Dr Ryan Mackle( left) Respiratory research fellow, department of respiratory medicine, Sydney Children’ s Hospital; PhD candidate, discipline of paediatrics and child health, school of clinical medicine, UNSW Sydney, NSW.
Mrs Melinda Gray( centre) Asthma clinical nurse consultant, department of respiratory medicine, Sydney Children’ s Hospital, NSW.
Dr Bernadette Prentice( right) Respiratory paediatrician, department of respiratory medicine, Sydney Children’ s Hospital; Conjoint lecturer, discipline of paediatrics and child health, school of clinical medicine, UNSW Sydney, NSW.
First published online on 15 November 2024
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BACKGROUND
ASTHMA remains one of the most
common chronic disorders worldwide. 1 The 21st century has seen significant improvements in asthma management across the age spectrum, with improved outcomes. However, there remains high levels of asthma disease burden, high levels of uncontrolled asthma and increased healthcare utilisation, particularly in the paediatric population. 2 Children with asthma are a unique population.
This How to Treat covers the presentation, the recommended diagnostic workup and the overall management, as well as the intricacies of asthma in children. It aims to ensure GPs can provide optimal asthma care for children in their community.
EPIDEMIOLOGY
IN Australia, one in 10 children has a diagnosis of asthma. The condition is more common in boys than girls, although this changes in mid-adolescence and adulthood. 3 Asthma predominantly occurs in Australian children in metropolitan regions where population levels and various modifiable
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environmental factors like house dust mites, pollution and household smoke are higher. 4
Mortality from asthma in children is currently at the lowest level for decades, at 0.2 per 100,000 population Australia-wide. 5 However, across all age groups these rates are higher the further one lives from urban centres, with mortality rates 1.6 times higher in outer regional areas despite incidence rates being lower in these regions. 4 Aboriginal and Torres Strait Islander populations have up to a 2.5-fold increased rate of mortality across all age groups compared with non-Indigenous populations. 5
Asthma management costs the Australian healthcare system about $ 851 million per annum, with most spent in primary care. 4 Salbutamol is the cheapest inhaler option available, and can be purchased over the counter without prescription. Inhaled corticosteroids( ICS) and combination inhalers like fluticasone propionate / salmeterol available on PBS authority prescription are more expensive. Private prescription outside of PBS criteria is even more costly. Other related costs including appointment fees( GP and / or non-GP specialist gap fees),
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days missed from work / school / childcare and travel costs for those living outside of urban centres also contribute to a family’ s financial burden. 6
CLINICAL PRESENTATION
THE most common clinical features
of asthma include wheeze, dyspnoea, chest tightness and / or cough. These symptoms do not necessarily mean a diagnosis of asthma is certain. However, if there are other features present, this makes the diagnosis more likely( see box 1). It is important to note that an isolated cough, particularly a nocturnal cough, in the absence of signs of airway flow limitation like wheeze or difficulty breathing, make an asthma diagnosis unlikely and alternative diagnoses should be considered( see table 1). 7
HIGH-RISK POPULATIONS AND ASTHMA RED FLAGS
THERE are several distinct population groups associated with a
heightened risk of morbidity and mortality from asthma. Box 2 lists the red flags for morbidity and mortality in asthma.
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Adolescents
Adolescents are more likely to engage in high-risk activities like vaping and often have poor treatment adherence and reduced healthcare engagement that can impact on asthma control. 7, 10-12 Hormonal changes, particularly in female adolescents, can also wreak havoc with asthma control. 3
Treatment compliance issues, while not unique to asthma in adolescence, can affect asthma control and quality of life. Poor preventer adherence can lead to short-acting beta 2 agonist( SABA) overuse; current guidelines have changed to reflect this and no longer recommend SABAs alone in adolescents. 1, 7
Several strategies specific to adolescents include shared decision-making with treatment options, for example, once daily versus twice daily preventer therapy, metered dose inhaler versus dry powder inhaler( DPI), or consideration of ICS / formoterol as needed when stable. Many adolescents think spacers are no longer required as they get older; however, continuing use of spacers
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