WASHINGTON, DC-Representatives from nine prominent health care organizations recently joined forces to create a new set of pediatric asthma guidelines, Pediatric Asthma: Promoting Best Practice.(1) "These are the first asthma guidelines devoted entirely to the pediatric patient," noted Laurie Smith, MD, chair of the Section on Allergy/Immunology at the American Academy of Pediatrics, one of the organizations involved in developing the guidelines.

Separate pediatric asthma guidelines are necessary because pediatric asthma rates are on the rise-they jumped 72% among children age 5 to 16 years from 1980 to 1994.(2) Furthermore, having specific pediatric recommendations prevents information on childhood asthma from being buried among adult data, said Gail G. Shapiro, MD, co-chair of the committee that created the guidelines.

KEYS TO SUCCESSFUL ASTHMA MANAGEMENT

The new guidelines remind physicians that asthma diagnosis consists of three basic steps:

• Suspect asthma if initial symptoms suggest it.
  
• Establish the diagnosis with a careful history, focusing on the patient's symptom patterns.
  
• Confirm the diagnosis with objective measures, particularly spirometry, which is the gold standard in asthma diagnosis.

Assessment frequency depends on disease severity and ranges from only two office visits a year for children whose asthma is under control to an office visit every 2 weeks for those with unstable asthma. To gauge severity, physicians need to consider a variety of factors, such as symptoms and school absences during any 2-week period, fatigue, poor school performance, and (in asthmatic infants) chest retractions and difficulty in feeding.

Spirometry is recommended at least once a year for all patients. It is also necessary at the initial visit, after the start of treatment (when symptoms and peak flow have stabilized), and to evaluate treatment changes. Long-term home peak flow monitoring is especially important for asthmatic children with poor symptom perception, moderate to severe disease, and/or a history of severe exacerbations.

Environmental triggers, such as viral upper respiratory infection, influenza, dust mites, and tobacco smoke, can worsen childhood asthma. The guidelines suggest many ways to minimize these triggers, such as annual influenza vaccination for children with persistent asthma who are not allergic to eggs (a component of the vaccine) and helping parents and other caregivers to stop smoking.

TWO USES FOR DRUG THERAPY

The goal of management, according to the guidelines, is to control asthma with as little medication as possible; in that way, adverse effects can be minimized. Long-term asthma control and quick relief of acute symptoms are the two uses of pharmacologic therapy for pediatric asthma. For long-term control, the guidelines recommend cromolyn sodium, inhaled and oral corticosteroids, leukotriene modifiers, long-acting ß₂-agonists, nedocromil sodium, and sustained-release theophylline. Short-acting inhaled or oral ß₂-agonists, short-course oral corticosteroids, and ipratropium bromide are recommended for quick relief.

Physicians should adopt a stepwise approach to these therapies, basing the amount and frequency of medication on disease severity. The following are the overall goals of pharmacologic therapy:

• Minimal or no symptoms during the day or night.
  
• Minimal or no asthma episodes.
  
• Minimal (less than once a day) short-acting ß₂-agonist use.
  
• A peak expiratory flow at least 80% of personal best.
  
• Minimal or no adverse effects.
  
• Normal activities.

Whether inhaled corticosteroids inhibit growth in children is controversial. According to the guidelines, the benefits of these medications offset this potential risk. Nevertheless, physicians should regularly monitor growth in pediatric asthma patients receiving inhaled corticosteroids.

EDUCATING PATIENTS AND THEIR CAREGIVERS

Although time-consuming, providing patients and their caregivers sufficient information about asthma on an ongoing basis will improve adherence to therapy. "Education works best when it's a partnership with the patient and family," said Dr. Smith. It's vital, she added, to share the information with grandparents, teachers, coaches, and others outside the immediate family who are involved with the patient's care.

Two crucial components of asthma education are a management plan and an action plan. The management plan can be a simple one-page sheet outlining daily interventions for long-term control. The action plan provides brief written instructions on handling asthma exacerbations.

Because children spend so much time at school, physicians should work with school personnel to ensure a safe, positive environment for asthmatic students. Asthma triggers in the school environment should be minimized as much as possible. Physicians and school personnel should work together to develop an asthma management plan and should provide help so that asthmatic students can adhere to it. School personnel should be educated about specific asthma monitoring and treatment techniques, including the action plan.

School personnel should also strive to provide a normal environment in which asthmatic students aren't singled out because of their disorder. "They should understand that just because a child has asthma doesn't mean he or she should necessarily be excused from [physical education] or put in a bubble," Dr. Shapiro emphasized. "It's important that children with asthma live a normal lifestyle. Almost everyone with asthma can do that."

-Timothy M. Begany

References
1. Rachelefsky GS, Shapiro GG, Bergman D, et al. Pediatric Asthma: Promoting Best Practice. 1999. Milwaukee, Wis: American Academy of Allergy, Asthma & Immunology Inc; 1999.
2. Mannino DM, Homa DM, Pertowski CA, et al. Surveillance for asthma-United States, 1960-1995. Mor Mortal Wkly Rep CDC Surveill Summ. 1998;47:1-27.