Asthma in Young Children

Asthma in Young Children

·        especially for Medication and Spacer Use

·        3^rd most common reason for admission (after Bronchiolitis and URTI/Otitis media).

·        Much much less common in < 1 years (NB bronchiolitis causes wheezing in young). Peak in 2 – 4 years 

·        Peak flow very unreliable under age 7 (and most bad asthmatics diagnosed from 2 – 5) ® have to rely on history 

·        History: 

o  Symptoms: waking at night with cough/wheeze, after exercise, how often are attacks, had time off school/kindy as a result, how long does preventer last

o  Environmental factors: smokers, pets, damp, obvious triggers 

o   Current treatment: medicines, do the family understand the difference between reliever and preventer, assess technique and compliance, is spacer accepted by child and is it washed

·        2 patterns on history: 

o  Episodic (intermittent): viral URTI ® cough and wheeze.  No interval symptoms 

o  Persistent (with exacerbations): interval symptoms (with exercise, at night), exacerbations with viral infection, interferes with everyday life

·        Symptoms in a toddler:

o  Cough, often worse at night 

o  May vomit with cough (NB exclude pertussis: cough ® choke ® vomit ® OK for an hour. In asthma, cough again straight away) 

o  Usually wheezy with URT infection 

o  Diagnosis difficult in an infant unless recurrent, strong immediate family history or evidence of atopy

·        Physical findings in a toddler:

o  Often normal chest exam

o  If severe chronic symptoms:

§  Hyperinflated chest (­ AP diameter)

§  Harrison‟s sulcus: dip in chest wall where diaphragm attaches

§  Eczema

§  Reduced growth (if severe)

o  Stethoscope can be confusing

·        Diagnosis: 

o  Cough is very common in kids (8 – 10 per year). But more during the day than at night. Won‟t slow them down when running

o  Is it asthma, bronchitis, bronchiolitis?

o  Trial of therapy (preventative as well as relievers) and review

·        Criteria for admission:

o  Pulse rate > 1.5 * normal

o  Respiratory rate > 70 minute 

o  ­Chest movements

o  Restlessness/apathy/CNS depression or cyanosis/pallor [signs of exhaustion]

·        Severity assessment:

·        Treatment: 

o  Avoid triggers: passive smoking, pets, house dust mite (dehumidifiers don‟t work), pollens, cold, exercise, damp houses, certain foods (overstated)

o  Infrequent episodic asthma:

§  Consider no therapy, avoid triggers 

§  If distressed with attacks: use bronchodilators + spacer only. Start during URTI phase. No preventative

o  Frequent Episodic Asthma (only get it with a cold):

§  Intervals between attacks < 6 weeks

§  Bronchodilator as needed with URTIs

§  Prophylaxis:

§  Sodium cromoglycate (Vicrom + spacer).  ?Evidence of poor efficacy

§  Nedocromil (Tilade + spacer)

§  Inhaled steroids: if it makes no difference then stop

·        Persistent Asthma

o   Male: female = 4:1 

o   Preventative. If mild try Vicrom or Tilade. Moderate or severe use inhaled steroids (takes 2 – 3 months for maximal effect). Titrate back once controlled

o   Bronchodilators as required 

o   Poor control: consider ­dose, check inhaler device and technique, poor compliance, environmental triggers 

·        Other treatment options: 

o   Long-acting b-agonists: salmeterol (Serevent), eformoterol (Foradil, Oxis)

o   Theophylline (Nuelin, Theodur): 3^rd line, gut ache ® poor compliance

o   If severe: alternate day oral prednisone treatment – reduced side effects (short and fat), and reasonable asthma control

·        Protocol for an acute attack:

o   Salbutamol dose: up to 5 years: 6 puffs via space.  Over age 5: 12 puffs via space

o   For severe add ipratropium (Atrovent)

o   For moderate and severe, give doses at 0, 20, 40 and 60 minutes and review at 75 minutes 

o   Oral Steroid for all except minor attacks: 1 mg/Kg/day ® ¯relapse