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Clinical: Managing asthma in children

Key learning points

 

  • A child’s asthma affects the whole family
  • Asthma is a variable condition – symptoms and triggers may change over time
  • Children can begin to monitor and manage their own asthma from a young age

More than a million children across the UK have asthma[1] – a diverse population with a huge variety of experiences. Some will grow out of their symptoms.[2] Others will find that preventer and reliever medications allow them to live virtually symptom free.

A few will face a long journey to find the right combination of drugs to keep symptoms under control with minimal side-effects. But a good relationship with the healthcare team can make a big difference to them all.

What symptoms suggest a child has asthma?

Diagnosing asthma in children can take months or years because there is no one definitive test[2] and children under five can’t easily perform a peak flow or spirometry test.

The main symptoms that might suggest asthma, especially if they occur when the child doesn’t have a cold or virus, or if they are set off by a variety of triggers, are:

  •  Wheezing and coughing, especially at night or in the morning.[2]
  •  Difficulty breathing.
  •  A tight, sore feeling in their chest – children often describe this as ‘chest hurting’ or ‘tummy ache’.

It’s even more likely to be asthma if the child:

  •  Has a family history of asthma, eczema or allergies.[2]
  •  Has eczema or an allergy, such as hay fever.[2]
  •  Has had bronchiolitis.[3]
  •  Was born prematurely, especially if they required a ventilator.[4]
  •  Had a low birth weight.
  •  Is exposed to second-hand cigarette smoke[5] or has a mother who smoked during pregnancy.[2]

Each person with asthma will react to different triggers.[6] Among the most common are cold weather, cold and flu viruses, smoke and house dust mites.[7] Exposure to one of their triggers causes the child’s inflamed airways to swell up, tighten, and fill with mucus, making it hard for them to breathe.[8]

It’s almost impossible to avoid exposure to many of these triggers, so rather than investing in expensive hypoallergenic bedding or air purifiers,[2] which have limited evidence of effectiveness, the best thing parents can do is ensure the asthma is well managed and the underlying inflammation is kept under control using a preventive treatment.

That way, a child’s airways are less likely to react when they meet a trigger and they’re more likely to stay well and out of hospital.[9]

What is well-managed asthma?

When treating children’s asthma, the aim is for them to have:

  •  No daytime symptoms.
  •  No night-time waking due to asthma.
  •  No need for rescue medicines (their blue reliever inhaler).
  •  No asthma attacks.
  •  For their asthma not to place any limits on their daily life (including school or exercise).[2]

Research shows that the things that make this most likely are:

  •  An up-to-date, personalised written asthma action plan.[2]
  •  Twice-yearly reviews with a GP or nurse.[2]
  •  Adhering to prescribed asthma treatments.

Treatments and techniques

Children who are judged (based on clinical history and symptoms) to be likely to have asthma will start on a trial of treatment.[2] The first step is a preventer inhaler, or (for children under five) leukotriene receptor antagonist tablets, to be taken every day to prevent the build-up of inflammation. Alongside this, they will also be given a short-acting reliever inhaler to be used when symptoms occur.

Before stepping up treatment (adding drugs or increasing the dose), make sure patients are adhering to their existing prescription by asking them to demonstrate their inhaler technique (with a spacer device) and estimate or record how many doses they have missed in the last week.[2]

If children have had no symptoms for three months and their asthma is well managed, consider reducing their dosage and reviewing – the aim is to keep good control on the lowest possible dose of preventer.[2]

Around 80% of people with asthma tell us that they also have hay fever, so to pick up seasonal variations, ask parents and children to monitor changes in their symptoms across a whole year, not just week to week, and recommend that they begin taking antihistamines around two weeks before the pollen they are allergic to is released.

Asthma attacks in children

Everyone who cares for a child with asthma should know how to treat an asthma attack. Parents are sometimes reluctant to call an ambulance and worry that they’ll be accused of overreacting, so giving clear, consistent guidance on what to do in an emergency will help parents stay calm.

When a child is having an asthma attack, parents or carers should:

  •  Help them sit up straight and stay calm.
  •  Help them take one puff of their reliever inhaler (usually blue) every 30-60 seconds, up to a maximum of 10 puffs.

 Call 999 for an ambulance if:

  •  Their symptoms get worse while they’re using their inhaler.
  •  They don’t feel better after 10 puffs.
  •  You’re worried at any time.
  •  If the ambulance is taking longer than 15 minutes, repeat step 2.[2]

Even if the child recovers before an ambulance becomes necessary, an attack is a sign that their asthma is not well managed and they should have an urgent review with their GP or an asthma nurse that day.

Children who are taken to hospital with their asthma should have a primary care review within two working days of being discharged to investigate why the attack occurred and whether their medication needs to be changed.[2]

Impact on families

Parents tell us that their child’s asthma affects their whole family. They may struggle to balance caring for the child with work and other family commitments, or feel that they have somehow caused their child to have asthma. This is where clear and sympathetic communication can make such a difference.

Parents who have been told that their children have ‘suspected asthma’ often feel frustrated that they can’t get a formal diagnosis more quickly.

Primary care nurses should be clear with parents that the delay is not a result of being ‘fobbed off’, and encourage them to monitor their child’s symptoms closely during a trial of treatment.

Explaining to parents how each of their child’s medicines works and regularly checking inhaler technique could help them support children to be adherent. Parents who understand the end goal of treatment are less likely to just ‘put up with’ worsening symptoms or stop their children playing the sport they love.

Helping parents take control

Parents whose children are being treated for asthma tell us that it can make them feel alone. Even if they see a GP or asthma nurse twice a year, it’s the parent who will be responsible for their child’s care the other 99% of the time.

A personalised child asthma action plan (integrated into EMIS, or downloadable from asthma.org.uk/advice/resources) allows you to set out clearly what actions should be taken every day, even if the child appears well; when they have increased symptoms after contact with a trigger; and in the event of an attack.

Studies show that adults who use an asthma action plan are four times less likely to have to go to hospital than those without,[10] and parents tell us that giving copies of their child’s action plan to other caregivers and teachers reassures them that their child is being cared for consistently.

Recent research suggests that few asthma attacks come out of the blue – they usually follow a period of worsening symptoms,[11] so monitoring is key. Even very young children can take part in this, using a calendar to record symptoms and possible triggers. Parents can order a free asthma calendar and stickers from asthma.org.uk/advice/resources. Spotting a pattern gives parents a chance to take action and seek advice before an attack happens.

Parents might also find it useful to film their child’s cough or wheeze to show you, instead of attempting to describe it in words.

One of the biggest barriers to living symptom free is poor inhaler technique. Children should have their asthma reviewed twice a year, so any change can be recorded and treatment adjusted if necessary.

Nurses should check that children are using inhalers and spacers correctly,[2] and that they (and their parents) understand what each one does.

Parents may be reluctant to give children more doses of inhaler because they fear the possible side-effects from inhaled steroids, so take the time to explore the relative risks and benefits.

Studies show that although there is a possibility that children will grow up to be shorter, the growth restriction is usually less than 1cm[12] – whereas leaving the inflammation untreated raises the risk of life-threatening asthma attacks and long-term lung damage.[13]

Resources

Asthma UK – asthma.org.uk, helpline (open Monday to Friday, 9 to 5, for healthcare professionals and anyone affected by asthma) 0300 222 5800

References

1 Asthma UK estimates from three sources: Health survey for England, 2001; Scottish Health survey, 2003; Welsh Health survey, 2005/06; Northern Ireland Health and Wellbeing survey, 2005/06.

2 British Thoracic Society Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma. brit-thoracic.org.uk/standards-of-care/guidelines/btssign-british-guideline-on-the-management-of-asthma/ (accessed 26 January 2017).

3 Wu P et al. Evidence for a causal relationship between respiratory syncytial virus infection and asthma. Expert Rev Anti Infect Ther2011;9:731-45.

4 NHS Choices. Causes of Asthma. nhs.uk/Conditions/Asthma/Pages/Causes.aspx (accessed 26 January 2017).

5 British Medical Association Board of Science. Breaking the cycle of children’s exposure to tobacco smoke. slough.gov.uk/downloads/BMA%20-board-of-science-children-exposed-tobacco-smoke.pdf

6 Global Initiative for Asthma. Causes of asthma and trigger factors. ginasthma.org/FAQs?faqid=2 (accessed 26 January 2017).

7 Asthma UK National Asthma Panel Survey (2004). Available on request from Asthma UK.

8 National Heart, Lung and Blood Institute. What is Asthma? nhlbi.nih.gov/health/health-topics/topics/asthma (accessed 26 January 2017).

9 Price D et al. Improved adherence with once-daily versus twice-daily dosing of mometasone furoate administered via a dry powder inhaler: a randomized open-label study. BMC Pulmonary Medicine2010:1 DOI: 10.1186/1471-2466-10-1. 

10 Adams RJ et al. Factors associated with hospital admissions and repeat emergency department visits for adults with asthma. Thorax2000;55:566.

11 Wasserfallen JB et al. Sudden asphyxic asthma: a distinct entity? Am Rev Respir Dis1990;142:108-11.

12 Sharek PJ et al. The effect of inhaled steroids on the linear growth of children with asthma: a meta-analysis. Pediatrics2000;106:E8.

13Bergeron C et al. Airway remodelling in asthma: From benchside to clinical practice. Pulsus Canadian Respiratory Journal2010;17:85-93.