Consultant for Pediatricians.
No. 9
A Guide to Monitoring and Achieving
Asthma Control in Children
Younger Than 5 Years
By KEVIN R. MURPHY, MD
Boys Town National Research Hospital, Omaha, Neb
MICHAEL H. MELLON, MD
Southern California Permanente Medical Group, San Diego, Calif |
September 3, 2009
Dr Murphy is director of allergy, asthma & pulmonology research at Boys Town National Research Hospital in Omaha, Neb. Dr Mellon is an asthma staff
pediatric allergist at Southern California Permanente Medical Group in San Diego, Calif.
HOW CAN CAREGIVERS HELP CHILDREN ACHIEVE ASTHMA CONTROL?
To facilitate asthma control, a detailed written asthma management plan should be provided to caregivers of children with either intermittent or persistent asthma. A plan is especially important for children with intermittent disease and a history of exacerbations because these patients can experience sudden and life-threatening exacerbations.6 The action plan should include specific symptoms indicative of worsening asthma, recommendations for SABA and OCS use, and when to seek medical care.
Once asthma is diagnosed in a child, asthma self-management education should be initiated and continued throughout the child's asthma care. Asthma self-management education provides patients and caregivers with the skills necessary to control asthma and improve symptoms. 6 The goals of therapy should be established between the caregiver and the HCP. Caregivers should be educated on how medications work and on proper device technique. Addressing caregivers' concerns and encouraging treatment adherence are important because caregivers play a major role in establishing and ensuring that the child's asthma is controlled.
After each HCP visit, it is also important for the caregiver to schedule a follow-up visit to continually ensure that the child's asthma is well controlled (Figure 1). The caregiver should ensure that a written asthma action plan is in place at all times and should review it with the HCP at each follow-up visit to determine whether any adjustment to the plan is necessary.6 Caregivers should also note any changes in the severity or frequency of the child's asthma symptoms, especially if wheezing occurs in the absence of a cold or with exercise, and should seek the HCP's advice if such changes are observed.
Case Study: Follow-up
After 4 weeks, Matt returns to the HCP's office for a follow-up visit. According to Matt's mother, his symptoms seem to be controlled. He has had symptoms of coughing and wheezing only once since his last visit and has not required any oral corticosteroids. Matt is sleeping through the night and has been taking his medications as prescribed. His mother reports that he has needed to use his albuterol only once in the past 2 weeks. Matt's PE results are normal. The HCP determines that Matt's asthma is well controlled (Figure 4) and continues to prescribe a nebulized ICS. The HCP reviews the written action plan with Matt and his mother, reviews device technique, and schedules a follow-up appointment in 3 months to review asthma control and medication requirements. Referral is made to the pediatric allergist for definitive allergy testing and collaborative consultation on longterm management.
CONCLUSIONS
The diagnosis and treatment of asthma in preschool-aged children is challenging. The role of asthma phenotypes in making treatment decisions for preschool-aged children is a focus of current research. Periodic and ongoing monitoring is necessary to ensure asthma control, defined by the degree to which both the impairment and risk domains of asthma are minimized by treatment. In these children, assessments by clinicians and caregivers are the primary means of monitoring asthma control. Allergy testing is indicated in young children with asthma. TRACK is a new validated and easy-to-administer caregiver completed questionnaire that can be used to aid caregivers and clinicians in evaluating respiratory control in children younger than 5 years with respiratory symptoms consistent with asthma symptoms. The role of TRACK in managing long-term, ongoing asthma is currently being studied. Caregivers have a very active role in managing a child's asthma control. The HCP should provide the caregiver with a written asthma management plan and asthma self-management education. Follow-up at regular intervals is necessary to maintain control of asthma in preschool-aged children.
REFERENCES:
1. American Lung Association. Childhood Asthma
Overview. http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=22782. Published April 2008.
Accessed January 16, 2009.
2. American Lung Association Epidemiology and
Statistics Unit Research and Program Services
Division. Trends in Asthma Morbidity and Mortality.
http://www.lungusa.org/atf/cf/%7B7A8D42C2-FCCA-4604-8ADE-7F5D5E762256%7D/ASTHMA%20JAN%202009.PDF. Published January 2009.
Accessed February 13, 2009.
3. GlaxoSmithKline. Children & Asthma in America.
Executive Summary. http://www.asthmainamerica.com/children_index.html. Accessed March 18, 2009.
4. Akinbami L; Centers for Disease Control and
Prevention National Center for Health Statistics. The
state of childhood asthma, United States, 1980-2005.
Adv Data. 2006;381:1-24.
5. Bisgaard H, Szefler S. Prevalence of asthma-like
symptoms in young children. Pediatr Pulmonol.
2007;42:723-728.
6. National Asthma Education and Prevention
Program. Expert Panel Report 3: Guidelines for the
Diagnosis and Management of Asthma. Full Report
2007. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed July 22, 2009.
7. Murphy KR, Zeiger RS, Kosinski M, et al. Test for
respiratory and asthma control in kids (TRACK): a
caregiver-completed questionnaire for preschool-aged
children. J Allergy Clin Immunol. 2009;123:833-9.e9.
8. Chipps BE, Spahn JD, Sorkness CA, et al. Variability
in asthma severity in pediatric subjects with asthma
previously receiving short-acting beta2-agonists.
J Pediatr. 2006;148:517-521.
9. Global Initiative for Asthma (GINA). Global
Strategy for the Diagnosis and Management of
Asthma in Children 5 Years and Younger. http://www.ginasthma.com. Accessed July 2009.
10. Eigen H. Differential diagnosis and treatment
of wheezing and asthma in young children. Clin
Pediatr (Phila). 2008;47:735-743.
11. Pedersen S. Preschool asthma—not so easy to
diagnose [letter]. Prim Care Respir J. 2007;16:4-6.
12. Martinez FD, Wright AL, Taussig LM, et al.
Asthma and wheezing in the first six years of life.
The Group Health Medical Associates. N Engl J
Med. 1995;332:133-138.
13. Taussig LM, Wright AL, Holberg CJ, et al.
Tucson Children's Respiratory Study: 1980 to present.
J Allergy Clin Immunol. 2003;111:661-675.
14. Castro-Rodriguez JA, Garcia-Marcos L. Wheezing
and asthma in childhood: an epidemiology approach.
Allergol Immunopathol (Madr). 2008;36:280-290.
15. Castro-Rodríguez JA, Holberg CJ, Wright AL,
Martinez FD. A clinical index to define risk of asthma
in young children with recurrent wheezing. Am
J Respir Crit Care Med. 2000;162(4 pt 1):1403-1406.
16. Bush A. Update in pediatric lung disease 2008.
Am J Respir Crit Care Med. 2009;179:637-649.
17. Heikkinen T, Järvinen A. The common cold.
Lancet. 2003;361:51-59.
18. Johnston NW, Johnston SL, Norman GR, et al.
The September epidemic of asthma hospitalization:
school children as disease vectors [published correction
appears in J Allergy Clin Immunol. 2007;
120:47]. J Allergy Clin Immunol. 2006;117:557-562.
19. Van Dole KB, Swern AS, Newcomb K, Nelsen
L. Seasonal patterns in health care use and pharmaceutical
claims for asthma prescriptions for preschool-
and school-aged children. Ann Allergy
Asthma Immunol. 2009;102;198-204.
20. Sears MR, Johnston NW. Understanding the
September asthma epidemic. J Allergy Clin Immunol.
2007;120:526-529.
21. Dales RE, Schweitzer I, Toogood JH, et al.
Respiratory infections and the autumn increase in
asthma morbidity. Eur Respir J. 1996;9:72-77.
22. Guilbert TW, Morgan WJ, Krawiec M, et al.
The Prevention of Early Asthma in Kids study:
design, rationale and methods for the Childhood
Asthma Research and Education network. Control
Clin Trials. 2004;25:286-310.
23. Nickel R, Kulig M, Forster J, et al. Sensitization
to hen's egg at the age of twelve months is predictive
for allergic sensitization to common indoor and
outdoor allergens at the age of three years. J Allergy
Clin Immunol. 1997;99:613-617.
24. Kulig M, Bergmann R, Tacke U, et al; The MAS
Study Group, Germany. Long-lasting sensitization to
food during the first two years precedes allergic airway
disease. Pediatr Allergy Immunol. 1998;9:61-67.
25. Guilbert TW, Morgan WJ, Zeiger RS, et al. Atopic
characteristics of children with recurrent wheezing
at high risk for the development of childhood asthma.
J Allergy Clin Immunol. 2004;114:1282-1287.
26. Guilbert TW, Morgan WJ, Zeiger RS, et al.
Long-term inhaled corticosteroids in preschool children
at high risk for asthma. N Engl J Med. 2006;
354:1985-1997.
27. Castro-Rodriguez JA, Rodrigo GJ. Efficacy of inhaled
corticosteroids in infants and preschoolers with
recurrent wheezing and asthma: a systematic review
with meta-analysis. Pediatrics. 2009;123:e519-e525.
28. Szefler SJ, Eigen H. Budesonide inhalation suspension:
a nebulized corticosteroid for persistent
asthma. J Allergy Clin Immunol. 2002;109:730-742.
29. Knorr B, Franchi LM, Bisgaard H, et al. Montelukast,
a leukotriene receptor antagonist, for the
treatment of persistent asthma in children aged 2 to
5 years. Pediatrics. 2001;108:e48.
30. Bisgaard H, Zielen S, Garcia-Garcia ML, et al.
Montelukast reduces asthma exacerbations in
2- to 5-year-old children with intermittent asthma.
Am J Respir Crit Care Med. 2005;171:315–322.
31. Garcia Garcia ML, Wahn U, Gilles L, et al.
Montelukast, compared with fluticasone, for control
of asthma among 6- to 14-year-old patients with mild
asthma: the MOSAIC study [published correction
appears in Pediatrics. 2005;116:1058]. Pediatrics.
2005;116:360-369.
32. Ostrom NK, Decotiis BA, Lincourt WR, et al.
Comparative efficacy and safety of low-dose fluticasone
propionate and montelukast in children with
persistent asthma. J Pediatr. 2005;147:213-220.
33. Sorkness CA, Lemanske RF Jr, Mauger DT, et
al; Childhood Asthma Research and Education Network
of the National Heart, Lung, and Blood Institute.
Long-term comparison of 3 controller regimens
for mild-moderate persistent childhood asthma: the
Pediatric Asthma Controller Trial [published correction
appears in J Allergy Clin Immunol. 2007;120:285].
J Allergy Clin Immunol. 2007;119:64-72.
34. Tasche MJ, Uijen JH, Bernsen RM, et al.
Inhaled disodium cromoglycate (DSCG) as maintenance
therapy in children with asthma: a systematic
review. Thorax. 2000;55:913-920.
35. Liu AH, Zeiger R, Sorkness C, et al. Development
and cross-sectional validation of the Childhood
Asthma Control Test. J Allergy Clin Immunol. 2007;
119:817-825.
36. Skinner EA, Diette GB, Algatt-Bergstrom PJ,
et al. The Asthma Therapy Assessment Questionnaire
(ATAQ) for children and adolescents. Dis Manag.
2004;7:305-313.
37. Zorc JJ, Pawlowski NA, Allen JL, et al. Development
and validation of an instrument to measure
asthma symptom control in children. J Asthma.
2006;43:753-758.
38. Juniper EF, O'Byrne PM, Guyatt GH, et al. Development
and validation of a questionnaire to measure
asthma control. Eur Respir J. 1999;14:902-907.
39. Juniper EF, O'Byrne PM, Ferrie PJ, et al.
Measuring asthma control. Clinic questionnaire or
daily diary? Am J Respir Crit Care Med. 2000;
162(4 pt 1):1330-1334.
40. Nathan RA, Sorkness CA, Kosinski M, et al.
Development of the asthma control test: a survey for
assessing asthma control. J Allergy Clin Immunol.
2004;113:59-65.
41. Vollmer WM, Markson LE, O'Connor E, et al.
Association of asthma control with health care
utilization and quality of life. Am J Respir Crit Care
Med. 1999;160(5 pt 1):1647-1652.
42. Lara M, Duan N, Sherbourne C, et al. Differences
between child and parent reports of symptoms among
Latino children with asthma. Pediatrics. 1998;102:E68.
43. Erickson SR, Munzenberger PJ, Plante MJ,
et al. Influence of sociodemographics on the healthrelated
quality of life of pediatric patients with asthma
and their caregivers. J Asthma. 2002;39:107-117.
44. Halterman JS, McConnochie KM, Conn KM,
et al. A potential pitfall in provider assessments of
the quality of asthma control. Ambul Pediatr. 2003;
3:102-105.
45. Bloomberg GR, Banister C, Sterkel R, et al.
Socioeconomic, family, and pediatric practice factors
that affect level of asthma control. Pediatrics. 2009;
123:829-835.
