asthma%20(pediatric)
ASTHMA (PEDIATRIC)

Asthma is a chronic inflammatory disease of the airways in the lungs of children and adults.
The patient usually complains of shortness of breath, chest tightness and coughing with wheezing.

A diagnosis of asthma in young children is more likely if they have symptom patterns, presence of risk factors for development of asthma and therapeutic response to controller treatment.
Goals of treatment are effective symptom control with minimal or no exacerbations, minimal or no nocturnal and daytime symptoms, no limitations on activities, minimal or no need for reliever treatment, and minimal adverse effects of medication.

Monitoring

Periodic Assessment & Monitoring

  • Periodic assessment & monitoring of asthma control should be performed to determine whether the goals of therapy are met (ie reduction of current impairment & future risk, & achievement of normal activity levels including exercise)
    • Several tools are used that allow patient & parents to record & describe the symptoms [eg asthma control test (ACT), childhood ACT, asthma quiz for kids, diaries]
  • Improvement of symptoms may be observed within days while max benefit may be achieved after 3-4 months
  • Regular follow-up is recommended to determine minimum controlling dose & necessary dose adjustments

Monitoring Signs & Symptoms

  • Daytime asthma symptoms (wheezing, cough, chest tightness or shortness of breath)
  • Nocturnal awakening as a result of asthma symptoms
  • Frequency of use of beta2-agonist (inhaled, rapid-acting) for relief of symptoms
  • Inability or difficulty in performing normal activities because of asthma symptoms

Pulmonary Function

  • Results in children 5 year of age & younger are unreliable or may not be reproducible
  • Spirometry
    • Low forced expiratory volume in 1 second (FEV1) is associated with increased risk of severe exacerbations
  • Peak Flow Monitoring
    • Peak flow meters function best as tools for ongoing monitoring, not diagnosis
    • Refer to the patient’s written asthma action plan for the patient’s personal best peak flow
    • Because measurement of peak expiratory flow (PEF) is dependent on effort & technique, patient instructions, demonstrations & frequent reviews are recommended

Quality of Life

  • Any school day missed because of asthma
  • Any reduction in usual activities (eg home, school, recreation, exercise)
  • Any sleep disturbance due to asthma
  • Any change in the caregiver’s activities due to asthma

History of Asthma Exacerbations

  • Frequency
  • Rate of onset
  • Severity
  • Cause

Monitoring Adherence to Therapy

  • Adherence to drug regimen
  • Patient concerns about drug regimen
  • Adverse effects experienced with the drug regimen

Monitoring Patient-Provider Communication & Patient Satisfaction

  • Patient’s negative attitude toward medication &/or reluctance towards self-management are risk factors for severe exacerbations

Prevention

  • It is believed that asthma development & persistence are driven by gene-environment interactions thus interactions during pregnancy & early in life has a great influence
  • Preventing the onset of disease is called primary prevention

Nutrition

Breastfeeding

  • It may decrease wheezing episodes in early life but may not prevent developing asthma
  • It is still encouraged for all of its positive benefits

Vitamin D

  • Some studies show that maternal intake of vitamins D & E lowers the risk wheezing illnesses in children

Allergens

  • There are conflicting evidences on the effect of pet allergens on patients with asthma
  • Dampness, visible mold & mold odor should be eliminated as studies suggested that exposure to these home allergens increase the risk of developing asthma

Vaccinations

  • Annual influenza vaccination may help reduce acute exacerbation in patients with moderate-severe asthma

Pollutants

  • Smoking during pregnancy has a strong effect on young children while post-natal maternal smoking has an effect only to asthma development in older children
  • Avoid exposure to environmental tobacco smoke during pregnancy & the first year of life
  • There is an increased risk of asthma associated with exposure to outdoor pollutants (eg residence near a main road)

Microbial effects

  • Exposure to microbiota may be of benefit in the prevention of asthma
  • Children exposed to potential allergens early in life (eg farm stables & animals, unprocessed milk) present with lower risk for asthma development compared to other children
  • Infants born via vaginal delivery may be at lesser risk for asthma than those born by caesarean section (C-section)
    • The mode of delivery may be associated with the differences between infants’ gut microflora

Medications & Other Factors

  • Paracetamol/Acetaminophen, analgesic & broad-spectrum antibiotics use in the 1st-2nd year of life is discouraged

Psychosocial Factors

  • There is an increased risk of asthma development if there is maternal distress that persists from birth through to early school age

Severity Assessment of Asthma Exacerbation

  • Asthma exacerbation is an acute or sub-acute deterioration in symptom control that is sufficient to cause distress or risk to health & would need specialist consult or requires treatment with systemic corticosteroid
    • Episode of progressive increase in wheeze & shortness of breath, cough especially when the child is asleep, lethargy or reduced exercise tolerance, impairment of daily activities (including feeding) & poor response to reliever medication
  • Severity must be assessed immediately through history, physical examination, & objective measures of lung function
    • Peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV1) & arterial oxygen saturation should be measured to determine the degree of hypoxemia
      • PEF or FEV1 are more reliable indicators of airflow limitation severity & may also help determine patients who require hospitalization (eg patients with pre-treatment FEV1 or PEF <25% predicted or personal best or patients with post-treatment FEV1 or PEF <40% predicted or personal best)
    • Evaluate patient’s severity for risk of death based on the following:
      • Past history of near-fatal asthma requiring intubation & mechanical intubation
      • Prior (within 1 year) hospitalization or emergency care visit due to asthma exacerbation
      • Currently using or recently stopped oral glucocorticosteroids
      • Currently not on inhaled glucocorticosteroids
      • Overdependent on rapid-acting inhaled beta2-agonists (eg use of >1 canister per month)
      • History of psychiatric disease or psychosocial problems
      • History of poor compliance with asthma medication or asthma action plan
      • Difficult to perceive airflow obstruction or severity
  • Severe asthma attack requires close supervision as it may be life threatening
    • Treatment should continue until PEF or FEV1 has returned to their previous ideal value or plateau
  • Immediate medical attention is needed when:
    • There is a presence of acute distress in the child
    • Inhaled bronchodilator did not relieved promptly the child’s symptoms
    • Progressively shorter period of relief after doses of rapid acting beta2 agonist
    • There is a need for a child <1 year to have repeated inhaled rapid acting beta2 agonist administration over several hours

Initial assessment of acute asthma exacerbation

Mild-Moderate

  • No altered consciousness
  • Arterial O2 saturation (SaO2) at >90-95% (>92% for children <5 years)
  • Talks in phrases/sentences
  • Pulse rate <100 beats/minute; <200 bpm (0-3 years)/<180 bpm (4-5 years) pulse rate
  • No central cyanosis
  • Increased respiratory rate
  • Variable wheeze intensity

Severe

  • Agitated
  • SaO2 at <92%
  • Talks in words
  • Pulse rate >200 beats/minute (0-3 years) or >180 beats/minute (4-5 years)
  • Cyanosis may likely be present
  • Subcostal &/or subglottic retractions present
  • Respiratory rate >30/minute
  • Wheeze may not be present

Life-threatening

  • Unable to speak 
  • Drowsy, confused or silent chest
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