Australian Doctor 16th May 2025

32 HOW TO TREAT: ASTHMA IN CHILDREN

16 MAY 2025 ausdoc. com. au aeroallergen minimisation strategies including mattress and pillow house dust mite protectors, regular household cleaning and removal of carpeted floors where possible. 59 HEPA filter air purifiers can also be considered, if financially accessible for families, as an additional measure of improving household environment and air

60, 61 quality.

COMORBIDITIES Other conditions like allergic rhinitis, obesity, anxiety and inducible laryngeal obstruction( ILO)/ vocal cord dysfunction( VCD) can impact asthma control.

Allergic rhinitis and asthma commonly occur together. 62 Adequate treatment of allergic rhinitis with intranasal steroids, antihistamines or on some occasions, immunotherapy, can result in improved asthma control; so consider this in children with uncontrolled asthma despite upwards titration in pharmacotherapy. 63 Obesity and asthma share some

64, 65 common causative factors. Counselling parents / carers and children on the effects of obesity on asthma control and general health is important. State-based initiatives like Go4Fun( NSW), Get Active Kids( Victoria) or KidSport( WA) can be useful parent-initiated interventions to introduce children and adolescents to more exercise and activity.

Anxiety is up to three times more likely in young people with asthma than in comparable healthy adolescents. 66 Both anxiety and depression have been associated with poor asthma control, so early multidisciplinary intervention including psychology at a younger age can be beneficial. 67

ILO and VCD are synonymous terms describing the involuntary paradoxical movement of vocal cords on inspiration. The common symptoms are shortness of breath, wheeze and / or stridor, which is not dissimilar to asthma. Have a low threshold for suspicion of ILO / VCD in children with asthma who

report an acute onset of exacerbation and an abnormal response to SABA use( rapid onset in less than one minute or no effect at all). Early referral to a respiratory specialist is recommended to facilitate diagnostic interventions like cardiopulmonary exercise testing with flexible nasendoscopy. This can avoid unnecessarily escalating preventer and reliever therapy as treatment is more focused on breathing techniques. 68

How to Treat Quiz.

1. Which THREE statements regarding the epidemiology of asthma are correct? a In Australia, one in 10 children has a diagnosis of asthma. b Asthma is more common in males than females throughout the life span. c The economic burden of asthma in Australia is higher in primary healthcare than hospital-based care. d Mortality from asthma is higher in children living in regional, rural and remote areas.

2. Which ONE lists the most common clinical features of asthma in children? a Isolated cough with sneezing and rhinorrhoea. b Family history of atopy and a nocturnal cough. c Wheeze, dyspnoea, chest tightness and / or cough. d Stridor and dyspnoea.

3. Which TWO statements suggest an alternative diagnosis to asthma in children is more likely? a Bilateral wheeze, dyspnoea and cough. b Dyspnoea, wheeze and cough on exertion. c Wheeze, hypoxia and crepitations in an eight-month-old child. d Unilateral wheeze, persistent cough and digital clubbing.

Anxiety is up to three times more likely in young people with asthma than in comparable healthy adolescents.

SMOKING CESSATION Antenatal maternal smoking and ongoing exposure to household smoke are risk factors for both asthma development and poor asthma control. 69 First-hand and second-hand smoke can reduce lung function, increase the number of exacerbations per year( including life-threatening episodes) and SABA use. 69 Vaping has also become increasingly popular with young adults, with some documented cases of life-threatening asthma exacerbations following the use of vape pens. 10, 70, 71 Vaping is still relatively new, and little is known about the long-term effects of vaping and asthma. However, as with cigarette smoking, discourage vaping in children, adolescents and their parents / carers. 10 Federal Government programs are available to encourage smoking cessation, utilising nicotine replacement therapy and / or psychology.

CASE STUDY

DANIEL is a six-year-old boy. He has presented four times to his local ED in the past six months with viral illnesses and on each occasion had

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4. Which THREE are red flags for morbidity and mortality in asthma? a Poor adherence to preventer therapy. b Short-acting beta 2 agonist

( SABA) overuse. c Multiple hospital presentations. d Higher socioeconomic status.

5. Which THREE are factors that specifically impact on asthma control in Aboriginal and Torres Strait Islander children? a Treatment adherence. b Lower sociodemographic factors. c Healthcare engagement. d Limited household smoking exposure.

6. Which TWO statements regarding the assessment of asthma are correct? a A diagnosis of asthma is more symptom-driven in children under six. b Skin prick testing is not useful in the assessment of asthma. c Fractional exhaled nitric oxide can be used to diagnose asthma. d Spirometry is most reliable in children aged older than five for both diagnosis and monitoring treatment response in asthma.

7. Which THREE statements regarding additional investigations in asthma are correct? a Raised serum eosinophils can be seen in uncontrolled asthma. b Allergic bronchopulmonary aspergillosis can be an important cause of persistent wheezing in children with asthma. c Low immunoglobulin( Ig) G and IgE are associated with uncontrolled asthma. d High-resolution CT chest may be indicated in the presence of red flags for other diseases.

8. Which TWO may be appropriate asthma care in children under six? a Regular low-dose ICS in all children under six. b A trial of salbutamol as required in children with wheeze. c Children may be trialled on combination inhalers( inhaled corticosteroids( ICS)/ LABA) if asthma is uncontrolled.

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ASTHMA IN CHILDREN

salbutamol responsive wheeze. His parents have continued to regularly help Daniel use salbutamol but have not sought GP review until now.

On review, the GP notes a strong family history of atopy. Daniel has some exertional symptoms, including reduced exercise tolerance when compared with his peers, that his parents had previously under-recognised. Based on the frequency of presentations, and known salbutamol responsiveness, his GP refers Daniel to the local paediatric hospital for formal spirometry and aeroallergen skin prick testing.

Daniel is started on an eightweek trial of low-dose ICS( fluticasone propionate 50μg two puffs twice daily via spacer).

At eight-week GP review Daniel has significant improvement in his exertional symptoms and has avoided further hospitalisation. Spirometry performed at the hospital demonstrated a mild obstructive defect with significant bronchodilator response and a raised FeNO. Skin prick testing identified sensitisation to house dust mites and various grasses.

A personalised AAP and school-specific AAP are developed, and the GP, Daniel and his parents discuss aeroallergen minimisation strategies. The GP provides Daniel’ s parents with asthma information sheets and links to online asthma educational resources. Follow-up is

d Montelukast is an alternative first-line monotherapy to ICS.

9. Which THREE statements regarding the management of asthma are correct? a Combinations inhalers( ICS / LABA) are indicated as first-line therapy in all children with asthma. b Prescribe a minimum of regular ICS and SABA as required for adolescents aged 12 or older. c In those aged 6-11 with frequent asthma symptoms, regular lowdose ICS and SABA as required is recommended. d ICS / formoterol may be preferable in adolescents over 12 with suspected medication compliance issues.

10. Which TWO statements regarding the non-pharmacological management of asthma are correct? a Regular asthma education and review is important in establishing good asthma control. b The routine use of asthma action plans results in fewer asthma exacerbations, fewer missed days of school / childcare, and better asthma control. c Spacers are not required in children over the age of 12. d There is no association between comorbid conditions like allergic rhinitis, obesity or anxiety and poorer asthma control. arranged for three months to discuss his AAP, asthma control and progress.

CONCLUSION

ASTHMA control and symptom burden in childhood can have a lasting impact on long-term disease progression, and healthcare utilisation. Despite being a treatable condition, children still die from asthma in Australia. Simple measures like regular GP review to assess control when well, symptom monitoring, review of treatment adherence, including avoidance of salbutamol overuse, can make a significant difference to a child’ s asthma control. Asthma remains an entirely manageable disease for most Australian children, and GPs remain an integral part of their asthma care throughout their life span.

Australian Doctor 16th May 2025 | Page 32

32 HOW TO TREAT: ASTHMA IN CHILDREN

32 HOW TO TREAT: ASTHMA IN CHILDREN

How to Treat Quiz.