Bronchial Asthma Management in Children

➡️Introduction

   Asthma is a chronic inflammatory disease of the airways, characterized by recurrent episodes of wheeze, chest tightness, cough, and shortness of breath and airflow obstruction resulting from edema, bronchospasm, and increased mucus production. Commonly associated with seasonal allergies (allergic rhinitis) and eczema (atopic dermatitis), these three conditions form what is known as the atopic triad. There is a wide range in the frequency and severity of the symptoms, but uncontrolled asthma and acute exacerbations can lead to respiratory failure and death. Around 14% of children worldwide have a diagnosis of asthma, making it the most common chronic respiratory disease of childhood. 

The prevalence of asthma among Egyptian children aged 3 - 15 years was estimated to be 8.2%. Poor asthma control is associated with a number of negative effects on children and families. For example, they are more likely to be absent from school, Caregivers also experience missed work days. Some children will experience severe symptoms and life-threatening attacks. Asthma is a multigenetic disease, where both genetic and environmental factors have significant roles in pathogenesis. Effective asthma management involves a holistic approach addressing both pharmacological and non-pharmacological management, as well as education and self-management aspects. Working in partnership with children and families is a key in promoting good outcomes. Education on how to take treatment effectively, trigger avoidance, modifiable risk factors and actions to take during acute attacks via personalized asthma action plans is essential.

 

➡️Scope

This guideline focuses on diagnosis, treatment and prevention of bronchial asthma in asthmatic children: preschoolers (5 years and younger), children (6 years and older) after treatment of acute asthma exacerbation.

 

➡️Guideline development process and methods

After reviewing all the inclusion and exclusion criteria the CPGs development group and methodologists recommended using the following guidelines

1. SIGN/BTS 158: British guideline on the management of asthma, 2019
2. Japanese pediatric guideline for the treatment and management of asthma (JPGL), 2020
3. Canadian Thoracic Society 2021 Guideline update: Diagnosis and management of asthma in preschoolers, children, and adults
4. European Respiratory Society clinical practice guidelines for the diagnosis of asthma in children aged 5–16 years, 2021
5. GINA Report 2024

 

➡️Recommendations and good practice statements

This version of the guidelines includes recommendations and good practice statements on the following subsections:

▪️ Diagnosis and management of asthma in children 5 years and younger

▪️  Diagnosis and Management of asthma in children 6 years and older

▪️ Prevention of Bronchial asthma

▪️  Difficult to treat asthma

▪️  Asthma resistant to therapy

▪️  Immunotherapy in asthma

 

We can summarize the guidelines for management of bronchial asthma in the following:

▪️ Clinical assessment to assess the initial probability of asthma is based on proper history taking with observation of clinical improvement in symptoms with inhaled beta-2 agonist, there is no role for x-ray except to exclude other diagnoses

▪️  Lung function testing, do not have a major role in the diagnosis of asthma in children less than 5 years while in children 6 years and older the diagnosis of asthma is based on the history of characteristic symptom patterns and evidence of variable expiratory airflow limitation and reversibility by spirometry or peak expiratory flow if available rather than relying on symptoms alone

▪️  For children aged 5 years and younger the best practice for the initial asthma management based on asthma severity is regular ICS or LTRA as controller treatment

▪️For children aged 6 years and older the best practice for the initial asthma management based on asthma severity is regular ICS, LTRA or ICS-LABA as controller treatment

▪️ Children should be reviewed after initial treatment every 2-3 months to review response and adjust treatment.

▪️  All children with asthma (and/or their parents or caregivers) should be offered self-management education, which should include a written personalized asthma action plan and be supported by regular professional review

▪️The child should be referred for expert assessment if symptom control remains poor and/or flare-ups persist, or if side-effects of treatment are observed or suspected

▪️ For prevention of asthma, breastfeeding should be encouraged for its many benefits, including a potential protective effect in relation to early asthma. Patients with asthma and parents/caregivers of children with asthma should be advised about the dangers of smoking and second-hand tobacco smoke exposure on their children. Also patients with moderate to severe asthma are advised to receive an influenza vaccination every year

▪️ For difficult to treat asthma patients should be systematically evaluated to confirm the diagnosis, check adherence to maintenance therapy, review history and examination for comorbidities and to identify modifiable risk factors and triggers

▪️ Severe asthma is a subset of difficult-to-treat asthma. In children 6 years and older it means asthma that is uncontrolled despite adherence with maximal optimized high-dose ICS-LABA treatment and management of contributory factors, or that worsens when high-dose treatment is decreased. Further assessment and management should be done by a specialist, additional investigations and assessment of asthma phenotype may be required

Allergen immunotherapy may be considered as add-on-therapy for asthmatic children who have clinically significant sensitization to aeroallergens including those with allergic rhinitis.