The American College of Allergy, Asthma and Immunology (ACAA) released a set of guidelines in July 2018 with the goal of helping pediatric medicine providers to select medications that are appropriate for each age group. The guidelines comprise a set of therapeutic scenarios based on age, and formularies for each, with a focus on asthma classifications per age group and how best to manage pediatric and teen asthma.
According to the Centers for Disease Control (CDC), it is estimated that the prevalence of asthma in children is 8.4 percent and for school age children ages 6 to 18 it is 10 percent. These statistics suggest that these younger age groups are not an insignificant population. Asthma causes not only missed school days, but also missed work days for parents, especially when pediatric asthma remains poorly controlled.
Why children are treated differently
Many providers are reluctant to give medications to young children. Significant symptoms usually have to appear for a provider to move to potent medications in children. The effect of the first line controller treatment of asthma, the inhaled corticosteroids, is still not completely understood in the pediatric community. It’s not clear that there are no long-term effects on growth. There are also concerns about children bringing short-acting bronchodilator inhalers to schools, and essentially allowing them unsupervised use.
Another challenge in asthma treatment in children is arriving at a diagnosis. Children will not usually express the symptoms of this disease like adults. Shortness of breath may be manifested by restlessness and can be misinterpreted as disruptive behavior, even ADD or ADHD. Physical examination findings often share features with viral illnesses that commonly go untreated.
Not all ages manifest the disease the same way. Asthma becomes more recognizable during teenage years because it interferes with daytime activities such as sports and social activities. In younger children, asthma interferes with sleep. Children with non-restorative sleep will not always behave in a sleepy manner as adults might, but rather with misbehaviors and poor concentration in class.
How the guidelines break down
This set of recommendations, called the Pediatric Asthma Yardstick, divided the population into three age groups: adolescents between 12 and 18 years of age, school age children between ages 6 and 11, and infants and young children 5 years old and under.
The concern among practitioners is not only the absenteeism associated with poorly controlled asthma, but also the long-term effects of uncontrolled airway inflammation on a pediatric lung development. This adds a different dimension to the consequences that the disease has in kids compared to adults.
For example, in adults with asthma, the main element that is measured is flow through the airways, while in children the focus is on the growing elasticity of the lungs. Since the airways in children are smaller, it doesn’t take much in terms of mucus plugs, to block flow to an entire area of the lung, causing increasing stiffness of the chest.
In the pediatric community, the goals of therapy are to maintain normal daily activity level and to minimize sleep disturbance.
New insights from the yardstick
The stepwise approach presented in the Pediatric Asthma Yardstick guidelines modifies some of the treatment protocols presented in the Global Initiative for Asthma (GINA), a set of medical guidelines that are regularly updated. The stepwise approach offers some specific recommendations:
Although mild, intermittent asthma is still treated by starting with a short-acting bronchodilator inhaler as needed, the inhaled corticosteroid medication is now also recommended to be included “as needed.” The goal of this recommendation is to minimize the overuse of the other types of inhaler medications that may make children cranky and also overmedicate them. There is a false sense of relief parents (and children) get that may increase the tendency to use these inhalers beyond the safe level for the pediatric community.
Follow up visit recommendations are more frequent with the changes in therapy that are discussed in the new guidelines. The whole idea is preventing a visit to the Emergency Room which may involve an all-day experience at the hospital rather than short visits to the doctor to keep the child patient stable.
The guidelines recommend that the inhaled corticosteroids are started with a low dose, and the doses are different for each age group and not guided by body weight as doses of many other medications typically are. There are different brands of inhaled medications and there will be variations of choices by providers and insurance coverage, so this document determines what constitutes “low dose corticosteroids” for different brands.
There’s consideration of delivery method for the different age groups, as younger children may not be able to follow directions and coordinate taking a deep breath with the delivery of the solid particles (drug) in the inhaler. For this reason, nebulizer treatments are preferred in the younger pediatric age group.
The new guidelines also incorporate recommendations regarding when to refer a pediatric or teen patient to a specialist, based on disease progression or (lack of) response to the recommended formularies. There is a lower threshold now with regards to children and stipulations for timing of referral to a pulmonologist or allergist.
There is also an updated recognition and understanding of factors that interfere with asthma control that are unique for this young population including:
- Environmental exposures such as allergens mainly indoors that can dramatically impact children are considered.
Comorbid conditions that perpetuate asthma in the pediatric community such as nasal infections, sinusitis, and gastro-esophageal reflux from childhood obesity are discussed more thoroughly.
There is recognition of the poor understanding of the treatment method in this young group and the reluctance children may have to follow instructions optimally.
Family stresses resulting from disruption of work, economic concerns affecting children, emotional upset, and even domestic violence which may be present in the family unit are considered.
The possibility that the family and child lack insurance coverage is included in the discussion.
Obviously, these factors are often more prominent and prevalent among those in the lower socioeconomic classes, reflecting the current data that correlates the issues affecting children with poorly controlled asthma. The guidelines may be especially helpful to this pediatric population.
The new guidelines recognize all these factors. The hope is that that this document will give clarity and lead to consistency of care among providers who treat children and teens with asthma. Poorly treated asthma in the pediatric population can have long-lasting negative health implications. Following well-proven and consistent protocols nationally will be a win-win for healthcare providers and the populations they service.