Asthma and Allergy – Management of Chronic Childhood and Adolescent Asthma

Introduction

The South African Childhood Asthma Working Group (SACAWG) convened on February 5, 1994 to review their previous
guidelines for the management of chronic childhood and adolescent asthma (Ref.1). The previous guidelines needed
changing because:

1. The scoring system presented proved impractical.
2. The central role of inflammation in asthma needed to be stressed.
3. Limited availability of certain drugs in rural areas required alternative agents to be suggested.
4. New inhaled long acting B-2-agonists and inhald steroids have been introduced.

The dominant pathophysiological process underlying asthma in children is airway inflammation.
Asthma is the commonest chronic disease in children and treatment may be expensive. Resources in our country
are limited and alternative cheaper drugs will be recommended in this statement. However, health practitioners should strive
to achieve the best possible therapy for each of their patients through motivation and education of parents, manufacturers and
health administrators, in order to ensure that appropriate drugs are accessible to all patients.

Paediatric vs Adult Asthma

The differences between paediatric and adult asthma need to be fully appreciated in childhood and adolescence, asthma is often triggered by environmental factors and allergens. The diagnosis, assessment of severity and monitoring of the effects of therpay are more difficult in young children because it may be possible to obtain reliable objective measurement of airway obstruction. Acute episodes of severe asthma often develop more rapidly in young children.

Diagnosis

Asthma is a clinical diagnosis. Asthma must be diagnosed in a child with chronic persisten or recurrent cough and/or wheeze that responds to a bronchodilator. Features supporting the diagnosis are a family and personal history of atopy, night cough, exercise-induced cough and/or wheeze and a seasonal variation in symptoms.

Furthermore, additional support for the diagnosis in older children (>5 years) is objective evidence of reversible airways obstruction. This forced expiratory volume in 1 second (FEV1) before and after B-2-agonist administration. An improvement of greater than 10% after 10 minutes indicates reversible airways obstruction.

Assessment of severity and control

The assessment presented has been kept as simple as possible but does not constitute a compromise as it conforms to international assessment criteria. The following points should be noted:

1. The assessment of severity is outlined in tabular form on Plate 2 on pages 122-123. A severity grading is important to place the child into a particular treatment category.
2. The assessment of severity refers to a child with regular or intermittent symptoms. The assessment and management of the acute attack is dealt with in a previous guideline .
3. Asthma presents as a spectrum of severity rather than in discrete severity groups. Practitioners should attempt to accurately grade each patient but must regard this only as a starting point.
4. If unsure of grading, place the child on the most likely therapy, give the patient a diary card (for symptoms and/or PEFR) and reassess after 4 weeks.
5. One or more features may be present to assign a grade of severity; a patient must be assigned to the most severe grade in which any feature occures.
6. Asthma can vary with time. Regular reassessment (at least every 3 months) with a veiw to reassignment of individual patients is necessary.
7. PEFR should not be used to classify patients during acute attacks.
8. In practice about 70% of childhood asthmatics will be found in the ‘mild’ 25% in the ‘moderate’ and 5% in the ‘severe’ categories.

Parents and patients should be taught that failure to respond to two doses of inhaled bronchodilator given 30 minutes apart constitutes a severe attack of asthma. This should not be managed at home without medical supervision.

Goals of management

The goal is effective control of asthma which strives to ensure that the asthmatic is able to lead a normal and physically active life. For a ‘normal life’ the aim is to:

1. Be completely free from any symptoms i.e. cough, wheeze and breathlessness.
2. Attend school regularly and participate fully in all school activities. including sports.
3. Have restful sleep free from night-time cough and/or wheeze.
4. Grow and develop normally.
5. Minimise the number of attacks of acute asthma.
6. Avoid hosiptal admissions.

Priniciples of management

A comprehensive therapeutic approach is required to meet the above objectives. This includes the following:

1. Early diagnosis and objective assessment of severity.
2. Control of the environment to exclude cigarette smoke and reduce exposure to triggers such as viral infections and allergens.
3. Optimal use of medications to limit side-effects and cost.
4. Ensure the patient receives the correct therapy by the most appropriate means (see Drug delivery systems).
5. Follow-up and regular re-evaluation.
6. Education of the patient and family which must include:

• Stressing the diagnosis and explaining the nature of the condition.
• Issuing a written plan of management.
• Informing all care givers, including teachers.
• Reassuring parents and patients of safety of continuous regular therapy.

Environmental control

Certain aspects, where practical, need to be emphasised:

1. Cigarette smoking is harmful to asthmatics. Smoking should not be allowed in the home of any asthmatic and active steps should be taken to inform household members of the problem, encouraging any smokers to quit. The need to help their child can be a powerful incentive to parents to quit smoking.
2. In the individual patient where house-dust mites have been shown to be a problem, appropriate control measures should be considered. These include plastic mattress covers, removal of bedroom carpets and washing blankets in hot water (>70 C). Although acaricides such as benzyl benzoate (Acarosan) are able to reduce house-dust mite levels in carptets, they are ineffective when applied to mattresses.
3. Pets should not sleep in children’s bedrooms. In addition, cats should be discouraged as pets in families with allergic children.
4. Certain preservatives can be potent triggers (e.g. benzoates and sulphites) and should be avoided.

Drug delivery systems

The inhaled method is the route of choice as lower doses can be used than with oral medication. Inhalation spacer devices (Aerochamber, Fisionaire, Volumatic) enable parents to administer aerosol therpay to children of all ages. If these spacer devices are not available, spacers can be made from a variety of cheap alternatives e.g. polystyrene cups, plastic bottles. If patients are on long term inhaled therapy, they should preferably use a spacer device rather than a home-made device. The ages at which different inhalers are appropriate are:

1. Spacer devices (with MDI) – birth to 5 years
2. Power devices – over 5 years
3. Metered dose inhalers (MDI) – over 8 years

These recommended age ranges should serve only as a guide as overlap often occurs. Certain devices to improve efficacy of inhaler therapy delivery outside these age ranges are now available e.g. Autohaler, Turbuhaler.

Principles of medication

When selecting medication for an asthmatic patient, the following principles apply:

1. Asthma is an inflammatory disease of the airways.
2. Regular anti-inflammatory medication is indicated for the moderate and severe categories.
3. Where B-2-agonists are used regularly (more than 3 times/week), daily anti-inflammatory therapy should be prescribed.
4. Inhaled therapy is preferable.
5. Syrupts and tablets are not necessarily cheaper.

Anti-Asthma Drugs

Bronchodilators

1. Short-acting B-2-agonists

Short acting B-2-agonists (rather than theophylline) should be used as first line bronchodilators in children because of their wide margin of safety and freedom from serious side-effects. Bronchodilators should be used intermittently for the relief of symptoms rather than as regular maintenance therapy. It is cheaper to use an inhaled B-2-agonist with a spacer than most theophylline preparations.

2. Long-acting B-2-agonists

Formoterol (Foradil) and salmeterol (Serevent) can be used in resistant nocturnal and exercise-induced asthma. When required, these agents should be considered as an addition to anti-inflammatory therapy in children with severe asthma.

3. Theophyllines

Where B-2-agonists or anti-inflammatory agents (inhaled cromoglycate and steroids) are not available, theophylline tablets and aqueous solution can be used for maintenance therapy (Ref. 3). Differing absorption profiles complicate treatment using the long-acting preparations. Controversy as to the correct therapeutic serum levles to advise further complicates theophylline therapy. Practitioners are therefore encouraged to motivate for the availability of anti-inflammatory agents in their institution.

4. Ipratropium bromide (Atrovent)

Ipratropium bromide may be a useful adjunct to regular B-2-agonist therapy in small children (<1 year) in whom cough and/or wheeze are major symptoms.

Anti-inflammatories

1. Sodium cromoglycate (Lomudal)

Sodium cromoglycate (Lomudal) is indicated for the prevention of moderate asthma. It must be taken regularly to be effective to reduce bronchial hyper-reactivity. It is also useful in the prevention of exercise-induced asthma when taken 30 minutes beforehand. Sodium cromoglycate is remarkably safe in children.

2. Ketotifen (Zaditen)

Ketotifen (Zaditen) may be a useful adjunct to bronchodilator therapy in young (<3 years old) highly allergic children who have atopic eczema or hay fever in addition to their asthma.

3. Inhaled steroids

Inhaled steroids should be used for prophylaxis in children with severe asthma. Steroid therapy should be tailored to the response documented by symptoms and, where possible, respiratory function testing. The lowest possible effective dose should be used. For inhaled beclomethasone (Becotide, Clenil, Ventzone, Viartox), doses <400ug/day are associated with minimal side-effects. Where higher doses are required, consideration should be given to using fluticasone (Flixotide) which to date has demonstrated reduced systemic effects. The efficacy and safety of inhaled steroids are increased by the use of spacer devices. Where cromoglycate is not available, low dose inhaled steroids may be considered.

4. Oral steroids

Short corses (+ 14 days) of oral steroids (prednisone 1-2 mg/kg/day) are generally necessary in the treatment of exacerbations of asthma (Ref. 3). Maintenance treatment with daily or alternate-day oral steroids is indicated only in those rare patients not controlled by high-dose inhaled steroids. In children on oral steroids extra care should be taken during episodes of increased stress e.g. surgery.

Other drugs

Antihistamines may be used for the treatment of hay fever in asthmatics with hay fever

Tapering and terminating therapy

Children on anti-asthma therapy should be reviewed at least ever 3 months, and if well controlled should be considered for reduction in treatment. Note that this should not be attempted during the patient’s worst season.

Referral to a specialist

Referral of patients to a specialist is recommended if the goals of management are not achieved, or for the following reasons:

1. Diagnosis in doubt.
2. Unstable asthma.
3. Ashtma interferes with normal life despite treatment.
4. Parents or General Practitioners need further support.
5. When oral steroids are required regularly.
6. After a life-threatening episode.

Unnecessary therapy

The following are without benefit in the treatment of childhood asthma: antibiotics, cough syrups, mucolytics, ionisers and breathing exercises. Physiotherapy is indicated in children only where lobar collapse is doumented. Frequent visits to the physiotherapist must indicate to the practitioner that the patient’s maintenance anti-inflammatory treatment needs revision.

Hazardous therapy

Rectal aminophylline and immunotherapy are dangerous and contra-indicated in childhood asthma.

This article was previously published in the South African Medical Journal and we thank the editor and publisher for allowing us to reprint this article here.
South African Childhood Asthma Working Group. Management of Chronic Childhood and Adolescent Asthma. SAMJ. 1994;84:862-866

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Copyright Allergy Society of South Africa