By Kathleen MacNaughton, R.N
The approach to treatment of asthma in children in many ways is similar to asthma treatment approaches for adults. However, kids’ asthma treatment is modified by age group, as recommended by the National Expert Panel Guidelines for Asthma Treatment. It also makes greater use of the stepwise approach to treatment of asthma, due to the greater variability in asthma status among kids.
The Expert Panel stresses that the goal of asthma therapy in kids is to maintain long–term control of asthma with the least amount of medication and hence minimal risk for adverse effects. They also talk about preventing asthma from worsening, or progressing, in children.
How Asthma Control Is Measured
Asthma control is measured both by impairment and risk.
Asthma impairment reduction is defined as
- Chronic and troublesome asthma symptoms, such as coughing or feeling breathless in the daytime, in the night, or after exertion, are prevented.
- Rescue inhalers are used for quick relief of asthma symptoms less than twice a week.
- Healthy pulmonary function is maintained.
- Usual activity levels, including school attendance and participation in sports and play activities, is possible.
- Child and parents are satisfied with asthma care.
- Repeat asthma flare–ups are prevented, thus minimizing the need for emergency care or hospitalization.
- Healthy lung growth occurs, with no worsening of airway function.
- Effective medication treatment occurs without serious or bothersome side effects.
Diagnosing Asthma in Kids Is the First Step
Before asthma treatment in children can begin, however, a diagnosis of asthma must be made. This is not as easy as it sounds. Asthma is often misdiagnosed in kids, which is what happens when their asthma–similar symptoms don’t really add up to asthma. Or, they may also be underdiagnosed, when instead of the correct asthma diagnosis, they are labeled as having wheezy bronchitis, sinusitis, reactive airway disease, respiratory infections, or something else.
Complicating factors is that children – especially very young ones – can’t always communicate well enough about how they are feeling or what they are struggling with. Some pulmonary function tests that can help nail down an asthma diagnosis are also not able to be used in young children. Doctors often have to rely solely on their physical exam of the child and the parents’ observations. Or, in some cases, they may give asthma medications for a trial period to see what happens. If symptoms improve when taking asthma medications, an asthma diagnosis may be more likely.
The problems with kids not getting the right diagnosis can be twofold
- Kids who are diagnosed in error as having asthma may be treated with the wrong medications for long periods of time and put at unnecessary risk.
- Kids who DO have asthma do not receive the treatment they need to maintain healthy lung function. As a result, their airways get worse and quality of life declines.
Stepwise Approach to Asthma Treatment by Age Group
When the Expert Panel Guidelines were updated in 2007, one of the changes was an emphasis on modifying the treatment approach for kids with asthma, based on their age group. The reason for this is based on a few factors. First of all, kids of different age groups may respond differently to medications or require them to be given differently, such as nebulizer vs. inhaler. Secondly, scientific evidence proving safety and effectiveness of asthma medications is lacking in younger age groups. Third, lung function can not be assessed easily in younger age groups, making it harder to measure how well a drug is working. Asthma wheezing types may also vary by age group, and there may be other influencing factors as well.
In general, daily, long–term asthma controller medicine is recommended for both of the age groups below. Depending on the degree of control, medication frequency and/or dosage may be stepped up to improve control. Now, let’s look at each age group separately:
- Age 0 to 4 years
Daily, long–term control therapy is recommended in this age group. It is aimed at reducing risk of asthma attacks and airway impairment in kids who had four or more episodes of wheezing in the past year that lasted more than 1 day and affected sleep AND who have risk factors for developing persistent asthma. It should also be considered for reducing impairment in infants and young children who consistently require symptomatic treatment more than 2 days per week for a period of more than 4 weeks. Thirdly, controller medications may be used in infants and young children who have a second asthma flare–up needing oral steroids within 6 months to reduce their risk. Finally, asthma controller medicines may be used during seasons of increased risk, in kids who have had problems in the past, namely in relation to respiratory infections, the most common trigger of asthma symptoms in young children.
In these infants and young children, the decision to add, or step up, treatment will be based mainly on severity and frequency of observed symptoms. - Age 5 to 11 years
In kids this age, daily long–term controller therapy is recommended when the kids have been classified as having persistent asthma. At this age, the doctor weighs any possible risks of taking long–term asthma medicines, such as delayed growth, against the risks of not treating asthma. Studies have shown that the benefits definitely outweigh the relatively small risks, in most cases.
- Symptoms, both in terms of frequency and severity.
- Asthma control scores (if available), which are simply a measure of the degree of control, based on tested survey tools that quantify various factors to come up with a score.
- Pulmonary function testing.
The doctor will also consider whether other health problems, such as sinusitis, may be interfering with asthma control. And finally, efforts at avoiding environmental triggers must be looked at. When a child continues to come into daily contact with triggers, asthma control will be challenged. It should be emphasized too that every child should have a written, personalized Asthma Action Plan that guides parents on a day to day basis with managing their child’s asthma.
When stepping up treatment, or addressing the other factors discussed above, doesn’t improve the child’s health status, then a referral to an asthma specialty doctor is strongly encouraged, particularly in the presence of any of the following conditions:
- Control is difficult to achieve.
- A child in the 0 to 4 years age group requires step 3 or higher care.
- A child in the 5 to 11 years age group required step 4 or higher care.
- The child has an asthma flare that requires hospitalization.
- Allergy tests or allergy shots are to be considered, due to suspicions of allergic factors.
Once control has been achieved, the Expert Panel still recommends that kids be seen by their doctors every 1 to 6 months. If a future step–down in treatment is planned, then the child should be seen at 3–month intervals until this occurs. Step–down should be considered if a child has been under control for at least 3 months.
Source: www.asthma.about.com