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Children should ideally experience no or minimal asthma-related symptoms, have little need for the use of rescue medications, have very infrequent exacerbations, and have no limitation to their daily activities including sport, 5 and this should all be achieved using the fewest possible medications. The cornerstone of asthma management is pharmacotherapy, which should always occur simultaneously with the avoidance of asthma triggers and the treatment of comorbidities.

Inhaled short-acting beta-agonists eg, salbutamol should always be readily available for asthma patients for when they experience asthma symptoms. Inhaled beta-agonists are the first-line treatment for relieving symptoms of acute asthma. School-aged children should always carry a short-acting beta-agonist in their school bags and an additional short-acting beta-agonist should be kept on the school premises.

As pressurized metered dose inhalers pMDIs should be used in conjunction with valved holding chambers, older children and adolescents often prefer taking smaller, unobtrusive dry powder beta-agonist inhalers to school. In such situations, it is important that a pMDI should also be available at the school in case of a severe asthma episode when the child may have difficulty using a dry powder inhaler.

Anticholinergics such as ipratropium bromide offer little benefit as an add-on bronchodilator treatment during acute asthma exacerbations and hence have a limited role in treating bronchoconstriction in children. Various options are available, as presented below. Inhaled corticosteroids form the basis of asthma preventer therapy in childhood. Inhaled corticosteroid use improves asthma symptoms and lung function, and reduces asthma exacerbations and hospitalizations.

While there will be rare individuals who respond better to a particular inhaled corticosteroid, the most common reason that children do not respond to their Outpatient management of asthma in children treatment is that they are either not taking it as prescribed or their device technique is poor.

Inhaled corticosteroids are usually prescribed for regular, daily, or bidaily use. There is some evidence in young children that intermittent high dose use of inhaled corticosteroids ie, a 2-week course initiated at the start of an exacerbation is not inferior to daily inhaled corticosteroids and may lead to lower steroid exposure than daily regimens. The modest delay appears not to be progressive or cumulative but may persist as a reduction in final adult height. The risk versus benefit of inhaled corticosteroids treatment for asthma needs to be considered on a case-by-case basis as uncontrolled asthma is not only associated with significant morbidity but also associated with growth impairment.

Long-acting beta-agonists in combination therapy. Montelukast has been proven to be effective in the treatment of pediatric asthma and provides a therapeutic alternative for patients with mild persistent asthma, exercise-induced asthma, and aspirin-sensitive asthma.

For moderate to severe persistent asthma, montelukast is inferior to inhaled corticosteroid treatment. The favourable side effect profile of montelukast makes it an excellent treatment choice where asthma can be well-controlled without the need for additional treatment. Montelukast can also be used as an add-on therapy to inhaled corticosteroids.

While the vast majority of children with asthma will achieve good symptom control with the use of inhaled corticosteroids with or without additional long-acting beta-agonists or leukotriene antagonists, there are a small number of children with severe asthma who need to try additional treatment options. These include the following treatments. Nedcromil sodium and sodium cromoglycate can be helpful in the management of individuals with severe exercise induced asthma.

Oral theophylline is a bronchodilator with additional anti-inflammatory properties. Omalizumab is an anti-IgE antibody that is administered by regular ie, fortnightly subcutaneous injections. Omalizumab reduces symptoms and exacerbations and improves lung function as well as quality of life in children with atopic asthma. Methotrexate, cyclosporine, azathioprine, mycophenolate mofetil, anti-TNF alpha, interferon gamma, and mepolizumab anti-IL-5 are drugs that are very rarely used in asthma that does not respond to conventional therapy. Regular systemic corticosteroids are not routinely used in asthma management in the outpatient setting.

The prescription of short courses of oral prednisolone for parents to administer at the start of an asthma exacerbation can be considered.

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Children with asthma should be monitored regularly to reassess asthma control and fine-tune treatment. Tools to determine asthma control, for example, asthma symptoms, spirometry, and biomarkers have been mentioned above. A distinction between current impairment and future risk needs to be made. Standardized questionnaires offer objective measures of current impairment.

Lung function testing offers an objective physiological marker of asthma control. Lung function should only be performed and interpreted where the necessary expertise is available. Home peak expiratory flow measurement, as a marker of airway obstruction and reactivity, has been shown to often be unreliable in children.

Asthma risk can be estimated by the number of exacerbations per year and side effects of medication. Children often have few interval symptoms but regular exacerbations. Asthma exacerbations are associated with a decline in lung function, which is accelerated in patients not treated with inhaled corticosteroids.

The stepping up and stepping down of asthma therapy at outpatient visits is based on asthma control, 17 interval symptoms, and risk. In a patient being treated with low dose inhaled corticosteroids the following options can be considered: increasing the dose of inhaled corticosteroids, adding a long acting beta-agonist, or adding montelukast.

Optimal response to the choice of step-up treatment will vary between individual patients, and asthma control is likely to improve with any of the step-up regimens. The main delivery devices used to deliver inhaled therapy to the airways in children with asthma are pMDIs with valved holding chambers, dry powder inhalers, and nebulizers.


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Each delivery method has specific advantages and disadvantages. Conversely, the use of pMDIs without holding chambers often result in very poor drug delivery in children. They offer the advantage of rapid drug delivery and can be used in very young children. Children as young as 2 years of age can be taught to use the mouthpiece of a holding chamber, 43 but guidelines still advocate for the use of a mask on a holding chamber for children under 4 years of age.

Drug delivery via holding chamber can be greatly reduced by the buildup of electrostatic charge over time. In Britain and Australia, parents are encouraged to wash plastic holding chambers in a mild detergent solution every 2 weeks in order to reduce electrostatic buildup. Dry powder inhalers are small and inconspicuous but can only be effectively used in children old enough to generate 30 to 60 litres per minute on inhalation through the inhaler.

Because of their size and bulkiness, the need to clean regularly, the time taken for drug delivery, and little to no clinical benefit over other delivery systems, nebulizers are not recommended or commonly used for the delivery of asthma preventer medications and should not be seen as first-line delivery devices. Correct device use and inhalation technique is crucial for optimal aerosol drug delivery. Inhalation technique in children is often suboptimal even after instruction.

The pMDI of certain drugs should be shaken just before actuation in order to mix the drug with the propellant. The time delay between actuation of the pMDI and inhalation through a holding chamber should be minimized as time delay reduces the available dose. Two to 3 tidal breaths are all that are required to empty most holding chambers. Where more than 1 actuation is required, additional actuations should follow inhalation of the initial dose and repeated shaking of the pMDI. A review on correct device use for different inhaler devices has recently been published.

Nonadherence or poor compliance with prescribed treatment is a major reason for suboptimal asthma control that should always be considered in the outpatient setting. Electronic adherence monitors provide the gold standard for adherence measurement, and certain devices providing reminders to patients to use their medications at preprogrammed intervals appear to improve adherence. Reasons for nonadherence are complex. Children are dependent on their parents for the administration of their medication. Parents sometimes pass the responsibility of medication administration on to the child before the child is old enough to take the responsibility.

In addition to asking about adherence, health care providers should ask about medication routines and who takes responsibility for them. A recent study demonstrated improved adherence and symptom control in adolescents after an 8-week long school-based intervention program. The outpatient setting is an ideal opportunity to ensure that a patient has an asthma action plan. All asthma patients or their parents should be well-informed on the best way to manage exacerbations.

A written action plan provides the necessary information for exacerbation management in an easily accessible format for use in an emergency. Appropriate counseling and support regarding smoking cessation should be provided to parents and adolescents where appropriate. Previous studies have demonstrated that taking atopic children with severe asthma out of their usual environment to a low allergen high altitude environment improves asthma control and airway reactivity and reduces airway inflammation.

Hence, while allergy testing may occasionally be helpful for individual patients with atopic asthma, the evidence for house dust mite and pet avoidance strategies as a management strategy of asthma remains weak, 70 and the avoidance of grass or tree pollen exposure is not usually practically feasible. As food allergens rarely play a role in asthma, dietary changes are not part of routine asthma management.

Acetamonophen use has been associated with the development of asthma as well as asthma symptoms. Hence, with current evidence, acetaminophen avoidance cannot be recommended in children with asthma. Asthma control with the lowest possible dose of medication is best obtained when comorbidities associated with asthma are managed. A strong association exists between asthma control and allergic rhinitis. Allergic rhinitis is common among asthma sufferers, and treatment of the rhinitis has a beneficial effect on asthma control.

Obstructive sleep disordered breathing is common in children with poorly controlled asthma. The management of sleep disordered breathing in children is discussed in detail elsewhere. Vitamin D plays a complex role in immune regulation, and there are associations between vitamin D and lung function, markers of inflammation, and response to corticosteroids. Treatments that are of no benefit and that may cause harm should be avoided.

Untreated gastroesophageal reflux has been postulated to be an aggravating factor in children with asthma. Symptoms of gastroesophageal reflux are common in asthma patients 83 and proton pump inhibitors are commonly used to treat these symptoms. A subgroup of children with proven gastroesophageal reflux diagnosed by esophageal pH monitoring did not show any improvement in asthma control in spite of 24 weeks of treatment with a proton pump inhibitor. Notably, the group treated with proton pump inhibitors had a 6-fold increase in activity-related bone fractures.

The use of proton pump inhibitors cannot therefore be recommended for the treatment of pediatric asthma. Parents of children with chronic disease often explore alternative medicine options.

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An awareness of available alternative medicine options is useful for clinicians managing children with asthma. Commonly used treatments include chiropractics, osteopathy, homeopathy, herbal medicines, use of salt rooms, yoga, and breathing exercises, among others. With the exception of breathing exercises, none of the therapies mentioned above have been shown to be of any clinical benefit as asthma treatments in rigorously designed scientific studies.

Breathing exercises have been shown to modestly improve asthma symptoms and reduce preventer use in adults with asthma. There is not enough evidence to recommend breathing exercises for the routine treatment of pediatric asthma. In order to achieve optimal health outcome, a functional partnership needs to be established between the doctor and the child-parent unit. The patient should understand the effect of treatment and the importance of adherence to medication during symptom free periods.


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Potential treatment side effects should be discussed openly so that parental concerns can be addressed. Asthma education is a continuous process needing regular repetition, especially when considering the practical aspects of device use. With a well-functioning doctor-patient partnership the majority of children with asthma can be effectively managed with low dose preventative treatment. Regular review of the basics ie, inhaler technique, adherence to treatment, trigger avoidance, comorbidities is the key to providing good clinical care for children with asthma.

Author Contributions. Wrote the first draft of the manuscript: AS. Contributed to the writing of the manuscript: ACM. All authors reviewed and approved of the final manuscript. Competing Interests. Disclosures and Ethics. As a requirement of publication the authors have provided signed confirmation of their compliance with ethical and legal obligations including but not limited to compliance with ICMJE authorship and competing interests guidelines, that the article is neither under consideration for publication nor published elsewhere, of their compliance with legal and ethical guidelines concerning human and animal research participants if applicable , and that permission has been obtained for reproduction of any copyrighted material.

This article was subject to blind, independent, expert peer review. The reviewers reported no competing interests. Provenance: the authors were invited to submit this paper. National Center for Biotechnology Information , U. Clin Med Insights Pediatr. Published online Apr Martin 1, 3.

Andrew C. Find articles by Andrew C. Author information Copyright and License information Disclaimer. Corresponding author email: ua. This is an open access article. Unrestricted non-commercial use is permitted provided the original work is properly cited. This article has been cited by other articles in PMC. Abstract The principal aims of asthma management in childhood are to obtain symptom control that allows individuals to engage in unrestricted physical activities and to normalize lung function.

Keywords: asthma, children, wheeze, management. Introduction Asthma is one of the most common chronic diseases in childhood, resulting in significant morbidity and health care expenditure. Diagnosis of Asthma Asthma may be underdiagnosed or overdiagnosed, depending on the presentation and the clinician involved. Table 1 Differential diagnosis of wheeze children. Open in a separate window. Investigations Spirometry Spirometry is particularly useful to confirm a diagnosis of asthma. Bronchial challenge testing In children where the diagnosis of asthma remains unclear following history, examination, and spirometry, bronchial challenge tests may be helpful.

Other investigations A chest X-ray may occasionally be useful to rule out other pathology. Asthma Severity Versus Asthma Control The separate concepts of asthma severity and control are used to conceptualize the disease of individual asthma patients. Pharmacotherapy Short-acting bronchodilators Inhaled short-acting beta-agonists eg, salbutamol should always be readily available for asthma patients for when they experience asthma symptoms.

Inhaled corticosteroids Inhaled corticosteroids form the basis of asthma preventer therapy in childhood. Long-acting beta-agonists can be used in combination with inhaled corticosteroids as step-up treatment when symptoms are not controlled by inhaled corticosteroids alone. Cystenyl leukotriene antagonists Montelukast has been proven to be effective in the treatment of pediatric asthma and provides a therapeutic alternative for patients with mild persistent asthma, exercise-induced asthma, and aspirin-sensitive asthma. Cromones Nedcromil sodium and sodium cromoglycate can be helpful in the management of individuals with severe exercise induced asthma.

Theophylline Oral theophylline is a bronchodilator with additional anti-inflammatory properties. Omalizumab Omalizumab is an anti-IgE antibody that is administered by regular ie, fortnightly subcutaneous injections. Treatments rarely considered for use in severe asthma Methotrexate, cyclosporine, azathioprine, mycophenolate mofetil, anti-TNF alpha, interferon gamma, and mepolizumab anti-IL-5 are drugs that are very rarely used in asthma that does not respond to conventional therapy. Prescription of parent-initiated oral corticosteroids for home use Regular systemic corticosteroids are not routinely used in asthma management in the outpatient setting.

Asthma monitoring Children with asthma should be monitored regularly to reassess asthma control and fine-tune treatment. Stepping up and stepping down therapy The stepping up and stepping down of asthma therapy at outpatient visits is based on asthma control, 17 interval symptoms, and risk. Delivery systems for inhaled therapy The main delivery devices used to deliver inhaled therapy to the airways in children with asthma are pMDIs with valved holding chambers, dry powder inhalers, and nebulizers.

Importance of correct technique Correct device use and inhalation technique is crucial for optimal aerosol drug delivery. Adherence to prescribed treatment Nonadherence or poor compliance with prescribed treatment is a major reason for suboptimal asthma control that should always be considered in the outpatient setting.

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Action plans The outpatient setting is an ideal opportunity to ensure that a patient has an asthma action plan. Comorbidities associated with poor asthma control Asthma control with the lowest possible dose of medication is best obtained when comorbidities associated with asthma are managed. Allergic rhinitis A strong association exists between asthma control and allergic rhinitis.

Pediatric Asthma Care at Children’s National

Obstructive sleep disordered breathing Obstructive sleep disordered breathing is common in children with poorly controlled asthma. Vitamin D deficiency Vitamin D plays a complex role in immune regulation, and there are associations between vitamin D and lung function, markers of inflammation, and response to corticosteroids.

Avoidance of treatment that is of no benefit or potentially harmful Treatments that are of no benefit and that may cause harm should be avoided. Proton pump inhibitors Untreated gastroesophageal reflux has been postulated to be an aggravating factor in children with asthma. Alternative medicine Parents of children with chronic disease often explore alternative medicine options.

Asthma Education and Partnership With the Child and Family In order to achieve optimal health outcome, a functional partnership needs to be established between the doctor and the child-parent unit. Competing Interests Author s disclose no potential conflicts of interest. Disclosures and Ethics As a requirement of publication the authors have provided signed confirmation of their compliance with ethical and legal obligations including but not limited to compliance with ICMJE authorship and competing interests guidelines, that the article is neither under consideration for publication nor published elsewhere, of their compliance with legal and ethical guidelines concerning human and animal research participants if applicable , and that permission has been obtained for reproduction of any copyrighted material.

Funding Author s disclose no funding sources. References 1. Early rattles, purrs and whistles as predictors of later wheeze. Arch Dis Child. Prevalence of viral respiratory tract infections in children with asthma. J Allergy Clin Immunol. A clinical index to define risk of asthma in young children with recurrent wheezing.

Global Initiative for Asthma. Updated Dec Classifying asthma severity in children: mismatch between symptoms, medication use, and lung function. Cut-off points defining normal and asthmatic bronchial reactivity to exercise and inhalation challenges in children and young adults. Eur Respir J. Cockcroft DW. Direct challenge tests: Airway hyperresponsiveness in asthma: its measurement and clinical significance. Mannitol dry powder challenge in comparison with exercise testing in children.

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The Thriving Child : Parenting Successfully Through Allergies, Asthma, and Other Common Challenges

Write a review Rate this item: 1 2 3 4 5. Preview this item Preview this item. Allow this favorite library to be seen by others Keep this favorite library private. Find a copy in the library Finding libraries that hold this item A prescriptive guidebook for parents describes the author's struggles to diagnose and protect her allergy-sufferer daughter, recounting how she detoxified her home, changed the family's diet, and learned whole-child disciplinary strategies. Reviews User-contributed reviews Add a review and share your thoughts with other readers.

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