Asthma in children

It is important not to underestimate the impact of asthma on children and their families.This update focuses on getting both the diagnosis and management of asthma in children right and how you can use the current British asthma guidelines to improve care

Asthma is the most common medical condition in children, with more than 1 million children in the UK currently receiving asthma treatment, and on average, three children with asthma in every school class.¹ The burden of asthma on children, young people and their families is high; quality of life is reduced and the use of healthcare resources is increased compared with those without asthma.²

THE IMPACT OF ASTHMA ON CHILDREN AND FAMILIES

Reduced quality of life in children with asthma and their family is common, with issues such as school absence, parental work absence, sleep deprivation and inability to participate in activities frequently reported.³ One study found that asthma caused activity restriction in 39% of families and caused lifestyle changes in 70%.⁴ Furthermore, there is a range of evidence confirming that poor asthma control is linked to poor quality of life.^5,6 Parental perceptions and perspectives may differ from those of the child with asthma therefore effective management strategies will require health professionals to consider both (see Table 1). Anxiety and depression in children with asthma further impacts upon health related quality of life and is an important consideration because at least 10% of children and young people experience mental health problems and there is significant overlap with those with long-term conditions.⁸

Tip

Try asking ‘If we could make one thing better about your/your child’s asthma what would you want it to be?’ The response will give you some idea of what is of greatest concern to the child/family and what might be motivating factors for gaining and maintaining control.

DIAGNOSIS

Asthma is currently over-diagnosed, but the trend in diagnosis rates resembles a pendulum, swinging one way and then the other.⁹ The current British asthma guidelines offer a clear diagnostic pathway utilising the helpful principle of ‘probability’ as the foundation for diagnosis.⁷ Diagnosing asthma is difficult in all age groups and even more so in young children who are unable to perform diagnostic tests. Children may be unable to clearly describe their symptoms or when they occur, for example a tight chest may be described as a ‘tummy ache’. History taking is fundamental and arguably the most important aspect in the diagnosis of asthma. The history is most likely to be provided by the parent or other carer and its reliability may therefore be affected by parental perceptions and interpretations of their child’s symptoms. Nonetheless, a good history should enable the health professional to determine an index of suspicion, that is the likelihood or probability of asthma (see table 2).

Probability will enable competent asthma trained health professionals to easily identify children in whom asthma is both highly likely (high probability) and highly unlikely (low probability). Often there are features in a child’s history that both increase and decrease the likelihood of asthma (intermediate probability) which parents and health professionals alike may find difficult to understand or interpret. There is no single test that can definitely confirm whether a child has asthma;⁷ it is only in understanding this that parents and health professionals can work together over a period of time to ensure any diagnosis made is accurate. The implications of an asthma diagnosis on a child and family are significant and there are also financial implications for the NHS, therefore getting the diagnosis right is vital.

A structured clinical assessment includes a review of the child’s medical records in addition to history taking. It is important to identify any historical record of features that might increase or decrease the probability of asthma. For example, a history of wheeze heard on auscultation by a health professional is an important feature that, depending on its context, provides helpful information. Wheezing is common in young children but does not necessarily mean that a child has asthma.⁷ If wheezing occurs only when a child has a cold (episodic viral wheeze) it is less likely to indicate asthma (lower probability) but if it occurs in response to other triggers too such as exertion, perfumes/air fresheners or exposure to animals (multiple trigger wheeze) it is more likely to indicate asthma (higher probability). Parents’ perception of what wheeze actually is varies, therefore wheeze heard on auscultation by a health professional and documented in the child’s medical record is more reliable that parent-reported wheeze.

The structured clinical assessment will be supported by clinical examination to identify any abnormality that may be consistent with asthma or an alternative diagnosis. Visual observation of the chest is useful in children therefore removal of clothing on the torso is essential.

• Chronic air trapping or hyperinflation is often evident in children who have had uncontrolled respiratory symptoms for some time; look for any abnormal chest shape.
• Auscultation of the chest may reveal wheeze (a high-pitched sound usually heard on expiration) indicating current bronchoconstriction but remember asthma is variable and the child may not be symptomatic at the time of examination.
• Observation of the child’s fingers and nails for any abnormality is helpful; for example, finger clubbing is a feature not usually seen in asthma but could indicate a cardiac condition and therefore if observed requires immediate specialist referral.
• A child’s skin should be observed for dryness or excoriation, which could suggest eczema and if present increases the probability of asthma.
• Observe the child’s face looking for signs of allergy such as a nasal crease or allergic shiners.

If, based upon the structured clinical assessment, asthma is suspected, objective testing should be carried out where possible to assist in confirming the diagnosis. Until the diagnosis can be confirmed the recorded code to use is “suspected asthma”.

Spirometry with reversibility testing is the preferred method for asthma diagnosis; in children, a 12% improvement in FEV1 post bronchodilator is considered a positive reversibility test. In theory, spirometry can be performed by some children from about 5 or 6 years of age, however in practice children are likely to older before they can complete full diagnostic spirometry. Post bronchodilator spirometry is usually only carried out if there is spirometric evidence of pulmonary obstruction; however, as normal values for children differ from adults the Lower Limit of Normal (LLN) must be used when interpreting spirometry in children. Currently there is limited access to paediatric quality assured diagnostic spirometry in the UK and other methods are more commonly used for asthma diagnosis.¹⁰

Peak expiratory flow rates (PEFR) can demonstrate variability which would support an asthma diagnosis, and measurements can be performed by children from about 5 or 6 years of age. However, the reliability of this method depends on a number of factors including patient technique and accurate recording of at least twice daily measurements over a 2-4 week period. Many children cannot reliably perform PEFR measurements until they are older and concordance with twice-daily measurements is often poor. Current British asthma guidelines do not recommend this method for diagnostic purposes in children.

Fractional Exhaled Nitric Oxide (FeNO) is an emerging method that can demonstrate inflammation in the airways. However, at present it is not well understood or widely available thus its use, particularly in primary care, is limited.

A trial of treatment (with ICS) is a common diagnostic technique for asthma in children. The theory being that if, based upon probability, asthma is suspected, and symptoms respond to a 6-8 week trial of ICS then the likelihood of asthma is increased. Caution is needed as the symptoms may have resolved spontaneously and it is wise to stop the ICS and monitor the child for returning symptoms, which will occur if the child has asthma.

Tip

When initiating trial of treatment in a child with suspected asthma remember to ensure parents are fully informed at the outset and understand that even if the response appears to be good, the next logical step will be to stop the trial and monitor for returning symptoms.

ASTHMA MANAGEMENT

Once an asthma diagnosis is made, the goal of management is to maintain control on the lowest possible dose of medication. ICS is the first-line treatment of choice and should be initiated in all children with asthma; very low dose or low dose is recommended depending on the age of the child.⁷ The range of drugs licenced for use in children is limited and Clenil 50mcgs 2 puffs twice a day (very low dose) or Clenil 100mcgs 2 puffs twice a day (low dose) is the usual starting point. Parents may be concerned about steroids but should be reassured that ICS is the most effective treatment for controlling asthma and that in recommended doses is very safe; guidelines suggest not exceeding 400mcgs per day (low dose) in under 5s and 800mcgs per day (medium dose) in 5-12 year olds; beyond this specialist referral is required.

Tip

Prescribers must remember that not all ICS products are dose equivalent and therefore must be prescribed by brand name.

Montelukast, an anti-leukotreine drug with some anti-inflammatory properties, is an option in children under 5 years of age who cannot take ICS, however ICS remains the first-line choice of regular prevention treatment. Montelukast can also be added to treatment in children already taking ICS but whose asthma is not fully controlled. Long-acting bronchodilators (LABA) are another add-on option for children over 5 years of age uncontrolled on ICS alone. LABA must always be used in conjunction with ICS, therefore the use of combination inhalers is recommended as this will avoid the risk of LABA being taken as monotherapy. Recently, Symbicort for use as both Maintenance and Reliever Therapy (SMART) became licenced from 12 years of age, and this may be an option to consider in some adolescents whose asthma is poorly controlled. However, full assessment of the reasons for poor control must be undertaken and managed as appropriate.

Tip

Growth, or failure to grow as expected, is an important marker of a child’s health and wellbeing. Parents will be reassured that their child’s growth is being monitored regularly. To monitor a child’s growth accurately, height (ideally measured using a Leicester height measure) and weight must be plotted on an appropriate centile chart and compared with previous records (see resources).

INHALER TECHNIQUE

Effective inhaler technique is of critical importance and is likely to need some time, patience and skill on the part of both health professional and parent/s to achieve. Most children with asthma use pressurised Metered Dose Inhalers (pMDI) with a spacer but, when older, other options include Dry Powder Inhalers (DPI) or Breath-Actuated pMDIs. Very young children will need a spacer with a facemask but once they can tidal breathe reproducibly through a mouthpiece there is no further need for the mask; indeed a spacer without a mask is preferred as soon as possible as drug deposition in the airways will be improved. Most children can use a spacer without a mask from 3 or 4 years of age. The UK Inhaler Group¹¹ recently published a set of national standards for inhaler technique and these are a useful guide for the steps to follow when teaching or assessing patient’s inhaler technique.

Tip

Prescribe a ‘play’ spacer when first starting a young child on inhaled therapy. This can become a ‘normal’ object and creative games can include giving teddy or dolly their inhaler when they have a cough.

ASTHMA CONTROL

Control of asthma is measured by the frequency and severity of symptoms and by markers of lung function. Consideration must be given to both current control and future risk of asthma attacks. Current symptom control is best assessed by use of a validated tool such as the Asthma Control Test (ACT) from 12 years and the Childhood Asthma Control Test (C-ACT) from 3-11 years of age, or the Asthma Control Questionnaire (ACQ).⁷ Not only will the score of the test provide a marker of current control, it will also be a useful benchmark for ongoing assessment. Questionnaires can be completed in the waiting room prior to the appointment. The need for short acting bronchodilators (SABA) is a critical marker of asthma control and regular use three times a week or more is a firm indicator of poor control. Assessment must consider the fact that some patients use SABA habitually and this practice should be actively discouraged. Any asthma attack is considered a complete loss of asthma control and a risk factor for future asthma attacks, therefore careful monitoring while control is regained and subsequently maintained is important. Assessment of lung function is useful and PEF measurements, ideally compared to the child’s previous best, less than 80% are an indicator of poor control.

Common reasons for poor asthma control are:

• Failure to take prevention treatment regularly as prescribed
• Poor inhaler technique resulting in sub-optimal doses of drug delivery to the airways
• Ongoing exposure to trigger factors
• Inadequate levels of treatment for the current disease severity (bearing in mind that asthma severity varies over time, and also that children’s treatment requirements may increase with advancing age).

Tip

Never increase treatment in a patient with poor asthma control without firstly ensuring that they are using their existing prevention treatment correctly and regularly as prescribed.

SELF-MANAGEMENT

Self-management support must be tailored to the individual therefore consideration of a range of factors are necessary.¹² The child’s age and ability to understand will primarily guide the focus of education and skill is necessary to involve both the child and parent/s in an effective manner. Any language barrier must be addressed, and often family members who speak English will attend to help. Remember to consider the child and parent’s lifestyle and address relevant issues such as home situation, hobbies, parents work and school. Every child with asthma must have a Personalised Asthma Action Plan and they/their family understand how to use it.⁷ The plan itself is a useful educational tool that can be used to guide education. For example the plan should have sections clearly identifying good asthma control (what every patient should be aiming for), worsening asthma (warning signs) and an asthma attack (emergency). These section can be discussed during the consultation and advice around actions to take specified.

Tip

Asthma UK asthma action plans for both children and adults (12 years+) are available to download and can also be embedded in the Emis Web system which means that it can be automatically saved to the patient record. Asthma UK also offers an excellent range of materials, including booklets and sticker charts, to support children and their families (see resources).

CONCLUSION

Asthma is common in children but getting the diagnosis right is of prime importance. A structured clinical assessment and the use of ‘probability’ provides a solid foundation for accurate diagnosis but until certain, the code ‘suspected asthma’ should be used. Parents must be fully informed and engaging both child and parents in the process of diagnosis and management will enable an effective partnership in care to develop. ICS remains the cornerstone of asthma management and most children with asthma respond well to very low or low doses. There are options for add-on therapy in those children who are not completely controlled on ICS alone but specialist paediatric opinion should be sought if there is difficulty gaining control with standard treatment. Inhaler technique is a key issue in paediatric asthma management and time must be taken at every consultation to carefully check that a child can use their inhaler correctly. Self-management support is an ongoing process and includes tailored education in addition to the development of a personalised Asthma Action Plan.

REFERENCES

1. Asthma UK. Asthma facts and statistics, 2017 https://www.asthma.org.uk/about/media/facts-and-statistics/

2. Wolfe I, Cass H, Thompson MJ, et al. Improving child health services in the UK: insights from Europe and their implications for NHS reforms. BMJ 2011;342:d1277

3. Asthma UK. Asthma Impact Survey 2016 Report

4. Carroll W, Wildhaber J, Brand P. Parent misperception of control in childhood/adolescent asthma: the Room to Breathe survey. Eur Resp J 2011;39(1): 90-96.

5. Gandhi P, Kenzik K, Thompson L, et al. Exploring factors influencing asthma control and asthma-specific health-related quality of life among children. Resp Res 2013;14(1):26.

6. Brand P, Makela M, Szefler S, et al (2015) Monitoring asthma in childhood: symptoms, exacerbations and quality of life. Eur Resp Rev 2015;24(136), pp.187-193.

7. BTS/SIGN. British guideline on the management of asthma, 2016. https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/

8. Department of Health and NHS England. Future in mind: Promoting, protecting and improving our children and young people’s mental health and wellbeing, 2015

9. Bush A, Fleming L. Is asthma overdiagnosed?. Arch Dis Child 2016;101(8):688-689.

10. Murray C, Foden P, Lowe L, et al. Diagnosis of asthma in symptomatic children based on measures of lung function: an analysis of data from a population-based birth cohort study. The Lancet Child & Adolescent Health, July 2017. DOI: http://dx.doi.org/10.1016/S2352-4642(17)30008-1

11. UK Inhaler Group. Inhaler standards and competency document, 2016. respiratoryfutures.org.uk/media/69775/ukig-inhaler-standards-january-2017.pdf

12. Pinnock H, Epiphaniou E, Pearce G, et al. Implementing supported self-management for asthma: a systematic review and suggested hierarchy of evidence of implementation studies. BMC Medicine 2015;13: 127. https://doi.org/10.1186/s12916-015-0361-0

Answers to Probability Activity 

Tilly: Probability – Low

Tom: Probability – Intermediate

Tania: Probability – High