website features descriptions of the core team, advisors, including some physicians, and collaborators. There is a blog outlining the company’s story. The app was last updated April 2017. It functioned well, although it did freeze once.
Users can customize their dragon’s name and colours. Language is plain and simple, targeted to children, with a reading level aimed at early elementary school or primary readers from six to nine years of age. There is some medical jargon specific to asthma. The app is available for free in the Apple Store and Google Play store. My three-year-old asked if we could play the dragon game.
What Experts Say
Watch our interview with pediatric respirologist Dr. Tom Kovesi about pediatric asthma.
Fifteen per cent of Canadian children and youth had asthma in 2011/2012, a 4.4 per cent annual increase since 2000/2001. More, according to AsthmaKids.ca, only 27 per cent of children use their physician recommended medication daily, whether they are experiencing problems or not.
One solution may be apps. “Smart Phone Apps: An Innovative Approach to Improving Pediatric Medication Adherence”, published in Innovations in Pharmacy, University of Minnesota Libraries Publishing, found that adapting medication adherence apps to children specifically, will encourage them to take greater responsibility in their medication regimen. “Increased responsibility will allow children to further educate themselves about their chronic conditions and self-care. (This) will aid children in their transition from childhood into adolescence and adulthood, which will facilitate medication adherence in these stages of life as well.”
Tariq Aslam, a British eye doctor, created his own solution when when his son struggled to use a spacer for his breathing problems. He designed a game-based app.
The app monitors breathing patterns to activate a series of interactive games which reward children for good inhaler use by letting them blow out on-screen fires and banish cartoon foes – like the ‘bad wolf’.
A proof of principle study, published in Pulmonary Therapy Journal, shows the app could help children learn how to use inhalers correctly and reduce anxiety about face masks and spacers. All children in the study said they enjoyed playing the game, and 91% said it helped them to take their medication. An overwhelming majority of parents – 13 out of 14 – also said they thought the app helped their child to use their spacer. They said it helped their child accept the spacer and made them calmer.
- MD Lougheed, C Lemière, SD Dell, et al. Canadian Thoracic Society Asthma Management Continuum — 2010 Consensus Summary for children six years of age and over, and adults. Can Respir J 2010;17(1):15-2
- Ducharme FM, Dell SD, Radhakrishnan D, et al. Diagnosis and management of asthma in preschoolers: A Canadian Thoracic Society and Canadian Paediatric Society position paper. Canadian Respiratory Journal: Journal of the Canadian Thoracic Society. 2015;22(3):135-143.
- Huckvale K, Car M, Morrison C, Car J. Apps for asthma self-management: a systematic assessment of content and tools. BMC Med. 2012;10:144.