CLINICAL PRACTICE GUIDELINE FOR ASTHMA IN CHILDREN 0-4 YEARS OF AGE AND 5-11 YEARS OF AGE

Asthma often begins in childhood. 50 to 80% of children with asthma develop asthma symptoms (coughing, wheezing, shortness of breath or rapid breathing, chest tightness) before 5 years of age. Factors associated with onset of asthma symptoms in children include: allergy, a family history of asthma and/or allergy, perinatal exposure to tobacco smoke, viral respiratory infections, smaller airways at birth and in early life, male gender and low birth weight. Asthma in children should be considered when there is a history of recurrent cough (especially nocturnal), wheezing, shortness of breath or rapid breathing and chest tightness. It should also be considered with repeated diagnoses of: reactive airway disease, allergic bronchitis, wheezy bronchitis, asthmatic bronchitis, recurrent pneumonia or recurrent bronchiolitis. Asthma in this age group can be divided into four classifications: Intermittent, Mild Persistent, Moderate Persistent and Severe Persistent. For any child with asthma, the severity of the disease can change over time. Any child with asthma may have a severe exacerbation. Classifying a child as having mild asthma (either intermittent or mild persistent) does not rule out the possibility of a severe exacerbation. Children with viral-induced wheezing may have severe episodes with complete resolution between episodes, and may remain symptom free for months. Children with more than two episodes of asthma symptoms per month have persistent asthma. How do you classify the childs asthma severity? 1. BEFORE THERAPY is started; classify severity according to the clinical features of the childs asthma. *See the classifying charts attached with this guideline. 2. BEFORE OPTIMAL THERAPY IS ATTAINED (i.e. the child is taking medication but optimal control of the childs asthma has not yet been achieved), classify severity according to the clinical features of the childs asthma, as indicated in the attached classifying charts. 3. AFTER OPTIMAL THERAPY IS ATTAINED, the childs asthma severity can be classified according to the level of treatment needed to maintain control. For example: For intermittent asthma, no daily medication is needed. However, the use of shortacting beta2-agonist more than 2 times per week may indicate the need to start long-term control medication. For mild persistent asthma, one daily long-term control medication is necessary. For moderate persistent asthma, inhaled corticosteroids with or without additional long-term control medications are recommended. For severe persistent asthma, multiple long-term control medications are required, including high-dose inhaled corticosteroids and, if needed, other medication, including oral corticosteroids.

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It is recommended that practitioners providing care to asthmatic patients document in the patients medical record the severity of the asthma using the four classifications: Intermittent, Mild Persistent, Moderate Persistent and Severe Persistent. Managing the Child with Asthma Successful asthma management has 4 components: 1. Regular assessment and monitoring 2. Control of factors that contribute to symptoms and disease severity 3. Pharmacologic therapy 4. Patient education The aim of asthma therapy in children is to maintain control of asthma with the least amount of medication and, hence, minimal risk for adverse effects. Management: *See attached tables for children aged 0-4 and children aged 5-11. Goals of Therapy for the Child with Asthma 1. Prevent chronic and troublesome symptoms. 2. Prevent exacerbations of symptoms. 3. Maintain normal activity levels. 4. Maintain normal pulmonary function. 5. Optimize pharmacotherapy, minimize side effects. 6. Satisfy the childs and the familys expectations/goals for asthma care. Referral to an asthma specialist (for consultation or co-management) is recommended when: The child has had a life-threatening asthma exacerbation. Goals of asthma therapy are not being met after 3-6 months of treatment; earlier if the child appears unresponsive to treatment. Signs and symptoms are atypical, or there are problems in differential diagnosis. Other conditions complicate asthma or its diagnosis (e.g., untreated sinusitis, rhinitis). Additional diagnostic testing is indicated (e.g., pulmonary function testing, allergy skin testing). The child or family needs additional education and guidance on complications or therapy, problems with adherence, or avoidance of triggers. The child is being considered for immunotherapy. The child has severe persistent asthma. The child is under 3 years of age and has moderate or severe persistent asthma. The child has used long-term oral corticosteroid therapy, high-dose inhaled corticosteroid therapy, or more than 2 bursts of oral corticosteroids in 12 months. The AAAAI (American Academy of Allergy, Asthma and Immunology) recommends that anyone with the diagnosis of asthma be seen by an allergy specialist at least once for diagnostic evaluation and skin testing to exclude allergy as a cause or etiology of their asthma.

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Identification of allergens in the environment may allow modification of that environment which in and of itself may allow management and excellent control without life long chronic use of medications. References: National Asthma Education and Prevention Program. NAEPP Expert Panel Report Guidelines for the Diagnosis and Management of Asthma-Update on Selected Topics 2002. NIH Publication No. 02-5075. June 2002. Reprinted May 2003. Pediatrics in Review, Volume 30, Number 10, October, 2009. National Heart, Lung and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. US Department of Health and Human Services, National Institutes of Health, August 2007. American Academy of Allergy Asthma & Immunology. Pediatric Asthma-Promoting Best Practice. 2002.

Chief Medical Officer - Pro Tem Medical Associates Clinic & Health Plans

Date

President Medical Associates Clinic

Date

Original: Revised: Revised: Revised:

10/99 02/01 03/02 03/03

Revised: Revised: Revised: Revised:

06/04 01/05 07/06 06/07

Revised: Reviewed: Revised: Reviewed:

07/08 10/09 02/11 02/12

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