Race-Specific and Race-Neutral Equations for Lung Function and Asthma Diagnosis in Black Children

Importance Use of the race-neutral Global Lung Initiative (GLI) equation has been shown to generate decreased lung function measures in Black children and adults. The effect on asthma detection and diagnosis in children is unknown. Objective To compare the use of race-specific vs race-neutral equations on subsequent asthma diagnosis in children. Design, Setting, and Participants The Childhood Asthma Management Program (CAMP, 1991-2012), the Cincinnati Childhood Allergy and Air Pollution Study (CCAAPS, 2001-2010), and the Mechanisms of Progression from Atopic Dermatitis to Asthma (MPAACH, 2016-2024) cohorts were included in this cohort study. Children in the CAMP cohort were aged 5 to 12 years with mild to moderate asthma. The CCAAPS and MPAACH cohorts included infants from atopic parents and children aged 0 to 2 years with atopic dermatitis, respectively. Data were analyzed from November 2023 to May 2024. Exposures Race-specific vs race-neutral GLI equations to define lung function. Main Outcomes and Measures Percent predicted values of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), asthma or asthma symptoms, and eligibility for reversibility testing were determined. Results Among 1533 children, there were 849 CAMP (median [IQR] age, 8.7 [7.1-10.6] years; 138 [16%] Black, 711 [84%] White, and 498 [59%] male participants), 578 CCAAPS (median [IQR] age, 6.9 [6.7-7.0]; 115 [20%] Black, 463 [80%] White, and 315 [55%] male participants) and 106 MPAACH (median [IQR] age, 7.4 [7.1-7.8] years; 62 [58%] Black, 44 [42%] White, and 62 [58%] male participants). The median (IQR) percent predicted FEV1 in Black children decreased by 11.9 percentage points (pp) (10.4-13.1 pp) in CAMP, 13.5% pp (11.8-14.6 pp) in CCAAPS, and 13.2 pp (11.6-14.6 pp) in MPAACH compared with the race-specific equation. The race-specific equation failed to detect reduced percent predicted FEV1 in 12 of 22 Black children in CCAAPS with asthma symptoms (55%) and 5 of 15 Black children in MPAACH with asthma (41%). In CCAAPS, children with less than 90% predicted FEV1 based on race-specific equations were eligible for postreversibility testing to objectively diagnose asthma. When this asthma diagnostic algorithm was applied, 16 of 36 Black children in CCAAPS (44%) and 6 of 16 Black children in MPAACH (38%) who were not eligible for reversibility testing based on the race-specific equation became eligible with a less than 90% predicted FEV1 based on the race-neutral equation. Conclusions and Relevance In this cohort study of 1533 children, the use of the race-neutral equation improved the detection of asthma in children. These results support the universal use of the race-neutral equation to improve asthma detection in children and help guide medical practice toward alleviating asthma-related health disparities.