Pediatric Asthma and Related Allergic and Nonallergic Diseases: Patient-Oriented Evidence-Based Essentials That Matter

Miles Weinberger

Pediatr Health. 2008;2(5):631-650.

Abstract and Introduction

Abstract

Asthma is the most common medical diagnosis among hospitalized children. In the USA, asthma has accounted for approximately 15% of nonsurgical admissions to hospital in the pediatric age group. Asthma is also one of the leading causes for emergency care requirements, one of the leading causes for missed school, and a cause for considerable morbidity, disability and occasional mortality at all ages. Despite these discouraging statistics, convincing data indicate that this failure of asthma management is not the result of inadequate therapeutic potential, but instead represents ineffective delivery of medical care. Management of asthma and its major co-morbidities, allergic and nonallergic rhinitis, and atopic dermatitis requires a knowledge of the alternative therapies, natural history, and educational techniques for providing patients and families with the ability to manage these troublesome chronic disorders.

Introduction

Asthma is the most common medical diagnosis among hospitalized children. In the USA, asthma has accounted for approximately 15% of nonsurgical admissions to the hospital in the pediatric age group. Asthma is also one of the leading causes for emergency care requirements, one of the leading causes for missed school, and a cause for considerable morbidity, disability, and occasional mortality at all ages.^[1]

Despite these discouraging statistics, convincing data indicate that this failure of asthma management is not the result of inadequate therapeutic potential, but instead represents ineffective delivery of medical care.^[2,3] Guidelines proposed by the National Asthma Education and Prevention Program (NAEPP) have been published as Expert Panel Reports beginning in 1991, with updates in 1997 and 2002.^[4,5,6] A 415 page 2007 Expert Panel Report 3 with a 60 page summary has now been released.^[7,8] An international guideline, the Global Initiative for Asthma (GINA) is a somewhat less weighty 92 pages; a 24 page 'Pocket Guide' version provides guidelines for treating children with asthma.^[201] Despite the considerable efforts and ambitious goal of these various guidelines for improving asthma outcome, indications are that these lengthy and complex guidelines are not followed by primary care physicians,^[9,10] and published reports continue to show little decrease in urgent care requirements, hospitalizations or deaths from asthma.^[11,12]

Several specialist guided and team-directed model programs involving selected primary care physicians have been shown to impact positively on the outcome of asthma in children.^[13,14,15] However, the greatest degree of effectiveness for asthma management has been documented for care programs directed by subspecialists that utilized continuity of care, an organized plan for effective therapeutic decisions, and patient education to carry out the plan.^{[2,16,17,18,19,20]} Even among particularly difficult groups of patients where socio-economic factors complicate care, controlled clinical trials have demonstrated that specialized programs substantially improve outcome.^[2,19]

Rhinitis, allergic and nonallergic, and atopic dermatitis are comorbid conditions frequently associated with asthma in addition to occurring independent of asthma. Published guidelines for these troublesome clinical problems have also been published in an attempt to improve care of these related disorders in primary care settings.^{[21,22,23,24,25,26,27]}

The purpose of this review is to identify those measures with accepted potential benefit for these disorders that are the most important and should be utilized in primary care. Additional measures that go beyond the common scope of primary care will also be discussed to identify where specialty care may provide additional benefit.

1 2 3 4 5 6 7 8 9 10 11 12

Next Section

Cite this: Pediatric Asthma and Related Allergic and Nonallergic Diseases: Patient-Oriented Evidence-Based Essentials That Matter - Medscape - Oct 01, 2008.

Table 1. Doses of Prednisone or Prednisolone to Obtain Maximal Effect on Asthmatic Airways
Age	Dose*
Infant	15 mg twice daily
1-3 years of age	20 mg twice daily
3-13 years of age	30 mg twice daily
>13 years of age	40 mg twice daily

*Reduce dose to morning only if irritability or insomnia is problematic after the initial 1 or 2 days of treatment.
Since there are insufficient dose-response data to support recommendations based on weight or body size, these are empirical doses based solely on experience that lower doses less reliably provide complete cessation of symptoms, with the goal of a 5- to 10-day course. Lower doses almost certainly will be adequate for some patients, and minor side effects require dosage to be limited in some patients to once daily in the morning only. There is no reason to taper short courses.^[63,64,65]

Table 2. Intervention Medication: Dosage and Decisions for Usual Treatment of Acute Symptoms of Asthma
Medication	Dosage	When to use
Albuterol (salbutamol), levalbuterol terbutaline, or pirbuterol by metered dose inhaler (see Figure 4 for administration issues).	Two to four inhalations is usual, but up to six inhalations can be used (one at a time) and is equivalent to the most common dosage by nebulizer.	As needed for cough, wheezing and labored breathing. Scheduled use has no advantage over use as needed and may be deleterious for some patients. Repeated requirements for bronchodilator use during an exacerbation generally warrants a short course of an oral corticosteroid.
Prednisone, prednisolone, methylprednisolone and dexamethasone as tablets. Liquid formulations and oral disintegrating tablets of prednisolone for young children (parenteral forms indicated only when concerned about oral retention).	Dosage as prednisone or prednisolone: see Table 1.	If bronchodilator subresponsiveness is identified by incomplete resolution of symptoms and signs from even repeat use of the bronchodilator, continue till asymptomatic; re-evaluate if not improving within 5 days or asymptomatic within 10 days. Don't taper.^[63,64,65]
Ipratropium aerosol	0.5 mg with 2.5-5 mg albuterol by nebulizer.	Indicated for severe acute asthma in the emergency room or hospital when response to a ß₂ agonist is inadequate for relief of respiratory distress.

Table 3. Maintenance Medication: Initial Dosage and Decisions for Treatment of Persistent Symptoms of Chronic or Seasonal Allergic Asthma
Medication	Dosage	When to use
Inhaled corticosteroid	Flovent 44 HFA® MDI (fluticasone suspension aerosol), two inhalations b.i.d. QVAR 40® MDI (beclomethasone solution microaerosol), two inhalations b.i.d. Pulmicort Flexhaler® (budesonide dry powder inhaler), one inhalation b.i.d.	First-line medication for persistent symptoms; use the Flovent or QVAR MDI with a valved holding chamber and mask for infants and toddlers; most can use a chamber without a mask by 4 years of age; the dry powder inhaler formulations can be used effectively in most children by 6 years of age.
Montelukast	4 mg sprinkle, 4 and 5 mg chewable, or 10 mg tablets (similar blood levels for each) once daily.	An alternative to an inhaled corticosteroid for mild persistent symptoms; modest additional benefit as an add-on to inhaled corticosteroids.
Long-acting ß₂ agonist	Advair 100/50® (fluticasone/salmeterol dry powder inhaler) one inhalation b.i.d. or Symbicort® (budesonide/formoteral MDI), two inhalations b.i.d.	When a conventional dose of inhaled corticosteroid does not maintain control; monitoring for the occasional patient made worse from the addition of long-acting ß₂ agonist is essential.
Slow-release theophylline	Begin with 10 mg/kg/day divided b.i.d. to a maximum of 150 mg b.i.d.; increase in increments if tolerated to 16 mg/kg/day to a maximum of 300 mg b.i.d.; monitor serum theophylline concentrations to attain peak serum concentrations of 10-15 µg/ml.^[95]	As an additive agent to an inhaled corticosteroid for the occasional patient where a long-acting ß₂ agonist worsens rather than improves asthma control. Awareness of drug interactions and effect of fever on theophylline levels is essential for safety.^[95]

Acute exacerbations, especially when induced by viral respiratory infection, require the intervention measures in Table 2.
b.i.d.: Twice daily; MDI: Metered-dose inhaler.

Sidebar: Executive Summary

Introduction

Asthma is the most common chronic disease of children.
Asthma causes more hospitalizations than any other medical problem in children.
Asthma is associated with rhinitis and atopic dermatitis as important co-morbidities.

Diagnosis of Asthma

Asthma is both under- and over-diagnosed.
There are conflicting definitions of asthma, particularly in young children, but a common definition can be applied to this complex of clinical patterns with similar end-organ responses.

Clinical Characteristics of Asthma

Intermittent asthma is most commonly a viral respiratory infection-induced phenotype in pre-school age children, but is seen at all ages.
The chronic phenotype is characterized by the absence of extended symptom-free periods.
The seasonal allergic phenotype is characterized by being limited to seasons that correspond to allergen-specific IgE released in response to seasonal inhalant allergens.

Severity of Asthma

Interference with activity from exercise limitation.
Interference with sleep from repeated nocturnal waking.
Frequency of requirements for intervention measures, inhaled bronchodilators and oral corticosteroids.

Treatment of Asthma

Intervention measures for relief of acute symptoms, albuterol and oral corticosteroids.
Maintenance medications for those with chronic or extended seasonal symptoms, inhaled corticosteroids, long-acting bronchodilators, leukotriene modifiers, immunotherapy and anti-IgE.

Treatment of Co-morbidities

Rhinitis, allergic and nonallergic, are commonly associated with asthma but also occur independently.
Atopic eczema, also known as atopic dermatitis, often precedes inhalant allergy-induced rhinitis and asthma.

Monitoring the Clinical Course of Asthma

Symptom identification by patient is essential to early intervention to prevent progression of exacerbations.
Scheduled re-evaluations for assessment and education are required to evaluate adequacy of treatment and assess adherence to the treatment plan.

Evaluating & Managing Difficult Asthma

Determine if difficulty is poor adherence.
Determine if diagnosis is incorrect.

Natural History of Asthma

How to respond to the question, 'Will my child outgrow his/her asthma?'.
Predicting the clinical course and outcome.

Rhinitis

Allergic and nonallergic rhinitis.
Selection of antihistamines.
Topical nasal steroids.

Atopic Eczema (a.k.a. Atopic Dermatitis)

Definition, a relapsing, highly pruritic, inflammatory skin disease associated with xerosis.
Nature of the cutaneous defect and relationship to morbidity, ceramide deficiency and defects in innate immunity.
Moisturizing and use of emollients for skin care hydration are the mainstay of therapy.
Topical corticosteroids and calcineurin inhibitors used judiciously are effective and safe.

Conclusion & Future Perspective

Asthma and its co-morbidities, often undertreated, are generally manageable with knowledgeable selection of therapy and adequate instruction of patients.
Careful ongoing evaluation, and an understanding of the disease on the part of the patient, is essential for a successful outcome.

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.