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Effective control of asthma in children

Erica Haines
RGN OHNC
Clinical Lead for Asthma
Education for Health
Warwick

With more than a million children suffering from asthma in the UK, correct diagnosis and management must be a priority for primary care nurses

There are approximately 1.1 million children with asthma in the UK and the British Thoracic Society and Scottish Intercollegiate Guideline Network (BTS/SIGN) guidelines for asthma management aim to provide comprehensive advice for patients of all ages in primary and secondary care settings.1,2
 
The 2011 update has recently been published online and includes the familiar stepwise approach to asthma management, helpfully divided into three age groups - the under-fives, five to 12 year olds and 12 years and over.
 
Diagnosis
Diagnosing asthma in preschool children can be difficult as there is no absolute definition that can be used in clinical practice. The BTS/SIGN guideline suggests that clinicians use a framework of 'probability' to arrive at a possible asthma diagnosis or exclude it (see Boxes 1 and 2).

[[Box 1,2 Erica]]

Remember, the diagnosis of asthma in children is a clinical one, based on recognising a characteristic pattern of episodic symptoms in the absence of an alternative explanation for them.2 With a thorough history and examination, a child can usually be classed into one of three groups:

  • High probability of asthma - diagnosis of asthma is likely.
  • Intermediate probability of asthma - diagnosis is uncertain.
  • Low probability of asthma - diagnosis other than asthma is likely.

Although there are several factors associated with a high risk of developing persisting wheeze or asthma in childhood, diagnostic difficulties may arise. Symptoms such as wheeze and cough are not specific to asthma and can be associated with other conditions, ranging from simple viral infections to more serious disorders, such as cystic fibrosis.3,4

The key is to take a detailed history (see Box 3) and always keep an open mind about alternative diagnoses, particularly if there appears to be little response to asthma therapy. However, trials of treatment may give false negative responses due to difficulty administering the medication or using too low
a dose.5

[[Box 3 Erica]]

Children under the age of two with respiratory symptoms cause enormous concern to both parents and health professionals. The diagnosis of asthma cannot be confirmed by any specific tests, response to treatment is variable and may not be effective.

There are often frequent viral respiratory infections that result in symptoms, administration of inhaled medicines is sometimes difficult and there may be parental concerns about regular treatment. Diagnosis is especially difficult in younger children and referral to a respiratory paediatrician may be needed if the diagnosis is in doubt or the child's condition is giving cause for concern.2

Differential diagnoses in infants and children
Cystic fibrosis is the most common inherited disorder and is characterised by recurrent chest infections, mucus abnormalities and failure to thrive. Failure to thrive is not a feature of asthma and might give an important clue to this condition.5 For this reason it is always important to plot the child's height and weight.

Wheezing that starts very early in life is unusual and might point to a congenital or developmental problem, such as vascular ring.

Foreign body inhalation could be a factor so always check to see if the symptoms started suddenly in a previously well child.
There is a long list of other conditions quite distinct from asthma that can cause recurrent wheezing, and careful consideration must be given to these.6 Persistent features, such as a moist cough or runny nose should always ring alarm bells.5 However, other indications for specialist referral in
children include:

  • Diagnosis unclear or in doubt.
  • Symptoms present from birth or perinatal lung problem.
  • Excessive vomiting or possetting.
  • Severe upper respiratory tract infection.
  • Persistent wet or productive cough.
  • Family history of unusual chest disease.
  • Failure to thrive.
  • Nasal polyps.
  • Unexpected clinical findings, eg, focal signs, abnormal cry, dysphagia, inspiratory stridor.
  • Parental anxiety or need for reassurance.

Asthma management
This summary starts with mild asthma and then works up the scale of severity.

Mild intermittent symptoms
If the symptoms are mild and intermittent treat them whenever they occur using a ß2 agonist inhaler - this will give quick relief of symptoms. ß2 agonists are not always effective in very young children, which isn't a reason to avoid using them in this age group, but be aware that:

  • The child may not tolerate the spacer and mask device to deliver inhaled therapy, resulting in poor adherence to therapy.
  • Drug deposition is limited because of poor inhaler technique, which may mean that a larger dose is needed.
  • The diagnosis may be incorrect or needs to be reconsidered.

Daily symptoms
If symptoms occur three times a week or more; cause waking one night a week or more; or if the bronchodilator has to be used more than three times a week, it makes sense to use regular prophylactic therapy.

Inhaled steroids remain the preferred preventer therapy for children - if there is an occasional breakthrough of symptoms the ß2 agonist inhaler will give rapid relief.2

Seasonal asthma sufferers may have either intermittent or daily symptoms during their season (eg, pollen-induced asthma only) and should be treated the same as anyone else with asthma. With practice and experience prophylactic therapy can be started before the season begins.

There are several therapeutic options available when the aims of treatment have not been achieved, but the main aim is to allow participation in all normal daily activities and sports without being restricted by asthma, using the minimum amount of treatment.

Poor control
If regular inhaled steroids (200-400 µg in children) of beclometasone (BDP) or equivalent, plus occasional bronchodilator, fail to achieve the aims of treatment, ie, if there are still symptoms, sleep disturbance or restriction of activities, then there are several therapeutic options. Before initiating an increase in inhaled therapy, consideration of the points below must be made:

  • Check that the diagnosis is correct.
  • Check whether the medication is being taken as prescribed.
  • Check inhaler technique. It may be necessary to reconsider the inhaler delivery system.
  • Check that triggers have been minimised and there isn't exposure to new triggers. This includes treating any comorbid allergic rhinitis.
  • Add in a long-acting ß2 agonist for adults and children (five to 12 years). However, even though long-acting beta agonists (LABAs) are the preferred option, leukotriene receptor antagonists (LTRAs) are also an option.
  • For children aged two to five years a leukotriene receptor antagonist is the preferred add-on therapy. In children under two years consideration should be given to diagnosis and referral considered. 

If there is no response to long-acting bronchodilators, stop use and increase the dose of inhaled steroid (400 µg in children beclometasone or equivalent) and deliver through a spacer device. If asthma is difficult to control at doses of 400 µg per day in the under-fives then the child should be referred to a specialist paediatrician with an interest in respiratory disease. No response to therapy should alert the specialist to review the diagnosis.

In children aged five to 12 years if poor asthma control persists consider additional therapies, eg, LTRAs, slow-release oral theophylline or a slow-release oral ß2 agonist. The dose of inhaled steroids may be increased to a maximum of 800 µg in five-to-12-year-olds; however, it is stressed that patients should also be under the care of a paediatrician at this stage. 

Allergic rhinitis
Allergic rhinitis can contribute to respiratory symptoms and is often undiagnosed, the symptoms frequently confused with infectious rhinitis (colds) which are extremely common in children. Symptoms that persist longer than two weeks should prompt a search for a cause rather than an infection.7 By the age of six to seven years the International Study of Allergies and Allergies in Childhood (ISAAC) shows the prevalence of doctor-diagnosed allergic rhinitis in the UK to be around 15% and nasal symptoms suggestive of allergic rhinitis to be actually over 20%.8

Rhinitis frequently precedes asthma, and treating allergic rhinitis has beneficial effects on asthma control, suggesting that upper airway disease is a risk factor for asthma and a shared pathophysiology.9,10

Concordance with therapy
To improve concordance with therapy asthma education should be planned and delivered according the child's age and level of understanding, involving them in their management and treatment as much as possible.11 Children with asthma and their parents, and young people with asthma should expect to:

  • Be offered accurate and timely information about their condition through a variety of mediums suitable for their age and understanding.
  • Discuss and receive a personal asthma action plan in a format that they can access and understand
  • Receive help in identifying and reducing exposure to triggers.
  • Be supported in monitoring their asthma symptoms.
  • Receive guidance and support as to how to use and record peak flow, if age appropriate.
  • Be given the opportunity to practice inhaler technique with an age-appropriate inhaler device.
  • Be confident in knowing how to respond when their asthma deteriorates.
  • Be confident in knowing what to do in an emergency.
  • Hold a full discussion with their healthcare professional about medication and side-effects.
  • Hold a full discussion with their healthcare professional about how asthma affects each aspect of their life including triggers at home and at school, and risk-taking behaviours where appropriate.
  • Opportunities to offer and receive support from other young people with asthma.
  • Be supported to take more responsibility for managing their asthma as they get older to receive a pre-school/school card that details their current treatment and what to do in an emergency in order to guide teachers and school staff.

Conclusion
Wheeze and cough are not specific to asthma and diagnostic difficulties may arise particularly in children. These symptoms may be associated with other conditions ranging from simple viral infections to more serious disorders such as cystic fibrosis.4 Recognising a characteristic pattern of episodic symptoms in the absence of an alternative explanation, in conjunction with a thorough history and examination, can usually allow classification into one of three groups; high, intermediate or low probability of asthma.2

Management of asthma is aimed at maximal control of symptoms using minimum treatment, ensuring co-morbidities such as allergic rhinitis are assessed for and treated, triggers are minimised and medication delivery is optimised. The key is to take a detailed history and always keep an open mind about alternative diagnoses, particularly if there appears to be little response to asthma therapy.5

References

  1. Asthma UK. For Journalists: Key Facts and Statistics. London: Asthma UK; 2011. Available from: www.asthma.org.uk/news_media/media_resources/for_journalists_key.html  accessed March 2011
  2. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. Edinburgh: SIGN; 2008
  3. Bush A. Diagnosis of asthma in children under five. Primary Care Respiratory Journal 2007;16:7-15.
  4. Hay A, Wilson AD. The natural history of acute cough in children aged 0-4 years in primary care: a systematic review. Br J Gen Pract 2007;52:401-9.
  5. Cochran D, Paton J. Wheezing in the under-5s: an approach to management. Airways Journal 2003;1202-5.6.
  6. National Asthma Education and Prevention Program. Third Expert Panel on the Diagnosis and Management of Asthma Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma Clinical Practice Guidelines. Available from: www.ncbi.nlm.nih.gov/books/NBK7232/
  7. Brown T, Adair R, Orr K, Scadding G. Childhood Allergic Rhinitis - within the 'one airway'. Practice Nurse Care Manual: Draft 2010. Adapted from: The BSACI guidelines on the management of allergic and non-allergic rhinitis (2008). Clinical and Experimental Allergy 2010;38: 19-42.
  8. Asher MI, Keil U, Anderson HR et al. International Study of Asthma and Allergies in Childhood (ISAAC): rationale and methods. Eur Respir J 1995;8(3):483-91.
  9. Bousquet J, Khaltaer N, Cruz AA et al. Allergic rhinitis and its impact on asthma (ARIA): 2008 update. Allergy 2008;63(Suppl 86):8-160.
  10.  Pawankar R. Allergic rhinitis and asthma: the link, the new ARIA classification and global approaches to treatment. Curr Opin All Clin Immunol 2004;4(1).
  11. Asthma UK. Standards of asthma services for children. London: Asthma UK; 2008. Available from: www.asthma.org.uk/scotland/our_work/influencing_policy/working_in_partne...