iaacon 2011

12th to 14th Aug

  •  

iaacon 2011

12th to 14th Aug

  •  

iaacon 2011

12th to 14th Aug

  •  

iaacon 2011

12th to 14th Aug

  •  

 

Management of Asthma in Children.
H.Paramesh. MD, FAAP, (USA) FIAP, FIAMS, FIAA, FICAAI
Sr.Pediatric Pulmonologist and Environmentalist
Lakeside Medical Center and Hospital 
Bangalore 560 042
E-mail: dr_paramesh1@yahoo.com


Introduction:
Asthma is a chronic inflammatory obstructive lung disease and a major clinical concern globally. It represents a great burden on family and society, accounts for a large number of lost school days and interfere in children’s academic achievements and social interaction. In addition, it poses a great burden on healthcare resources and economics. The prevalence of asthma is increasing worldwide, however recent data shows stabilization or some lower trend, but the persistent asthma is increasing in prevalence.

It is important to diagnose asthma properly so that proper medical management can be instituted to avoid airway remodelling and contain the cost of hospitalization and use of medications.

What are the challenges in managing asthma under 5 yrs children?

  1. The major difficulty is in the diagnosis of asthma with objective proofs. Hence they most often called as post viral reactive airway disease, cough variant asthma and often treated as recurrent pneumonia.
  2. We often have to look for other causes for wheeze in infants.
  3. The efficacy of the drugs and their safety is not tested. There is lack of data on new therapies.
  4. We have to choose proper inhalation delivery system which is appropriate to the child.
  5. The terms used by the parents like – Breathlessness, short of breath, chest congestion, rattling, difficult to breath are not reliable for wheeze.
  6. Use of preventers is based on extrapolation of older children and adults and on expert opinion, which may not be appropriate.


The Prevalence and Spectrum of Asthma:
It is observed that 77 percent of asthma develops in children under five years and 26.3 percent over five years and they present predominaently as cough followed by wheeze, vomiting, abdominal pain and chest pain7 as shown in the graph I and II.

 

Graph I : The Prevelence of Asthma in Children
 
Graph II : Presenting symptoms of Asthma in Children


Tests for Diagnosis and Monitoring Asthma

Suspect asthma clinically in children with wheeze, three time or more in a year having atopic features in a child or family history of atopy and good response to bronchodilators and the peak expiratory flow showing 15 percent improvement after inhalation of salbutamol is diagnostic of asthma.

There is no tests to diagnose asthma in children under 5years. The therapeutic trial of treatment with quick relievers and inhaled steroids for 8 – 12 weeks showing improvement during therapy and relapse after stopping therapy is diagnostic of asthma. Chest x-ray is needed only if there is a doubt in the diagnosis.

The tests for atopy – The skin prick test is less reliable in children under 5 year of age. The total IgE level for atopic background is beneficial for counseling and for environmental control. Specific IgE antibodies for allergens is needed only for immunotherapy is needed.5
While evaluating an infant with wheeze always pay attention to growth and development and consider the possible congenital lesions, structural lesions, foreign body aspiration, cystic fibrosis and immune deficiency diseases etc.

Which child will develop persistent Asthma?

A child with increased IgE level at 9 months of age, a child with atopic dermatitis, allergic rhinitis in the first year, severe lower respiratory tract infection needing hospitalization and decrease pulmonary function testing by 6 years of age. Please note that “Atopy is the strongest predictor for wheezing in infants progressing to asthma”

Management of Asthma in Children

   
The management of asthma is considered under four part components:

I Component: is to develop a partnership between the patient, parent and doctor in education about the disease process, chroncity of the disease and the need to use the  preventers for a long time, misconception and fear about, inhalation therapy and steroids. In our set up only 8% of the time father accompanies the child with mother unlike in western countries. It is very essential to include the grandparents who play a major role in child care and for better compliance in our set up.

The impact of education has shown a significant reduction in hospital admission and emergency room visit in our set up as shown in graph-3.
 
 

Graph-3
 

II Component: is to identify and reduce the exposure to risk factors for asthma.

The various risk factors are listed in the table – 1. with explanation.

 Table – 1
Risk Factors for Development of Asthma.
  • Aeroallergens:
    • Perennial inhalant allergens are important risk factors for asthma.
    • Especially when sensitization occurs in association with frequent lower respiratory tract infections.
  • Irritants:
    • Air Pollution
    • Tobacco smoke
    • Biomass fuels
  • Microbes and their products:
    • Exposure to Lipopolysaccaride endotoxin from microorganisms in farming environment has protective effect (Hygeine Hypothesis)
    • Probiotics has no effect in development of asthma
    • Avoid Broad spectrum antibiotics unnecessarily
    • Maternal Diet – Pregnancy and / or Lactation
    • Insufficient data
    • Breast feeding decreases childhood wheeze syndromes for URI and
    • LRI
    • Little evidence that breast feeding prevents development of persistant asthma.
  • Psychosocial factors:
    • Stress in family or other primary caregivers during the first year of life is associated with an atopic profile and wheeze in infants and asthma at age 6-8 years.
    • Maternal distress in early life may play a role in the development of asthma, especially if the distress prolongs beyond post partem period.
  • Other risk factors:
    • ‘C’ section in allergic parents have higher risk
    • Paracetamol during Pregnancy and in childs first year of life.
    • Avoid aspirin, nonsteroidal anti-inflammatory drugs, betablockers.

 

While advising environment control one has to keep in mind the various factors that is existent in their country since it varies in different countries.

The indoor air pollution from use of biomass fuel for cooking with ill ventilated houses also contribute significantly for the development and to trigger asthma.

III Component: is to assess, treat and to monitor asthma. The current concept is focused more on clinical control of asthma. The level of control is:
Asthma: Controlled; 
Asthma: partly controlled;  
Asthma: Poorly controlled.
This classification is based on the following clinical features as desceibed on the following features as described in table-3.

 

Table-3
Level of Asthma Control in Children.
Features Controlled (All of the following) Partly Controlled (Any feature present in any week) Uncontrolled (3 or more features of partly controlled asthma in any week)
Daytime Symptoms None
(< 2 / week)
> 2 / week > 2 / week
Limitation of activities None Any Any
Nocturnal symptoms / disturbed sleep None Any Any
Need for quick reliever < 2 days / week > 2days / week > 2 days / week

 

During pharmacotherapy the most concern of the health providers is the use of steroids and its ill effects. The physician should address these issues for better compliance.

The current data shows that –

  • The uncontrolled or severe asthma can affect the growth and final adult height.
  • Growth retardation may be seen in excessively in the age group of 4-10 years with high doses of inhaled steroids, and also adrenal crisis.
  • The changes in growth rate during first year of treatment appears to be temporary.
  • Asthmatics who are on inhaled steroid with usual doses attain normal height at later age.
  • There is no effect on bone density and cataract, in patients who are on inhaled steroids.
  • Long term use of inhaled steroids is not associated with increased episodes of lower respiratory tract infection and tuberculosis.
  • The increased incidence of Dental caries is not from inhaled steroids but from beta-2 agonists from decreased oral pH.
     

Drugs used in Asthma:

Inhaled beta-2 agonists are the most effective drugs for quick relief of symptoms and MDI with valved transperent spacer is the preferred delivery system. Inhaled steroids are the best preventers for asthma. Low dose steroids don’t have any side effects both on growth and the Hypothalamic-Pituitary-adrenal axis (HPA). Local side effects like hoarseness, candidiasis are rare in children. The use of oral steroids are limited to acute severe exacerbation from viral or otherwise.

The leukotriene modifiers reduces the viral induced asthma in 2-5 years old children but don’t reduce the frequency of hospitalization and use of oral steroids. As an add on drug to inhaled steroids in this age group is not evaluated specifically.

The theophylline is less effective than of low dose inhaled steroids and one can expect the side effects.

Long acting beta – 2 – agonists like Salmeterol / Formeterol  must be used in combination with an appropriate dose of inhaled steroids.

The Immunotherapy is not recommended for treatment or prophylaxis of asthma in this age group.

The equipotent dose of steroids is shown in table-4.

 

Table-4
Equipotent Doses of Inhaled Steroids in Children in micrograms.
Drug Low Dose Medium Dose High Dose
Beclomethasone 100-200 >200-400 >400
Budesonide 100-200 >200-400 >400
Budesonide Nebuliser 250-500 >500-1000 >1000
Fluticasone 100-200 >200-500 >500
Mometasone 100-200 >200-400 >400
Ciclosonide 80-160 >160-320 >320
  • Note: 50% reduction of fluticasone dosage is not valid
  • Comparison is based on efficacy data

 

Our Treatment of Persistent Asthma
 

  • Use quick relievers 2 puffs three times a day in a spacer until cough stop 100 percent.
  • Use Inhaled Fluticasone – 100 to 250 micrograms in a spacer
    • Follow up in 2 weeks
      • Improvement
        • Atopic
          Continue Treatment for 1-3 months and reduce dose accordingly
        • Non Atopic
          Continue for a month and reduce accordingly
      • No Improvement
        • Look for comorbidities and technique of inhalation
        • Add leukotriene inhibitor, follow after 2 weeks
  • I always start with high dose of steroids and reduce the dose. This gives better response to be appreciated with the parents and there will be better compliance of medication.
  • Always check the technique of inhalation

 

IV Component: is to identify and manage the acute exacerbation of asthma attack. The indications for immediate referral of the patient to the hospital are listed in table-5.

 
 Table – 5
Risk Factors for Urgent Medical Attention
  1. Children less than 1 year needing repeated quick relievers
  2. Symptoms not relieved by inhaled bronchodilators on three times in 1-2 hrs interval.
  3. The period of relief after a dose of inhaled quick relievers becomes progressively shorter
  4. History of previous severe attack with ventilatory failure
  5. Acutely distressed (Subcoastal retraction, cyanosis)
  6. Head bobbing
  7. Absent social smile and not able to feed.
  8. Oxygen saturation in room air is < 92%

 

Any child who gets severe attack should be tackled as an emergency with proper medications and monitoring, since most of the calamities occurs during this stage only.

In my practice I use this pnemonics for follow up of children with asthma for better advice and compliance. ILL, HELL, PILL, SKILL and WELL

1) What makes you feel ILL?

  • If they say during sleep: I adjust the dosages and
  • May be use long acting theophylline. If it is during exercise, I advice use of short acting beta-2 agonists or montelukast.
  • Emotion stress: Councel them.

2) What makes you feel HELL?

  • If it is during thunderstorm: - I suspect the Didymella fungal spore allergy.
  • Smoke, colds, scents: -  Suggest avoid the irritants
  • Soon after going to bed: - Suspect Rhinosinusitis with post nasal drip.
  • 1AM to 3AM: Suspect Gastroesophageal reflux(GER)
  • 3AM to 5PM: It is normal circadian rhythm where airway caliber is 10% less due to natural decreased secretions of steroids and sympathomimetics. I use long acting beta-2 agonists or long acting theophylline.

3) What is your PILL?

  • I will ask what are the medications, timings and how often he used quick relievers, which help to increase the dose of preventers.

4) What is your SKILL?

  • The technique of inhalation is assessed and any fine adjustment that is needed is taught.

5) What is needed to be well?

  • Use of traditional foods. More of fresh vegetables.
  • Good environment control
  • Use of VAASTU in building new house with good ventilation, sunshine which is based on Vedic mathematics and windrose data.
  • Participate in school activity
  • Yogic exercises for better posture
  • Regular medication and follow up


Conclusion:

 

  • The ten commandments of proper asthma control in children are:
  • Aim is to have good control of asthma with 4 piller strategy “Parent, Patient, Grandparents and Physician” bonding
  • Avoid passive tobacco smoking
  • Diagnosis is largely based on clinical features / family history
  • Asthma education is a must
  • Avoid prolonged use of systemic steroids or high doses of inhaled steroids.
  • MDI with valved spacer is a preferred delivery system
  • Inhaled B2 agonists are the most effective quick relievers
  • Doubling the dose of inhaled steroids is the best option in uncontrolled asthma or addition of Leukotriene inhibitor is preferred.
  • Always look for proper technique of inhalation
  • Assess regularly

Suggestive readings:
 

  1. Paramesh .H. Text Book Practical Pediatric Pulmonology: J.P. Brothers, medical publishers 2009
  2. Paramesh .H. Asthma and Environment.Ind.J.of ped supplement 2006; 73: S51-55
  3. Paramesh .H. Asthma in children: seasonal variations. International J.on Environment and health. 2008 vol2, nos 3/4
  4. Paul D Robinson, Peter Van As peren Asthma in childhood. P.C.N.A. Feb 2009; Vol 56 No 1. 191-215
  5. Global Initiative for Asthma - 2009
  6. Paramesh .H. Epidemiology of Asthma in India. Indian Journal of Pediatr  2002, 69: 309-312
  7. Paramesh .H., Cherian .E. Pediatric allergies. Text book of tropical allergy immunology by wiquar Sheik – 2006.
  8. Roduit c, Scholtens S et al. Thorax 2009; 64: 107-13
  9. Rebordosa et al. Int .J. epidmiol 2008; 37: 385 -90

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