Asthma affects about 7 million children, and caused about 10.5 million missed school days in 2008.(1,2) Higher prevalence among African Americans, Puerto Ricans, lower socioeconomic classes, residents of the Northeast, and boys up to age 14. Characterized by a shift to Th2 phenotype resulting in eosinophil recruitment, inflammation, and allergy. Linked to Western lifestyle, urban living, dust mites, other allergens, antibiotic use, diet, and respiratory infections during infancy. 2007 National Heart, Lung, and Blood Institute (NHLBI) Expert Panel Report 3 recommends 4 components of effective asthma care.(3)
Step 1: Accurate Diagnosis with history, physical, albuterol response, spirometry: before bronchodilator: FEV1
Step 2: Assess Severity. Classification in pediatric patients determined by lowest level of treatment needed for control. Monitor therapeutic efficacy every 1 to 6 months. Encourage self-monitoring by patient or family with daily diary or self-assessment forms. Expert Panel Report III
Patient, parent education, and collaboration are key from diagnosis onward. All patients should have a written asthma action plan containing specific names of daily medications; ways to control environmental factors; specific ways to recognize and deal with worsening symptoms, including which medications to take and when to seek emergency treatment; and key phone numbers (physician and ED). Expert Panel Report III
CLASSIFICATION OF ASTHMA SEVERITY IN CHILDREN 0-4 YEARS NOT RECEIVING LONG-TERM CONTROLLER MEDICATION (3)Expert Panel Report III
CLASSIFICATION OF ASTHMA SEVERITY IN CHILDREN 5-11 YEARS NOT RECEIVING LONG-TERM CONTROLLER MEDICATION (3)Expert Panel Report III
Requires multifaceted approach to reduce allergens; consider immunotherapy in patients with documented reaction to a specific antigen; toll-free hotlines with information about reducing allergen exposure, including specific products: Asthma and Allergy Foundation of America 800-727-8462; Allergy and Asthma. Expert Panel Report III
Step-wise approach tailored to patient’s needs and age (0-4 years, 5-11 years, and 12 or older). Intermittent asthma: quick-acting inhaled β2-selective agonist for symptom relief; Apparent mild persistent asthma: first line is low-dose inhaled corticosteroid (ICS); Apparent mild persistent asthma in children under age 4: budesonide first line, followed by montelukast in children over 1 year. Expert Panel Report III
Moderate persistent asthma: medium-dose daily ICS. Referral to asthma specialist if a child needs more than medium-dose ICS, or if under age 4 and does not meet therapy goals by 3 to 6 months; Consider: Spacers for patients of all ages, especially those under age 4. Home nebulizers in young children, especially those under 12 months. Expert Panel Report III
Upwards of 50% to 80% of children who have asthma experience symptoms before the age of 5 years. Diagnosis is not straightforward in this age group, and asthma may be misdiagnosed as chronic bronchitis, wheezy bronchitis, reactive airway disease, recurrent pneumonia, gastroesophageal reflux, and recurrent upper respiratory tract infections.As a reminder of the importance of fully exploring recurrent respiratory symptoms in your young patients, the slides here distill the 4 primary components of effective asthma care as put forth in 2007 in the National Heart, Lung, and Blood Institute’s (NHLBI) Expert Panel III Report.
References:
1. Van Garsse A, Magie RD, Bruhnding A. Pediatric asthma for the primary care practitioner. Prim Care. 2015;42:129-142. http://www.ncbi.nlm.nih.gov/pubmed/?term=10.1016%2Fj.pop.2014.09.013.
2. Akinbami L, Moorman J, Liu X. Asthma prevalence, health care use and mortality: United States, 2005-2009. National Health Statistics Reports. US Department of Health and Human Services; Hyattsville (MD): Centers for Disease Control and Prevention; 2011 (32). http://www.cdc.gov/nchs/products/nhsr.htm. Accessed February 1, 2015.
3. Expert Panel report 3 (EPR3): guidelines for the diagnosis and management of asthma. Bethesda (MD): National Heart, Lung, and Blood Institute; 2007. (NIH publication no 08-4051). http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed February 9, 2015.
