1. 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

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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.

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

10. Children age 5-12 yrs

11. Children age 5-12 yrs

12. Children age 5-12 yrs

13. Children age 5-12 yrs

14. Children age 5-12 yrs

15. Children age 5-12 yrs

16. Children Less than 5 yrs

17. Children Less than 5 yrs

18. Children Less than 5 yrs

19. Children Less than 5 yrs

20. Children Less than 5 yrs

21. 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

22. 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

24. 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: (plus editorial)

27. 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: 2
3.6
No AR
at baseline (n=528) AR
at baseline (n=162)

28. 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 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:
0.5
0.0
Patients untreated for AR (n=1357)
Patients treated for AR (n=3587)

29. 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

30. The end, any questions