1. Paediatric Asthma 26 th November 2014 Julie Westwood Asthma Nurse Specialist RHSC 0131 536 0773

2. Topics to explore Normal childhood Diagnosing asthma in children Considering the probability Treatment

3. Normal Childhood Some facts <2 years of age –Average of 12 URTIs (colds) per year –Cough can last for up to 14 days with each cold (i.e. up to 24 weeks cough/yr) <6 years of age –50% of children will have had at least one episode of wheeze (c10% have asthma) I.e. almost normal to wheeze

4. Asthma in children SIGN/BTS Guideline October 2014 (online) 141 Diagnosis by probability (introduced 2008) Adolescent section Supersedes 101

5. Probability

6. Asthma in children - high probability > 1 of: wheeze, cough, difficulty breathing, chest tightness esp if: –Frequent and recurrent –Worse at night / early morning –In response to triggers –Occur apart from colds Personal history of atopic disorders Family history of atopic disorder/asthma Widespread wheeze heard on auscultation History of improvement in symptoms or lung function in response to adequate treatment

7. Asthma in children - low probability Symptom with URTI only – with no interval symptoms Isolated cough in the absence of wheeze or difficulty breathing History of moist cough Prominent dizziness, light headedness or peripheral tingling Repeatedly normal physical examination of chest when symptomatic Normal PEF/Spirometry when symptomatic No response to trial of asthma therapy Clinical features pointing to alternative diagnosis

8. Asthma in children - intermediate probability In between the two! Try reversibility – using PEFR Trial of treatment Ensuring appropriate devices and explanation of medication use Consider other testing but ? not appropriate in primary care (exercise testing, allergy testing)

9. Asthma treatment in children

12. Prescribing for an acute asthma exacerbation in children Oral Prednisolone 3 day course Prescribe according to age <12 months (2mg/kg once per day) 1-2 years 20mg once per day 3-4 years 30mg once per day  5 years 40mg once per day (reducing course should be given, if previous 3 day course in past month)

13. Prescribing for an acute asthma exacerbation in children in any age group Increased Bronchodilator: Salbutamol - remember the 4’s 4 puffs 4 times a day 4 days Acute attack 10 puffs Salbutamol through Spacer – no more than 2 multi doses within 24hrs without review

14. Please consider…. Oral Prednisolone for Preschool Children with Acute Virus-Induced Wheezing Jayachandran Panickar, M.D., M.R.C.P.C.H., Monica Lakhanpaul, M.D., F.R.C.P.C.H., Paul C. Lambert, Ph.D., Priti Kenia, M.B., B.S., M.R.C.P.C.H., Terence Stephenson, D.M., F.R.C.P.C.H., Alan Smyth, M.D., F.R.C.P.C.H., and Jonathan Grigg, M.D., F.R.C.P.C.H. n engl j med 360;4 nejm.org January 22, 2009

15. Viral wheeze is common Conventional ‘asthma’ treatments may not be effective Caution – repeated oral steroid prescribing without perceived day 1 response Limited effect from inhaled steroids Is Montelukast a good alternative?

16. ACUTE PRE-SCHOOL WHEEZE –Montelukast may shorten duration of symptoms around colds and respiratory viruses –Some suggestion of acute reduction in trouble breathing in association with infections Bacharier J Allergy Clin Immunol 2008

17. Ref Help