Pediatricians' Ready Reference Guide for managing asthma in children

One of these challenges is to reduce hospitalization rates that have remained unchanged over time, particularly in young children (aged 0-4 years) who have the highest hospitalization rates.²

Further work also needs to be done to address the persistent disparity in asthma burden by race, gender, socioeconomics, and overall health status. Recent statistics show that the prevalence of asthma in non-Hispanic black children is 16% compared with 9% in Hispanic children and 8% in non-Hispanic white children, and that asthma diagnosis is more prevalent in boys than girls (16% vs 12%).¹ Children from poor families also have more asthma compared with children from higher socioeconomic families (13% vs 8%), and children in fair or poor health are 5 times as likely to have asthma compared with children in excellent or very good health (37% vs 8%).

To help physicians meet these challenges and offer the best help to children and their families who present with asthma, guidelines specifically developed for managing asthma in children by an expert panel of the National Asthma Education and Prevention Program at the National Heart, Lung, and Blood Institute (NHLBI) provide scientifically based information on classifying and assessing asthma severity and control as well as key components to achieve and maintain asthma control. Developed initially in 1997 and called the Expert Panel Report (EPR) 2, the guidelines have undergone 2 updates with the most recent update in 2007 called the EPR3.²

In the EPR3, asthma assessment and treatment recommendations are provided for 3 age groups of children: 0 to 4 years, 5 to 11 years, and 12 years and older.

The guidelines focus on 4 key components of achieving and maintaining asthma control:

1. assessing and monitoring asthma severity and control;

2. education for a partnership in care;

3. control of environmental factors and comorbid conditions that affect asthma;

4. medications.³

The guidelines offer a stepwise approach to treatment that incorporates these components, with an emphasis on initiating medications based on disease severity and increasing (stepping up) or decreasing (stepping down) use of medications based on disease control. The type, amount, and scheduling of medication is determined by asthma severity for initiating therapy and on the level of asthma control for adjusting therapy.²

This article highlights key recommendations from the EPR3 on the stepwise approach to therapy to achieve and maintain control following an assessment and classification of asthma severity and control. Primary focus is given to the pharmacologic treatment of asthma in children, with minimal focus on education and control of environmental factors and comorbidities. Physicians interested in more information on these important areas are referred to a summary report of the EPR3 published by the National Institutes of Health.³

Classifying asthma severity to initiate treatment

To obtain the best assessment of asthma severity, initial assessment should be done prior to the initiation of long-term medications to control disease or be inferred from the least amount of treatment needed to maintain control. The guidelines include 2 main areas that need to be assessed to determine control: current impairment and future risk.⁴ The guidelines categorize disease severity as intermittent or persistent based on symptoms, use of rescue medications, frequency of exacerbations, and pulmonary function tests. Persistent disease is further categorized as mild, moderate, or severe. Initial treatment is based on the level of asthma severity. Table 1 provides a summary of the classification of asthma and initiation of treatment for each age group.

Assessment of control to adjust treatment

The goal of asthma therapy is to maintain long-term control of asthma with the least amount of medication to minimize the risk of adverse effects.² The guidelines emphasize the need to recognize and distinguish between long-term control of current impairment and control of future risk to make appropriate treatment decisions and adjustments.

Maintenance of long-term control of current disease impairment is indicated by prevention of chronic symptoms; the need for infrequent use of short-acting beta-agonists (SABAs); and maintaining normal lung function and normal activity levels.² Long-term control of future disease risk is indicated by the prevention of exacerbations; minimizing emergency care and hospitalization; preventing the loss of lung function or reduced lung growth; and minimizing the adverse effects of treatment.

To achieve long-term control (ie, of current impairment and future risk) of asthma, periodic monitoring and assessment is needed along with treatment adjustment when necessary. Table 2 summarizes assessment of asthma control and treatment adjustment by age. The guidelines recommend monitoring every 2 to 6 weeks for newly diagnosed children or those with uncontrolled disease; every 1 to 6 months for children with controlled disease; and every 3 months if therapy is expected to change.²

Treatment based on stepwise therapy

The guidelines recommend a stepwise approach to treatment: Treatment is increased (stepped up) as needed for uncontrolled asthma or more severe disease and decreased (stepped down) as possible to achieve and maintain long-term asthma control.² If a step increase is needed, physicians should first check inhaler technique, adherence to treatment, environmental control, and comorbid conditions to ensure an increase in medication is what is needed. A step down in treatment is possible if asthma is well controlled for at least 3 months.⁵

The recommended adjustments to therapy by age and level of control are shown in Table 3. As shown in the table, inhaled corticosteroids remain the most effective therapy recommended for long-term control in all age groups.

Medications for rescue treatment

The guidelines emphasize the importance of early rescue treatment to provide the best strategy for managing asthma exacerbations. For children with mild exacerbations that can be managed at home, early treatment should include appropriate intensification of treatment by increasing inhaled short-acting beta agonists (SABAs) and in some cases adding a short course of oral systemic corticosteroids.² For children with more severe exacerbations that require urgent care, early treatment should include SABA to relieve airflow obstruction (with the addition of inhaled ipratropium bromide for severe exacerbations); systemic corticosteroids to decrease airway inflammation or for patients who don’t respond promptly to a SABA; and possibly adjunct treatment such as intravenous magnesium sulfate or heliox. Table 4 highlights medications for rescue treatment by age and disease severity.

Medications for maintenance treatment

The guidelines emphasize that asthma is a chronic inflammatory disorder of the airway, and that effective control of persistent asthma requires daily medication for long-term control that suppresses airway inflammation.² Medication management to maintain asthma control includes increasing the dose of inhaled corticosteroids (ICS) to medium dose before adding adjunctive therapy in patients aged 0 to 4 years with asthma that is not well controlled. For children aged 5 to 11 years and those aged 12 years and older, increasing the ICS dose to medium or adding adjunctive therapy to a low ICS dose are considered equal options. Table 5 highlights medications for maintenance treatment by age and disease severity.

Summary

The most recent NHLBI guidelines provide physicians with improved ways to assess and monitor disease severity and control in children with asthma, and offer a stepwise approach to treatment geared to achieving and maintaining control with minimal adverse effects. Emphasized is the importance of recognizing and managing control of both current impairment and future risk of disease. By offering treatment recommendations based on age and disease severity, the guidelines offer a way for physicians to manage better the individual needs of their patients.

REFERENCES

1. Bloom B, Jones LI, Freeman G. Summary health statistics for U.S. children: National Health Interview Survey, 2012. National Center for Health Statistics. Vital Health Stat. 2013;10(258).

2. National Heart, Lung, and Blood Institute (NHLBI). National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Full Report 2007. NIH Publication No. 07-4051. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007:S94-S138.

3. National Heart, Lung, and Blood Institute (NHLBI). National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Summary Report 2007. NIH Publication Number 08-5846. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. Available at: www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf . Accessed April 25, 2014.

4. Reddy AP, Gupta MR. Management of asthma: the current US and European guidelines. In: Brasier AR (ed). Heterogeneity in Asthma. Advances in Experimental Medicine and Biology (Book 795). New York: Springer Science+Business Media; 2014.

5. University of Michigan Health System (UMHS). Clinical care guidelines on asthma. Quick reference charts for the classification and stepwise treatment of asthma. Available at: www.med.umich.edu/1info/fhp/practiceguides/asthma/epr-3_pocket_guide.pdf. Accessed April 25, 2014.

Ms Nierengarten, a medical writer in St. Paul, Minnesota, has over 25 years of medical writing experience, coauthoring articles for Lancet Oncology, Lancet Neurology, Lancet Infectious Diseases, and Medscape. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.