Author's details
- Dr Hauwa Umar Mustapha
- MBBS, MWACP, Senior Registrar in paediatrics
- Aminu Kano Teaching Hospital, Kano.
Reviewer's details
- Dr Hakeem Edun Babatunde
- (MBBS, FMCPaed)
- Vaccine & Immunity Theme, MRC Unit The Gambia at LSHTM, Banjul, The Gambia
Asthma in Children
Asthma is a chronic inflammatory lung airway condition resulting in episodic, reversible airflow obstruction. This chronic inflammation heightens the airway’s twitchiness to common provocative exposures. The episodes of airflow obstruction are termed exacerbations.
Asthma affects over 300 million individuals globally with increasing prevalence in developing countries. It is a major public health concern affecting all age groups. It poses a substantial burden on patients, their families, community and health care systems. It is more prevalent in urban areas than in rural areas. Acute severe asthma occurs in about 1% of patients and mortality from it is 4.9% – 6.0%.
• Respiratory tract infections – viral and bacterial
• Indoor allergens – house dust mites, animal dander, cockroach
• Seasonal aeroallergens – pollens, moulds
• Air pollutants – tobacco smoke, dust, smoke
• Strong noxious odours or fumes
• Occupational exposures – farms, insecticides
• Exercise and stress
• Cold dry air
• Uncontrolled asthma symptoms
• Previous severe asthma exacerbation (intensive care unit admission, intubation for asthma)
• Sudden asphyxia episodes (respiratory failure, arrest)
• Two or more hospitalisations for asthma in the past year
• Three or more emergency department visits for asthma in the past year
• Increasing and large diurnal variation in peak flows
• Use of >2 canisters of short-acting β-agonists per month
• Poor response to systemic corticosteroid therapy
• Monotherapy with LABA
• Chronic severity with impaired lung functions
• Non-compliance to controller medications, ICS not prescribed, incorrect inhaler techniques
• Co-morbid conditions such as obesity, chronic rhinosinusitis, food allergy, GERD and other atopic conditions.
• Dysfunctional family unit
Presentation is usually at night or early morning hours. It may also show seasonal variation. They include:
• Fast breathing/difficulty in breathing/shortness of breath
• Cough
• Chest tightness
• Refusal to feed
• Refusal to lie down
• Difficulty speaking
• Wheeze
• Use of accessory muscles
• ± fever
• Physical examination in individuals with asthma is often normal. Frequent findings include:
• Ill-looking, in respiratory distress
• Cyanosis
• Tachypnoea
• Hyper-resonant percussion notes
• Reduced air entry
• Rhonchi/silent chest
• Tachycardia
• Pulsus Parodoxus is usually present
• Low SpO2
• Based on severity, asthma is classified as:
• Mild/moderate asthma: patient talks in phrases, prefers sitting or lying posture, not agitated, tachypnoeic with no use of accessory muscles of respiration, normal pulse rate and oxygen saturation (on air) of 90-95%, PEF >50% predicted or best.
• Severe asthma: patient talks in words, sits hunched forwards, agitated, tachypnoeic with use of accessory muscles, tachycardic, oxygen saturation <90%, PEF ≤50% predicted or best.
• Life-threatening asthma: patient is drowsy, confused or silent chest
• Spirometry/peak expiratory flow (PEF) with reversibility test
• Arterial blood gas analysis
• Chest radiography
• Serum electrolytes
• Serum glucose level
• Full blood count
• Urgent care is sacrosanct. The patient is better managed in an acute care facility
• ABC of resuscitation
• High flow oxygen via a non-rebreather face mask to maintain oxygen saturations > 94%
• Heliox - 70:30 or 80:20
• IV Fluids
• Nebulised Salbutamol 2.5 mg (<5 years), 5mg (≥5 years). - Repeat every 20 – 30 minutes according to patient’s response.
• Give oral prednisolone within one hour of presentation at a dose of 1-2 mg/kg body weight or 20 mg (2 – 5 years), 40 mg (>5 years). IV Hydrocortisone 4 mg/kg (maximum dose 100mg) to be given if oral steroids are not tolerated.
• Add nebulised ipratropium bromide 250 micrograms (2-11 years), 500 micrograms (≥12 years).
• Repeat these every 20 – 30 minutes for the first 2 hours after which they can be given 4-6 hourly according to clinical status.
• Consider adding 150 mg of magnesium sulphate to each nebulised salbutamol and ipratropium in the first hour in children with a short duration of acute severe asthma symptoms presenting with SpO2 <92%
• Nebulised corticosteroids could be considered an add-on to ipratropium bromide and nebulised salbutamol. Budesonide 0.5-1 mg or fluticasone 0.5-1 mg could be used.
NB: Budesonide is superior as it has faster absorption time, more water solubility, longer deposition on airways and less risk of causing pneumonia when compared to fluticasone.
• If there is no or limited response to the above treatment then second-line therapy should be initiated.
• Albuterol 0.15 mg/kg (minimum dose 2.5 mg) every 20 minutes for 3 doses then, 0.15 to 0.3mg/kg up to 10 mg every 1 to 4 hours as needed
• Albuterol can also be given as continuous nebulisation: for patients weighing ≥20 kg: 10 mg/hour, <20 kg: 7.5 mg/hour
• Nebulised adrenaline - α and β agonist activity
• IV Magnesium Sulphate 10% 40 mg/kg (max 2 grams) over 20 minutes.
• Consider early addition of a single IV Salbutamol bolus 15 micrograms/kg (maximum 250mcg) over 10 minutes in a severe attack where the child has not responded to initial inhaled therapy. - Concentration of 10mg/50 ml diluent @ 0.3ml/kg/hr = 1 microgram/kg/min.
• Consider a continuous intravenous infusion of salbutamol for severe refractory asthma. 1-2micrograms/kg/min with doses up to 5microgram/kg/min on PICU. Requires ECG monitoring.
• IV Aminophylline loading dose 5 mg/kg over 20 minutes; followed by infusion: 2 years – 12 years (1 mg/kg/hr); > 12 years (500 – 700 micrograms/kg/hr).
• IV Theophylline loading dose – 6mg/kg then 1mg/kg/hr
• Concentration: 500 mg/500ml diluent @ 1ml/kg/hour = 1mg/kg/hour
NB: Do not give a loading dose if a patient is on a maintenance oral aminophylline/theophylline but check therapeutic levels (theophylline target level 10 – 20 mg/L)
• Terbutaline - Subcutaneous terbutaline sulphate has been recommended for hospitalized children or adolescents older than 12 years with asthma exacerbation, at a dose of 0.25 mg every 20 minutes for a total of 3 doses. Children ≤12 years - 0.01 mg/kg (maximum dose is 0.25 mg) every 20 minutes for a total of 3 doses, repeated every 2 to 6 hours as needed
• To accelerate the therapeutic effect of terbutaline, an intravenous loading dose of 2 to 10 mcg/kg infused for 10 minutes is recommended, followed by a continuous infusion of 0.1 to 10 mcg/kg/min.
• IV Epinephrine can be considered as an alternative to selective β2 agonists - IM: 0.01 mg/kg (0.01 mL/kg/dose of 1mg/mL solution) not to exceed 0.5 mg every 20 minutes for 3 doses
• Persistent hypoxia +/- rising hypercapnia despite maximal medical treatment
• Increasing respiratory compromise despite maximal medical therapy
• Depressed level of consciousness or progressive agitation
• Use of continuous inhaled β-agonist therapy
• Exhaustion
• Failure to improve despite therapy
• Respiratory or cardiorespiratory arrest
The patient is discharged with significant improvement in symptoms and a PAS score of ≤ 7. Start or step up controller medications while continuing the reliever drug as needed. Complete 3-5 days of prednisolone. Follow up with the child in 1-2 days.
- The long-term goals of asthma management are risk reduction and symptom control.
- Assessment and monitoring: Standardized assessment of asthma control (e.g., Asthma Control Test, exacerbations in past 12 months).
- Education
- Specify goals of asthma management
- Explain basic facts about asthma:
- Contrast normal vs asthmatic airways.
- Link airway inflammation, “twitchiness,” and bronchoconstriction.
- Long-term-control and quick-relief medications
- Address concerns about potential adverse effects of asthma pharmacotherapy.
- Teach, demonstrate, and have the patient show proper technique for Inhaled medication use (spacer use with metered-dose inhaler)
- Control environmental factors and co-morbid conditions
- Investigate and manage factors that contribute to asthma severity:
- Environmental exposures
- Comorbid conditions
- Controller medication: GINA now recommends that all adults and adolescents with asthma should receive inhalational corticosteroid (ICS)-containing controller treatment.
- Prevention and treatment of exacerbations
- Severity and control which are based on the domains of impairment and risk
- Create a written 2-part Asthma Action Plan
- Daily management
- Action plan for asthma exacerbations
- Regular follow-up visits:
- Twice yearly (more often if asthma is not well controlled)
- Monitor lung function at least annually
Environmental tobacco smoke elimination or reduction in home and automobiles
Allergen exposure elimination or reduction in sensitized asthmatic patients:
- Long-acting Beta-agonists (LABA) are suitable for patients with nocturnal asthma. It is also effective for those who frequently require SABA inhalations during the day to prevent exercise-induced bronchospasm. Should not be used as a monotherapy. Examples are salmeterol and formoterol.
- Inhale corticosteroids. ICS is the cornerstone of asthma control. It improves lung function and reduces asthma symptoms and acute exacerbations. Examples are fluticasone, budesonide, mometasone and cyclosenide. Side effects include oral thrush and dysphonia.
- Systemic corticosteroids: These are used mainly for acute exacerbation and for control in the immediate period after treatment of exacerbation. This is a short-term treatment. Examples are methylprednisolone and prednisolone.
- Leukotriene modifying agents (LTRAs): these are bronchodilators with targeted anti-inflammatory properties. They reduce exercise-, aspirin-, and allergen-induced bronchoconstriction. They are recommended as an alternative treatment for mild persistent asthma and as an add-on medication with ICS for moderate persistent asthma. Examples of LTRAs are Zileuton a leukotriene synthesis inhibitor. Montelukast and Zafirlukast are leukotriene receptor antagonist.
- Non-steroidal anti-inflammatory agents (NSAIDs): Has anti-inflammatory effects. Can be used for exercise-induced asthma. Examples are cromolyn and nedocromil. Nedocromil is more effective than cromolyn.
- Long-acting inhaled anticholinergics: They are alternatives to LABA in ICS/LABA combination. Tiotropium is an example.
- Biologic therapies: This is an add-on medication for poorly controlled asthma despite optimal dosing of conventional medications. Examples are Omalizumab (anti-IgE), Mepolizumab (anti-IL-5) and Dupilumab (anti-IL-4 receptor α antibody).
- Allergen immunotherapy: These are controlled doses of allergen administered in gradually increasing doses over 3-5 years. There is a risk for anaphylaxis and should be given in a well-equipped hospital. The mode of administration is subcutaneous or sublingual.
Asthma is a very common chronic illness among children. Acute severe asthma can have fatal consequences if not addressed promptly. The use of appropriate medications and optimal dosing is essential for the prevention of catastrophic outcomes. Management of asthma entails general health promotion and prevention of specific diseases and triggers. There is a need for prevention of complications and rehabilitation.
A 7-year-old child from a rural Sub-Saharan African village presents with worsening symptoms of cough, wheezing, and shortness of breath over the past six months, triggered by dust, smoke from cooking fires, and seasonal changes. The child lives in a mud-brick house with exposure to indoor air pollution. There is no family history of asthma, but the child has a history of frequent respiratory infections.
Upon examination, the child exhibits wheezing and mild respiratory distress, consistent with asthma. The diagnosis is confirmed, with environmental factors like cooking smoke identified as major triggers. Treatment includes inhaled short-acting beta-agonists (SABA) for relief, inhaled corticosteroids (ICS) as a controller, and recommendations for improved ventilation and reduced exposure to smoke. The mother is educated on managing the condition and recognizing exacerbations. This case highlights the impact of environmental factors in asthma management in rural Sub-Saharan Africa.
- Kliegman RM, St Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, Behrman RE (ed). Nelson Textbook of Paediatrics. 21st edition. Philadelphia, Elsevier Inc; 2020
- Azuibuke JC, Nkangieme KEO (ed). Paediatric and Child Health in Tropical Regions. 3rd Edition. Lagos, Educational Printing and Publishing; 2016
- GINA Science Committee.Asthma management and prevention for adults and children older than 5 years; a pocket guide for health professionals; 2021 www.ginasthma.org
- Akhiwu HO, Asani MO, Johnson AB, Ibrahim M. Epidemiology of pediatric asthma in a Nigerian population. J Health Res Rev 2017;4:130-6.
- Children’s Hospital Colorado. Asthma Exacerbation Management; Clinical Pathway.
- Indinnimeo L, Chiappini E, del Giudice MM et al. Guideline on management of the acute asthma attack in children by Italian Society of Pediatrics . Journal of Pediatrics (2018) 44:46 https://doi.org/10.1186/s13052-018-0481-1
- Corrales AY, Soto-Martinez M, Starr M. Management of severe asthma in children. Australian Family Physician Vol. 40, No. 1/2, January/February 2011.
- Hancock S, Ahmed A, Gillespie M. Sheffield Children’s (NHS) Foundation Trust. Acute Asthma Management Guideline for infants greater than 2 years old
- Nievas IFF, Anand KJS. Severe Acute Asthma Exacerbation in Children: A Stepwise Approach for Escalating Therapy in a Pediatric Intensive Care Unit. J Pediatr Pharmacol Ther 2013;18(2):88–104
- Serebrisky D and Wiznia A. Pediatric Asthma: A Global Epidemic. Annals of Global Health. 2019; 85(1): 6, 1–6. DOI: https://doi.org/10.5334/aogh.2416
Author's details
Reviewer's details
Asthma in Children
- Background
- Symptoms
- Clinical findings
- Differential diagnosis
- Investigations
- Treatment
- Follow-up
- Prevention and control
- Further readings
Asthma is a chronic inflammatory lung airway condition resulting in episodic, reversible airflow obstruction. This chronic inflammation heightens the airway’s twitchiness to common provocative exposures. The episodes of airflow obstruction are termed exacerbations.
Asthma affects over 300 million individuals globally with increasing prevalence in developing countries. It is a major public health concern affecting all age groups. It poses a substantial burden on patients, their families, community and health care systems. It is more prevalent in urban areas than in rural areas. Acute severe asthma occurs in about 1% of patients and mortality from it is 4.9% – 6.0%.
- Kliegman RM, St Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, Behrman RE (ed). Nelson Textbook of Paediatrics. 21st edition. Philadelphia, Elsevier Inc; 2020
- Azuibuke JC, Nkangieme KEO (ed). Paediatric and Child Health in Tropical Regions. 3rd Edition. Lagos, Educational Printing and Publishing; 2016
- GINA Science Committee.Asthma management and prevention for adults and children older than 5 years; a pocket guide for health professionals; 2021 www.ginasthma.org
- Akhiwu HO, Asani MO, Johnson AB, Ibrahim M. Epidemiology of pediatric asthma in a Nigerian population. J Health Res Rev 2017;4:130-6.
- Children’s Hospital Colorado. Asthma Exacerbation Management; Clinical Pathway.
- Indinnimeo L, Chiappini E, del Giudice MM et al. Guideline on management of the acute asthma attack in children by Italian Society of Pediatrics . Journal of Pediatrics (2018) 44:46 https://doi.org/10.1186/s13052-018-0481-1
- Corrales AY, Soto-Martinez M, Starr M. Management of severe asthma in children. Australian Family Physician Vol. 40, No. 1/2, January/February 2011.
- Hancock S, Ahmed A, Gillespie M. Sheffield Children’s (NHS) Foundation Trust. Acute Asthma Management Guideline for infants greater than 2 years old
- Nievas IFF, Anand KJS. Severe Acute Asthma Exacerbation in Children: A Stepwise Approach for Escalating Therapy in a Pediatric Intensive Care Unit. J Pediatr Pharmacol Ther 2013;18(2):88–104
- Serebrisky D and Wiznia A. Pediatric Asthma: A Global Epidemic. Annals of Global Health. 2019; 85(1): 6, 1–6. DOI: https://doi.org/10.5334/aogh.2416
Content
Author's details
Reviewer's details
Asthma in Children
Background
Asthma is a chronic inflammatory lung airway condition resulting in episodic, reversible airflow obstruction. This chronic inflammation heightens the airway’s twitchiness to common provocative exposures. The episodes of airflow obstruction are termed exacerbations.
Asthma affects over 300 million individuals globally with increasing prevalence in developing countries. It is a major public health concern affecting all age groups. It poses a substantial burden on patients, their families, community and health care systems. It is more prevalent in urban areas than in rural areas. Acute severe asthma occurs in about 1% of patients and mortality from it is 4.9% – 6.0%.
Further readings
- Kliegman RM, St Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, Behrman RE (ed). Nelson Textbook of Paediatrics. 21st edition. Philadelphia, Elsevier Inc; 2020
- Azuibuke JC, Nkangieme KEO (ed). Paediatric and Child Health in Tropical Regions. 3rd Edition. Lagos, Educational Printing and Publishing; 2016
- GINA Science Committee.Asthma management and prevention for adults and children older than 5 years; a pocket guide for health professionals; 2021 www.ginasthma.org
- Akhiwu HO, Asani MO, Johnson AB, Ibrahim M. Epidemiology of pediatric asthma in a Nigerian population. J Health Res Rev 2017;4:130-6.
- Children’s Hospital Colorado. Asthma Exacerbation Management; Clinical Pathway.
- Indinnimeo L, Chiappini E, del Giudice MM et al. Guideline on management of the acute asthma attack in children by Italian Society of Pediatrics . Journal of Pediatrics (2018) 44:46 https://doi.org/10.1186/s13052-018-0481-1
- Corrales AY, Soto-Martinez M, Starr M. Management of severe asthma in children. Australian Family Physician Vol. 40, No. 1/2, January/February 2011.
- Hancock S, Ahmed A, Gillespie M. Sheffield Children’s (NHS) Foundation Trust. Acute Asthma Management Guideline for infants greater than 2 years old
- Nievas IFF, Anand KJS. Severe Acute Asthma Exacerbation in Children: A Stepwise Approach for Escalating Therapy in a Pediatric Intensive Care Unit. J Pediatr Pharmacol Ther 2013;18(2):88–104
- Serebrisky D and Wiznia A. Pediatric Asthma: A Global Epidemic. Annals of Global Health. 2019; 85(1): 6, 1–6. DOI: https://doi.org/10.5334/aogh.2416