Asthma in children Dr Gulamabbas Khakoo BMBCh, FRCPCH Consultant Paediatrician, Hillingdon Hospital Consultant in Department of Paediatric Asthma, Allergy and Immunology, St Mary’s Hospital, W2

Talk outline BTS / SIGN 2008 guidelines Diagnosing asthma Inhaled steroids Allergy and asthma Allergic rhinitis

2008 BTS / SIGN guideline on the management of asthma in children The British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) together publish the evidence-based British Guideline on the Management of Asthma. The guideline is intended to be a comprehensive resource for those caring for individuals in asthma, whether in the community or hospital. The asthma guideline is regularly updated to incorporate the results of the latest research. BTS=British Thoracic Society; SIGN=Scottish Intercollegiate Guidelines Network. Pharmacological management. Thorax 2008;63(Suppl IV):iv1-iv121 Reference Pharmacological management. Thorax 2008;63(Suppl IV):iv1-iv121

2008 Guidelines 2.1 DIAGNOSIS IN CHILDREN (1) Clinical features that increase the probability of asthma More than one of the following symptoms: wheeze, cough, difficulty breathing, chest tightness, particularly if these symptoms: are frequent and recurrent are worse at night and in the early morning occur in response to, or are worse after, exercise or other triggers, such as exposure to pets, cold or damp air, or with emotions or laughter occur apart from colds Personal history of atopic disorder Family history of atopic disorder and/or asthma Widespread wheeze heard on auscultation History of improvement in symptoms or lung function in response to adequate therapy

2008 Guidelines 2.4 DIAGNOSIS IN CHILDREN (2) Clinical features that lower the probability of asthma Isolated cough in the absence of wheeze or difficulty breathing History of moist cough Prominent dizziness, light-headedness, peripheral tingling Repeatedly normal physical examination of chest when symptomatic Normal PEF or spirometry when symptomatic No response to a trial of asthma therapy Clinical features pointing to alternative diagnosis

2008 Guidelines Failure to gain weight Clinical features pointing to another diagnosis: Failure to gain weight Clubbing Fatty stools Productive sputum Other chest findings eg crackles, unequal BS Inspiratory noises Barking cough Early onset rhinorhoea GOR symptoms Absence of nocturnal symptoms

CHILD with symptoms that may be due to asthma Clinical assessment High Probability Intermediate Probability Low Probability Trial of Treatment Response? Asthma diagnosis confirmed Continue Rx and find minimum effective dose No Assess compliance and inhaler technique. Consider further investigation and/or referral Consider tests of lung function and atopy Consider referral Investigate/treat other condition Response? Yes Further investigation Consider referral No Yes Continue Rx 7

Inhaled steroids Inhaled steroids should be considered for patients with any of the following asthma-related features: exacerbations of asthma in the last two years using inhaled β2 agonists three times a week or more symptomatic three times a week or more waking one night a week.

General advice Follow SIGN / BTS guidelines 2008 Correct inhaler device and technique Compliance issues Written asthma plans

Children age 5-12 yrs

Children age 5-12 yrs

Children age 5-12 yrs

Children age 5-12 yrs

Children age 5-12 yrs

Children age 5-12 yrs

Children Less than 5 yrs

Children Less than 5 yrs

Children Less than 5 yrs

Children Less than 5 yrs

Children Less than 5 yrs

Using the guidelines Non-compliance with inhaled steroids up to 70% or more in very young and teenagers Inhaler technique needs checking regularly Large volume spacer is gold standard Dry powder inhalers only in >6-8yo Inhaled steroids and LTRAs more likely to improve symptoms in atopic children In asthma + rhinitis, LTRAs may be more beneficial

Allergies and asthma Look for other co-morbid conditions, especially allergic rhinitis (and food allergies) Consider skin prick testing (for aeroallergens) if: Seasonal symptoms (pollens, molds) Household pets (animal dander) Perennial symptoms (house dust mite, molds) Change in environment changes symptoms

Steroids in viral induced asthma Oral prednisolone in pre-school viral-induced asthma No evidence of efficacy in hospitalised children (except ? multi-factor asthma or atopic children) High-dose fluticasone in pre-school viral-induced asthma Modest reduction in duration of symptoms and less use of relief beta agonists, but a small reduction in linear growth NEJM 2009;360:329-53 (plus editorial)

Allergic rhinitis is a risk factor for asthma Allergic rhinitis increases the risk of asthma ~3-fold Subjects with asthma at 23-year follow-up (%) 12 p<0.002 10 10.5 8 6 4 Subjects were sent a questionnaire about allergies 23 years after assessment for the presence of allergies as college freshmen. Reference Settipane et al. Allergy Proc 1994; 15: 21-25. 2 3.6 No AR at baseline (n=528) AR at baseline (n=162)

Treating allergic rhinitis cuts asthma costs 61% fewer hospitalisations in treated patients Patients hospitalised over 1-year period (%) 2.5 p<0.01 2.0 2.3 1.5 1.0 0.9 Retrospective cohort study involving 4944 patients aged 12-60 years. Assessed the impact of prescription medication use for allergic rhinitis (nasal steroid or antihistamine) on asthma-related resource utilisation. Asthma-related events were defined as hospitalisations or emergency department visits within 31 days of a prescription for allergic rhinitis. Slide shows hospitalisations over a 1-year period according to treatment for allergic rhinitis. Reference Crystal-Peters et al. J Allergy Clin Immunol 2002; 109: 57-62. 0.5 0.0 Patients untreated for AR (n=1357) Patients treated for AR (n=3587)

Summary Importance of clinical history especially in the very young Look for other markers of allergy 2008 BTS / SIGN guidelines as a framework Refer to secondary care if inadequate response to treatment or possible alternative diagnosis Asthma management plans, compliance, age-appropriate delivery device Allergic rhinitis

The end, any questions