COMPLACENCY is the biggest threat to the effectiveness of asthma management in children, a leading paediatrics expert has claimed.
Professor Adam Jaffe, John Beveridge professor and head of the discipline of paediatrics at the University of NSW, said that while the overall prevalence of asthma in Australian children had decreased in recent years from one in six to approximately one in 10, he was disturbed by the number of children who had died from asthma in NSW alone in the past decade.
In a Perspectives article published in the MJA, Peter van Asperen, professor of paediatric respiratory medicine at the University of Sydney, wrote that the results of the NSW Child Death Review Team annual report showed that 20 children, aged up to 17 years, had died from asthma in NSW from 2004 to 2013. (1)
Professor van Asperen wrote that for 17 of the children who died, factors which may have increased their mortality risk were identified, including suboptimal asthma control, presentation to hospital, poor adherence to medication, lack of a written asthma action plan and exposure to tobacco smoke.
He said innovative educational strategies and tools such as Practitioner Asthma Communication and Education (PACE) and Giving Asthma Support to Patients (GASP) were important “for promoting asthma management guidelines and reducing asthma morbidity and mortality in children”. (2), (3)
Professor Jaffe agreed that education was paramount because “there is a lot of presumed knowledge in the community, and we need to build awareness among GPs, nurses and paediatricians of exactly what to look for in children with asthma and how this should be managed”.
He told MJA InSight that having an updated, written asthma action plan that the child, their parents and their school understood was vital to treatment adherence.
“It’s also important for GPs to discuss with parents the environmental risk factors that can be reduced, like exposure to tobacco smoke.”
In his MJA article, Professor van Asperen said that a concerning trend was the large number of children taking combination inhaled corticosteroid long-acting β agonists (ICS–LABA) therapy, which had been linked to potential adverse effects, including increased exacerbation risks, loss of bronchoprotection against exercise-induced asthma, and reduced efficacy of short-acting β agonists.
Professor Tim Usherwood, head of the department of general practice at Sydney Medical School (Westmead), agreed that ICS-LABA therapy may be inappropriately prescribed to children with asthma, and emphasised the need to stick to the guidelines articulated in the Australian Asthma Handbook. (4)
He said it was important for clinicians to be aware that LABA was not the only option available to treat children whose asthma was inadequately controlled on low-dose ICS.
“Increasing the dose of corticosteroid or adding montelukast should also be considered.”
Professor Usherwood told MJA InSight that to further encourage treatment adherence, four things should always be checked — that the diagnosis was correct, the child had the right type of inhaler and the skills to use it, and that they were using it as prescribed.
"Once a child’s asthma is fully controlled, the GP should review their progress regularly, perhaps every 3 months.”
A US study published last week in JAMA Pediatrics examined the impact of an intervention to help children to adhere to asthma treatment using speech recognition software that creates computer-generated telephone conversations. Speech recognition telephone calls to parents were triggered when an ICS refill was due or overdue. (5)
The research found the intervention led to a 25.4% higher adherence to ICS compared with children who did not receive the intervention. However, asthma-related urgent care events did not differ between the two groups.
Professor Anne Chang, NHMRC practitioner fellow at the Royal Children’s Hospital, Brisbane, said the answer to whether adherence to guidelines led to better patient outcomes was still unclear, but believed the Australian context differed from conditions in the US.
“Australian guidelines have been implemented more effectively with a multipronged approach by the government, GPs, parents and schools”, Professor Chang told MJA InSight.
However, she said guidelines could only go so far in addressing the diagnostic challenges of paediatric asthma, which sometimes led to delays in treatment. One reason for this was the difficulty in diagnosing asthma in children aged under 5 years.
“In older children we can run objective tests for hyper reactivity, lung function and exercise, but it’s hard to do this in very young children. [Diagnosis] is still a problem.”
1. MJA 2015: 202; 125-126
2. National Asthma Council Australia: PACE
3. J Prim Health Care 2014: 6: 238-244
4. National Asthma Council Australia: Australian Asthma Handbook 2014
5. JAMA Pediatrics 2015: Online 9 February
(Photo: Ian Boddy / Science Photo Library)