Management of asthma in children

Diagnosis and management of asthma in children

Asthma is the the most common chronic respiratory condition of childhood worldwide, with around 14% of children and young people affected. Despite the high prevalence, paediatric asthma outcomes are inadequate, and there are several avoidable deaths each year. Characteristic asthma features include wheeze, shortness of breath and cough, which are typically triggered by a number of possible stimuli. There are several diagnostic challenges, and as a result, both overdiagnosis and underdiagnosis of paediatric asthma remain problematic.Effective asthma management involves a holistic approach addressing both pharmacological and non-pharmacological management, as well as education and self-management aspects. Working in partnership with children and families is key in promoting good outcomes. Education on how to take treatment effectively, trigger avoidance, modifiable risk factors and actions to take during acute attacks via personalised asthma action plans is essential.This review aimed to provide an overview of good clinical practice in the diagnosis and management of paediatric asthma. We discuss the current diagnostic challenges and predictors of life-threatening attacks. Additionally, we outline the similarities and differences in global paediatric asthma guidelines and highlight potential future developments in care. It is hoped that this review will be useful for healthcare providers working in a range of child health settings.

Global impact of asthma on children and adolescents' daily lives: the room to breathe survey

OBJECTIVE

To establish children and adolescents' perspectives regarding their asthma and its impact upon their daily lives.

DESIGN

A 14-item questionnaire.

SETTING

Canada, Greece, Hungary, The Netherlands, the United Kingdom, and South Africa.

PARTICIPANTS

Children/adolescents (aged 8-15 years) with physician-diagnosed asthma.

INTERVENTION

Interviews were conducted by telephone (Canada, Greece, Hungary, The Netherlands, and the United Kingdom) or face-to-face (South Africa).

OUTCOME MEASURES

Asthma symptoms, impact on activities, and quality of life.

RESULTS

Of the 943 children/adolescents interviewed, 60% were male. Most (81%) described their asthma as "not too bad" or "I only get it every now and then," with only 4% reporting their asthma as being "very bad"; however, 92% experienced asthma-related coughing and 59% reported nocturnal awakening. Over half (57%) of children/adolescents believed they could predict when their asthma would make them ill; the most common initial symptoms being breathlessness (41%) and bad cough (33%). They considered the worst things about having asthma to be the symptoms of an asthma attack (32%) and not being able to play sport (25%). Almost half (47%) of children/adolescents felt that their asthma affected their ability to play sport or engage in physical activity. One in ten reported they had suffered asthma-related bullying.

CONCLUSIONS

Children/adolescents underestimate the severity of their asthma, and overestimate its control, indicating that they expect their illness to be symptomatic. Asthma has a substantial impact on their daily lives, particularly on physical activity and social functioning. Efforts are required to improve asthma control and expectations of health in children/adolescents.

Anti-asthmatic drug prescriptions to an Italian paedriatic population

To estimate the prevalence and evaluate the appropriateness of anti-asthmatic drug prescriptions in an Italian paediatric population, drug prescriptions involving 24,407 children <18 years old, dispensed during 2003 by the retail pharmacies of the local health unit in Lecco, Italy, were analysed. Children > or = 6 years old receiving anti-asthmatics were categorized into three subgroups based on the number of boxes prescribed: occasional (one box), low (two and three boxes) and high (> or = four boxes) users. A logistic regression analysis was performed to estimate the relationship between the drug use patterns and formulations, antibiotic co-prescriptions, systemic steroid prescriptions and rate of hospitalization. Anti-asthmatic drugs were prescribed to 6594 (12%) children and adolescents; 58% of whom received only one box of the drug. Prevalence varied according to age, with the highest values at 1 and 4 years (24% and 21% respectively), and decreased to 6% in 17-year-old adolescents. Inhaled steroids were the most prescribed drugs (83%). The most common of these was beclomethasone. Occasional, low and high users represented 58%, 29%, and 13%, respectively, of the treated population > or = 6 years old. High users were found to be at increased risk of systemic steroid prescriptions (OR 8.6) and hospital admission for asthma (OR 6.8). This study confirms that in Italy the prevalence of anti-asthmatic prescription is much higher than prevalence of disease, indicating that anti-asthmatics are over-prescribed. Moreover, steroids, especially nebulized, are mainly prescribed only once in a year, supporting the idea that are prescribed not for asthma, which as chronic disease requires a chronic therapy. The approach to create subgroups on the basis of number of boxes prescribed seems to be effective in estimating asthma severity and appropriateness of the therapies.

What drives prescribing of asthma medication to children? A multilevel population-based study

PURPOSE

Diagnosing asthma in children with asthmatic symptoms remains a challenge, particularly in preschool children. This challenge creates an opportunity for variability in prescribing. The aim of our study was to investigate how and to what degree patient, family, and physician characteristics influence prescribing of asthma medication in children.

METHODS

We undertook a multilevel population-based study using the second Dutch national survey of general practice (DNSGP-2), 2001. Participants were 46,371 children aged 1 to 17 years belonging to 25,537 families registered with 109 general practitioners. Using a multilevel multivariate logistic regression analysis with 3 levels, our main outcome measure was the prescribing of asthma medication, defined as at least 1 prescription for beta(2)-adrenergic agonists, inhaled corticosteroids, cromones, or montelukast during the 1-year study period.

RESULTS

We identified characteristics significantly associated with prescribing asthma medication on all 3 levels (child, family, and physician). The variance in prescribing among physicians was significantly higher with children who were younger than 6 years than with children aged 6 years and older (95% CI, 3.5%-25.2% vs 2.4%-13.4%). Several diagnoses other than asthma and asthmatic complaints were strongly associated with prescribing asthma medication, including bronchitis/bronchiolitis (OR = 9.04; 95% CI, 7.57-10.8) and cough (OR = 6.51; 95% CI, 5.68-7.47).

CONCLUSIONS

Our study shows a much higher variance in prescribing patterns among general practitioners for children younger than 6 years compared with older children, which could be a direct result of the diagnostic complexities found in young children with asthmatic symptoms. Thus diagnostic gaps may lead to more physician-driven prescribing irrespective of the clinical context.

Asthma School Program in children and their parents

BACKGROUND

This study was undertaken to analyze the clinical efficiency of Asthma Education Intervention (AEI, Asthma School) in children and their parents, a program was designed to produce acceptable asthma knowledge and to improve the treatment.

METHODS

This study assessed the effectiveness of an educational intervention within 12 months after attending Asthma School. The study was designed as a population based cohort study. The project endorsed by the European Respiratory Society (ERS) Educational Grant was launched in 2004 and finished in 2006, but the Asthma School continued working. Three hundred and two asthmatics recruited during hospital treatment of acute asthma exacerbation completed the study together with their parents. The intervention group of 231 asthmatics received full Asthma School program. The non-intervention group enrolled 71 asthmatics receiving usual instructions for asthma management. Clinical and educational outcomes were investigated immediately after completion of the program and 12 months later.

RESULTS

Significant achievements were found in the intervention group in asthma knowledge (baseline score 63%, 82% after 12 months, P<0.05), compliance (70% before, 90% after), and inhalation technique (20% before, 70% after). No change was found in the attitude and behavior regarding asthma prognosis in adolescent patients and parents.

CONCLUSION

This study together with others clearly confirm the effectiveness of educational intervention for childhood asthma.

Asthma education and monitoring: what has been shown to work

Cochrane systematic reviews and meta-analyses on education and monitoring of asthmatic children have come to divergent conclusions, mainly because of the heterogeneity of education programmes and patients. There is little doubt that education is useful. However, the useful components of the education programmes remain to be elucidated, not only by randomized controlled trials but also by observational studies performed within distinct asthma phenotypes. Any education and monitoring package needs to contain basic explanation about the disease and its influencing factors, as well as inhalation instructions. There is no good evidence to justify home monitoring of lung function; symptom monitoring suffices. Probably, the crucial part of asthma education programmes is a high level of agreement between patient and doctor regarding the goals of the treatment (patient-doctor partnership). Therefore, further exploration of the patient's needs should be worthwhile.