G. Hedlin

Problematic severe asthma in children, not one problem but many: a GA2LEN initiative

Although most children with asthma are easy to treat with low doses of safe medications, many remain symptomatic despite every therapeutic effort. The nomenclature regarding this group is confusing, and studies are difficult to compare due to the proliferation of terms describing poorly defined clinical entities. In this review of severe asthma in children, the term problematic severe asthma is used to describe children with any combination of chronic symptoms, acute severe exacerbations and persistent airflow limitation despite the prescription of multiple therapies. The approach to problematic severe asthma may vary with the age of the child, but, in general, three steps need to be taken in order to separate difficult-to-treat from severe therapy-resistant asthma. First, confirmation that the problem is really due to asthma requires a complete diagnostic re-evaluation. Secondly, the paediatrician needs to systematically exclude comorbidity, as well as personal or family psychosocial disorders. The third step is to re-evaluate medication adherence, inhaler technique and the child’s environment. There is a clear need for a common international approach, since there is currently no uniform agreement regarding how best to approach children with problematic severe asthma. An essential first step is proper attention to basic care.

Assessment of problematic severe asthma in children

Assessment of problematic severe asthma in children should be performed in a step-wise manner to ensure an optimal approach. A four-step assessment scheme is proposed. First, a full diagnostic work-up is performed to exclude other diseases which mimic asthma. Secondly, a multi-disciplinary assessment is performed to identify issues that may need attention, including comorbidities. Thirdly, the pattern of inflammation is assessed, and finally steroid responsiveness is documented. Based upon these four steps an optimal individualised treatment plan is developed. In this article the many gaps in our current knowledge in all these steps are highlighted, and recommendations for current clinical practice and future research are made. The lack of good data and the heterogeneity of problematic severe asthma still limit our ability to optimise the management on an individual basis in this small, but challenging group of patients.

Comparison of clinically diagnosed asthma with parental assessment of children's asthma in a questionnaire

Epidemiological evaluations of the prevalence of asthma are usually based on written questionnaires (WQs) in combination with validation by clinical investigation. In the present investigation, we compared parental assessment of asthma among their preschool children in response to a WQ with the corresponding medical records in the same region. An International Study of Asthma and Allergies in Childhood (ISAAC)‐based WQ was answered by 75% of the parents of 6295 children aged 1–6u2003yr. Clinically diagnosed asthma, recorded in connection with admissions to the hospital or a visit to any of the outpatient clinics in the same region, were analysed in parallel. Finally, a complementary WQ was sent to the parents of children identified as asthmatic by either or both of this approaches. In response to the WQ 5.9% were claimed to suffer from asthma diagnosed by a doctor. According to the medical records, the prevalence of clinically diagnosed asthma was 4.9%. The estimated prevalence among children requiring treatment for their asthma was 4.4%. The sensitivity of the WQ was 77%, the specificity 97.5%. In the 1–2u2003yr age group the sensitivity was only 22%. This WQ was able to identify 54% of the children with a medical record of asthma. Forty percent of the children claimed by their parents to be asthmatic had no medical record of asthma. An ISAAC‐based parentally completed WQ provided an acceptable estimation of the prevalence of asthma in children 2–6u2003yr of age, although only half of the individual patients identified in this manner are the same as those identified clinically.

Monitoring asthma in children

The goal of asthma treatment is to obtain clinical control and reduce future risks to the patient. To reach this goal in children with asthma, ongoing monitoring is essential. While all components of asthma, such as symptoms, lung function, bronchial hyperresponsiveness and inflammation, may exist in various combinations in different individuals, to date there is limited evidence on how to integrate these for optimal monitoring of children with asthma. The aims of this ERS Task Force were to describe the current practise and give an overview of the best available evidence on how to monitor children with asthma. 22 clinical and research experts reviewed the literature. A modified Delphi method and four Task Force meetings were used to reach a consensus. This statement summarises the literature on monitoring children with asthma. Available tools for monitoring children with asthma, such as clinical tools, lung function, bronchial responsiveness and inflammatory markers, are described as are the ways in which they may be used in children with asthma. Management-related issues, comorbidities and environmental factors are summarised. Despite considerable interest in monitoring asthma in children, for many aspects of monitoring asthma in children there is a substantial lack of evidence. ERS statement summarising and discussing the available literature on monitoring children with asthma http://ow.ly/H01NG

Pharmacological treatment of severe, therapy-resistant asthma in children: What can we learn from where?

There is a lack of high-quality evidence on what treatment should be used in children with properly characterised severe, therapy-resistant asthma. Data have to be largely extrapolated from trials in children with mild asthma, and adults with severe asthma. Therapeutic options can be divided into medications used in lower doses for children with less severe asthma, and those used in other paediatric diseases but not for asthma (for example, methotrexate). In the first category are high-dose inhaled corticosteroids (ICS) (≤2,000 &mgr;g·day−1 fluticasone equivalent), oral prednisolone, the anti-immunoglobulin (Ig)E antibody omalizumab, high-dose long-acting &bgr;2-agonists, low-dose oral theophylline and intramuscular triamcinolone. If peripheral airway inflammation is thought to be a problem, the use of fine-particle ICS or low-dose oral corticosteroids may be considered. More experimental therapies include oral macrolides, cyclosporin, cytotoxic drugs such as methotrexate and azathioprine, gold salts, intravenous infusions of Ig, subcutaneous &bgr;2-agonist treatment and, in those sensitised to fungi, oral antifungal therapy with itraconazole or voriconazole. Those with recurrent severe exacerbations, particularly in the context of good baseline asthma control, are particularly difficult to treat; baseline control and lung function must be optimised with the lowest possible dose of ICS, and allergen triggers and exposures minimised. The use of high-dose ICS, leukotriene receptor antagonists or both at the time of exacerbations can be considered. There is no evidence regarding which therapeutic option to recommend. Better evidence is required for all these treatment options, underscoring the need for the international and co-ordinated approach which we have previously advocated.

Group discussions with parents have long‐term positive effects on the management of asthma with good cost‐benefit

AIMnTo investigate if an intervention with extra information and support in a group setting to parents of preschool children could improve adherence and clinical outcome.nnnMETHODSnThis is a controlled, prospective study where the parents of 60 newly diagnosed preschool asthmatic children aged 3 mo-6 y were randomized to either a control group or to an intervention that consisted of four group sessions in close connection with the diagnosis. The basic education on asthma and the written treatment plan were the same in both groups. The outcome measures were questionnaires to the parents and classification of the children according to symptoms and medication. The adherence rate and the burden of asthma were calculated with the help of diaries and weighing of the MDIs used between 12 and 18 mo after inclusion.nnnRESULTSnThe follow-up rate was 85% after 18 mo. The parents presence in the sessions was around 70%, with no gender difference. The parents view on adherence issues improved significantly in the intervention group. In the control group, 30% had poor adherence compared to 8% in the intervention group (p=0.015). Both the parents and the paediatricians underestimated the number of children with poor adherence. The children in the intervention group had significantly fewer exacerbation days during the last 6 mo-2.1 compared to 3.9 d/child-although they had lower inhaled steroid doses after 18 mo. An economic calculation showed that the intervention was profitable.nnnCONCLUSIONnThis intervention resulted in an improvement in the parents view on adherence, in the measured adherence rates and in the clinical outcome.

Exhaled NO and eosinophil markers in blood, nasal lavage and sputum in children with asthma after withdrawal of budesonide

Background:u2002 There is a need for controlled trials among children with asthma to evaluate and compare different markers of inflammation.

Down-regulated IL-5 receptor expression on peripheral blood eosinophils from budesonide-treated children with asthma

Background:u2002The expression and function of cytokine receptors on peripheral blood eosinophils (PBE) from healthy and asthmatic children are poorly characterized.

The burden of asthma as reflected by the prevalence defined by doctor's diagnosis and the use of healthcare services by preschool children in a Swedish region.

Aim: Epidemiological data and reports on the prevalence and burden of preschool asthma are mainly based on questionnaires and generally give a prevalence of above 6% in Sweden. In this study we used other ways of studying the prevalence, risk factors and the use of healthcare services in a defined region. Methods: The catchment area included 9410 children aged 0‐6 y. All outpatient clinics had computerized records of patients and visits to the outpatient clinic could be studied as well as admissions to hospital for asthma between 1988 and 1998. Results: According to patients’record data, the prevalence of doctor‐diagnosed asthma was 4.5% in 1998. Seventy‐nine percent of recorded patients are seen outside the hospital, thus the burden of asthma for the health system is mainly on the outpatient clinics. Admissions and especially readmissions to the hospital have decreased during the past decade. One‐third of the children with newly diagnosed asthma had recurring exacerbations and risk for persistent asthma.

Childhood asthma in the Year of the Lung

Paediatric asthma may be named “the illness of our time”. It is as complex as the life of our time; it has increased in occurrence over the last 50 to 60 years to become the most common illness of childhood and adolescence and, despite the very extensive efforts to try to find out the cause of this increase, we must be honest and say that we do not know. Asthma has both a chronic and an acute presentation, causing reduced quality of life in many children and their families 1.nnThe chief editors of the European Respiratory Journal ( ERJ ) have decided that in the Year of the Lung, we should have a series of articles on paediatric asthma, outlining the many different faces of this disease and to tell something of the story of the venture …