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Tue 20 May 2008 04:00 AM

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Pediatric Asthma

New evidence-based asthma guidelines address the specific needs of children in three age groups.

New evidence-based guidelines address the needs of children in three age groups.

There is a great deal of excitement about new asthma guidelines released this summer by the National Heart, Lung and Blood Institute, in part because they drill down to the specific needs of children under age 12.

The 417 -page Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma released this past summer marks a departure from previous guidelines for several additional reasons, says Dr. Kenan Haver, assistant professor of pediatrics at Harvard Medical School. For one thing, it is entirely evidence based.

Diagnosing asthma in very young children is often challenging.

"Eighteen panel members spent three years looking at the medical literature and assessed the strength of evidence supporting each recommendation. Further, while previous asthma guidelines emphasized the classification of asthma severity, the new guidelines incorporate both asthma severity and control, and do so within the context of impairment and future risk," he says.

"This version of the guidelines is much more clinically focused and comes closer to real-life asthma management than previous versions," says Haver, whose clinical research includes evaluating therapies for the treatment of pediatric asthma.

"It reflects the fact that, as practitioners, we are most concerned with how well a patient's asthma is controlled."

In this In Practice feature Haver highlights some of the key changes to the guidelines as they relate to pediatric asthma patients.


Asthma is a chronic inflammatory disease of the airways. Diagnosing asthma in very young children is often challenging. The EPR 3 Report acknowledges that underdiagnosis and undertreatment are key problems in this age group.

But what it doesn't mention, says, Haver, is the problem of overdiagnosis. "You don't want to saddle someone with a chronic illness if they don't have it," he says, explaining we have learned from large cohort studies that about half of all children wheeze, within their first 3-6 years of life.

But many of them don't grow up to have asthma.

The guidelines include Asthma Predictive Index, which can be used to help parents and pediatricians identify children at risk for developing asthma.

The index looks at things like the length of wheezing episodes, parental history of asthma, the presence of atopic dermatitis, allergic sensitization, minor wheezing unrelated to colds, a blood eosinophil count equal to or greater than 4 percent, and an allergy to milk, eggs, or peanuts.

New categories and questionnaires

In the past, patients were divided into two categories: children and adults.

Now a third category has been added to the guidelines, so there are separate recommendations for children ages 0-4, 5-11, and 12 and above. (Note that the guidelines acknowledge that studies on children age 0-4 are limited. Other than the recommendation for low-dose inhaled corticosteroids, all other recommendations are "based on expert opinion and extrapolation from studies in older children").

Each group has its own chart for classifying asthma severity, and its own "Stepwise" approach to managing the disease. Each also includes a questionnaire for helping determine whether a patient's asthma is well controlled.

The most popular questionnaire is the Asthma Control Test, says Haver. For kids ages 12 and over, the test includes questions such as "how much time did you miss school or work?" "How frequent are your symptoms?" "How often are you out of breath?" "How often do you need a rescue inhaler?" and "How would you rate your asthma?"A score of 19 or below suggests that the person's asthma is not well controlled and serves as a trigger that something needs to be done. Younger children have their own version of the Asthma Control Test.

It includes just four questions for the children - using a smiley-face scale instead of numbers - and three questions for the parents or guardian.

Not only do these streamlined questionnaires make it easier to determine a patient's asthma control, says Haver, but they also may help patients and their families raise their expectation of what constitutes good asthma control and what it takes to get there.

Severity is assessed not only on the basis of current symptoms, but also on the risk of future exacerbations.

The goal, he says, should be complete control of symptoms - not, for example, coughing at night three times a week.

Stepping down

If you drill down deeper into the Stepwise approach, there are some small but important changes.

For instance, "mild intermittent" asthma is now just called "intermittent" - reflecting the fact that it is still possible to have a severe exacerbation with intermittent disease.

In addition, classification of severity now considers new dimensions of both "impairment" and "risk." In other words, severity is assessed not only on the basis of current symptoms, but also on the risk of future exacerbations.

This assessment is then used to guide decisions for initiating treatment in children not currently taking long-term control medications, and decisions for adjusting therapy.

But perhaps the most significant change is the emphasis of advice to step down treatment if symptoms remain under control for a specified time period.

This reflects a significant shift in thinking, and is based on studies that have shown that while daily treatment with inhaled corticosteroids early in the course of disease may improve symptoms, it will not alter the underlying progression of the disease.

Therefore, in children age 5-11, the guidelines specify that inhaled corticosteroids "should be used to control symptoms, prevent exacerbations, and improve the child's quality of life, but their use should not be initiated or prolonged for the purpose of changing the progression or underlying severity of the disease. (Evidence A)."

Another change: the current guidelines are more supportive of combination therapy using an inhaled steroid with either a long-acting beta agonist or a leukotreine receptor agonist.

At step 3, however, the recommendation for combination therapy in children is much weaker than it is for adults.

For children age 0-4, the recommendation for combination therapy is more controversial than for the other groups, says Haver, because fewer studies have been conducted on children in this age group.

Also, it is often possible to control young children's asthma with inhalers that contain only corticosteroids.

There is another advantage to the combination therapy, says Haver. Oftentimes people will neglect to take (or give their children) the prescribed inhaled cortcosteroids because there is no immediate symptom relief.

In contrast, combination therapy makes people feel better right away, so they are more likely to be consistent about taking their medication.

This article is provided courtesy of Partners Harvard Medical International. 2008 President and Fellows of Harvard College.

InformationThe 417 -page Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma can be viewed at:

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