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5/29/2018 8:12:13 PM

The truth about asthma and your kids: How to keep them out of the emergency room

Asthma is a chronic disease, and a common one in children. Depending on their symptoms and severity, children with asthma may be on “rescue” medications that they use only when they are having asthma symptoms, usually delivered through inhalers, or they may also take “controller” medications like inhaled corticosteroids every day, whether they’re feeling sick or well.

More symptoms or more impairment can mean more complex regimens, combining different kinds of drugs.

“Asthma is quite a variable disease; there’s not a one-size-fits-all,” said Dr Stanley Szefler, the director of paediatric asthma research at Children’s Hospital Colorado, and the author of a recent review of asthma across the life span.

“It’s a careful balance between symptoms and prevention and then the underlying things that may be going on.”

A youth uses an albuterol inhaler for asthma. (Photo: Max Whittaker © 2018 The New York Times)

DAMAGED LUNGS OVER TIME

The goal is to prevent the kinds of serious exacerbation that can land children in the emergency room or hospital. In addition to the dangers of respiratory distress, repeated exacerbations can lead to damaged lungs and worsened lung function over time, said Dr Heather Hoch, a paediatric pulmonologist at Children’s Hospital Colorado.

She presented research done with Szefler and other colleagues at the Pediatric Academic Societies meeting in early May, looking at children with asthma in the Colorado area to see which ones were most at risk for exacerbations. They found that children from birth to four years old were at higher risk than those over five, and that poor children were at higher risk.

They also looked at a biologic marker for allergic activity called the eosinophil count; eosinophils are a type of white blood cell associated with allergies and with asthma. The study found that children with higher eosinophil counts were at greater risk for asthma exacerbations.

Exacerbations were more common in spring and fall, so families with children in the higher risk groups should be especially careful at those times of the year. Earlier research had shown that fall was a high-risk time for children with severe asthma, but this study extended the work into a population with milder, more common levels of illness.

“Spring and fall are just hard times for kids with asthma,” Hoch said. “I tell families, be extra vigilant especially if their kids are allergic.”

You may not know your child’s eosinophil count, she said, but if a child with asthma has had a positive allergy skin test, or reacts to pollen with nasal congestion and itchy watery eyes, that’s a child whose family should take extra care in the spring and the fall, taking all the medications on schedule and avoiding possible triggers that can set off asthma.

LOOK AT ASTHMA OVER THE LONG HAUL

But there are also risks as we move into the summer, which is generally an easier time for children with asthma, so much so that many families are tempted to take “holidays” from at least some parts of the medication regimen.

Knowing which children are at highest risk for exacerbations may help doctors work with families around those decisions, Hoch said, and make sure that as the season changes to autumn, children are as well protected as possible.

“Parents should look at their child’s asthma over the long haul, not just day to day or week to week,” Szefler said.

Avoiding triggers can mean keeping the child away from tobacco smoke as much as possible, and reducing exposure to specific allergens, like cats and dogs, but it also means trying hard to reduce exposure to viral infections.

“Viruses are a huge trigger for exacerbations, especially in these allergic kids,” Hoch said. Prevention means vigilant hand hygiene, and of course, children should get their flu vaccines promptly in the fall.

According to the research literature, Hoch said, previous exacerbations are the most reliable predictor of future asthma exacerbations in children. And what’s most important for prevention is “that the kids actually take the medications being prescribed,” Hoch said. “Like any chronic disease, adherence is usually pretty poor.”

Parents may feel reluctant to give medications every day to a child who doesn’t look immediately ill, and they may have concerns about how the child will be affected by being on inhaled steroids for years.

Given in the usually prescribed doses, Szefler said, the inhaled steroids have been shown to have an early effect on some but not all children’s growth, reducing height by one centimetre.

“It seems to be permanent but not progressive,” he said, “one centimetre you may see in the first year.” But continued use of the steroids doesn’t mean that the cumulative effect gets larger.

USE LOWEST DOSE OF INHALED STEROIDS

Because of this impact on the child’s growth, the recommendation is to use the lowest effective dose of inhaled steroids, with the goal of keeping the child healthy: “If you have a kid who has significant asthma, the bigger concern about growth and development is asthma, not inhaled steroids,” Hoch said.

Families are often faced with changing regimens: “Every time I see a patient, I’m deciding where are they from a medication standpoint,” she said. “Do I need to think about stepping them up, or are they doing great, and maybe I can talk about stepping them down?”

New technologies may make it possible in the future for the inhalers themselves to monitor whether the medications are being used correctly, but even without those tools, it’s important for paediatricians to talk with families in detail about how regularly the children are getting their medicine.

Most children with asthma are managed by general paediatricians and family physicians. The children who get referred to paediatric pulmonologists are often those whose asthma has proved difficult to control, so that they do keep getting “stepped up” and may end up on higher doses than usual, or multiple medications at the same time.

Avoiding exacerbations is important, but the overall goal of managing asthma in children is not just keeping them out of the hospital, but also keeping them in their full range of activities – they shouldn’t be missing school, and they shouldn’t be sitting out the fun.

“The vast majority of kids with asthma, if we treat them appropriately and they take their medications, they can do whatever they like,” Hoch said. “I like to remind families we have Olympic athletes” with asthma.

When new families come in, she tells them, “If you take these medications and you avoid things that are going to make your asthma worse like tobacco smoke, you should be able to do anything in life you want to do, run and play on the soccer field, play football – you just have to take the medications to get your lungs back to the place everyone else is starting from.”

By Perri Klass, MD © 2018 The New York Times

  
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