global strategy for asthma management and prevention

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GINA_WR_2006.qxp:GINA_WR_2006.qxp 7/20/07 4:11 PM Page *10EXECUTIVE SUMMARYMANAGING ASTHMA IN CHILDREN 5 YEARS AND YOUNGERINTRODUCTIONSince the first asthma guidelines were published morethan 30 years ago, there has been a trend towards producingunified guidelines that apply to all age groups. Thishas been prompted by the recognition that commonpathogenic and inflammatory mechanisms underlie allasthma, evidence-based literature on the efficacy of keycontroller and reliever medications, and an effort to unifytreatment approaches for asthma patients in different agecategories. This approach avoids repetition of details thatare common to all patients with asthma. There is relativelylittle age-specific data on management of asthma inchildren, and guidelines have tended to extrapolate fromevidence gained from adolescents and adults.This revision of the Global Strategy for AsthmaManagement and Prevention again provides a unified textas a source document. Each chapter contains separatesections containing details and management advice forspecific age categories where these are consideredrelevant. These age groups include children 5 years andyounger (sometimes called preschool age), children olderthan 5 years, adolescents, adults, and the elderly. Most ofthe differences between these age groups relate to naturalhistory and comorbidities, but there are also importantdifferences in the approach to diagnosis, measures forassessing severity and monitoring control, responses todifferent classes of medications, techniques for engagingwith the patient and his/her family in establishing andmaintaining a treatment plan, and the psychosocialchallenges presented at different stages of life.Special challenges that must be taken into account inmanaging asthma in children in the first 5 years of lifeinclude difficulties with diagnosis, the efficacy and safety ofdrugs and drug delivery systems, and the lack of data onnew therapies. Patients in this age group are oftenmanaged by pediatricians who are routinely faced with awide variety of issues related to childhood diseases.Therefore, for the convenience of readers this ExecutiveSummary extracts sections of the report that pertain todiagnosis and management of asthma in children 5 yearsand younger. These extracts may also be found in themain text, together with detailed discussion of otherrelevant background data on asthma in this age group‡.As emphasized throughout the report, for patients in allage groups with a confirmed diagnosis of asthma, the goalxof treatment should be to achieve and maintain control(see Figure 4.3-2) for prolonged periods, with due regardto the safety of treatment, potential for adverse effects,and the cost of treatment required to achieve this goal.DIAGNOSIS OF ASTHMA IN CHILDREN 5 YEARS ANDYOUNGERWheezing and diagnosis of asthma: Diagnosis of asthmain children 5 years and younger presents a particularlydifficult problem. This is because episodic wheezing andcough are also common in children who do not haveasthma, particularly in those under age 3. Wheezing isusually associated with a viral respiratory illness—predominantly respiratory syncytial virus in childrenyounger than age 2, and other viruses in older preschoolchildren. Three categories of wheezing have beendescribed in children 5 years and younger:• Transient early wheezing, which is often outgrown inthe first 3 years. This is often associated withprematurity and parental smoking.• Persistent early-onset wheezing (before age 3). Thesechildren typically have recurrent episodes of wheezingassociated with acute viral respiratory infections, noevidence of atopy, and no family history of atopy.Their symptoms normally persist through school ageand are still present at age 12 in a large proportion ofchildren. The cause of wheezing episodes is usuallyrespiratory syncytial virus in children younger than age 2,while other viruses predominate in children ages 2-5.• Late-onset wheezing/asthma. These children haveasthma that often persists throughout childhood andinto adult life. They typically have an atopicbackground, often with eczema, and airway pathologythat is characteristic of asthma.The following categories of symptoms are highlysuggestive of a diagnosis of asthma: frequent episodes ofwheeze (more than once a month), activity-induced coughor wheeze, nocturnal cough in periods without viralinfections, absence of seasonal variation in wheeze, andsymptoms that persist after age 3. A simple clinical indexbased on the presence of a wheeze before the age of 3,and the presence of one major risk factor (parental historyof asthma or eczema) or two of three minor risk factors(eosinophilia, wheezing without colds, and allergic rhinitis)has been shown to predict the presence of asthma inlater childhood.‡ References and evidence levels are deleted from this extracted material but are provided in the main text.
GINA_WR_2006.qxp:GINA_WR_2006.qxp 7/20/07 4:11 PM Page *11Figure 4.3-1. Levels of Asthma ControlCharacteristicControlled(All of the following)Partly Controlled(Any measure present in any week)UncontrolledDaytime symptoms None (twice or less/week) More than twice/week Three or more featuresLimitations of activities None Anyof partly controlledasthma present inNocturnal symptoms/awakening None Anyany weekNeed for reliever/rescue treatmentNone (twice or less/week)More than twice/weekLung function (PEF or FEV1) ‡ Normal < 80% predicted or personal best(if known)Exacerbations None One or more/year* One in any week †* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate.† By definition, an exacerbation in any week makes that an uncontrolled asthma week.‡ Lung function is not a reliable test for children 5 years and younger.Alternative causes of recurrent wheezing must beconsidered and excluded. These include:• Chronic rhino-sinusitis• Gastroesophageal reflux• Recurrent viral lower respiratory tract infections• Cystic fibrosis• Bronchopulmonary dysplasia• Tuberculosis• Congenital malformation causing narrowing of theintrathoracic airways• Foreign body aspiration• Primary ciliary dyskinesia syndrome• Immune deficiency• Congenital heart diseaseNeonatal onset of symptoms (associated with failure tothrive), vomiting-associated symptoms, or focal lung orcardiovascular signs suggest an alternative diagnosis andindicate the need for further investigations.Tests for diagnosis and monitoring. In children 5 yearsand younger, the diagnosis of asthma has to be basedlargely on clinical judgment and an assessment ofsymptoms and physical findings. A useful method forconfirming the diagnosis of asthma in this age group is atrial of treatment with short-acting bronchodilators andinhaled glucocorticosteroids. Marked clinical improvementduring the treatment and deterioration when it is stoppedsupports a diagnosis of asthma. Diagnostic measuresrecommended for older children and adults such asmeasurement of airway responsiveness, and markers ofairway inflammation is difficult, requiring complexequipment 41 that makes them unsuitable for routine use.Additionally, lung function testing—usually a mainstay ofasthma diagnosis and monitoring—is often unreliable inyoung children. Children 4 to 5 years old can be taught touse a PEF meter, but to ensure accurate results parentalsupervision is required.ASTHMA CONTROLAsthma control refers to control of the clinicalmanifestations of disease. A working scheme based oncurrent opinion that has not been validated provides thecharacteristics of controlled, partly controlled anduncontrolled asthma. Complete control of asthma iscommonly achieved with treatment, the aim of whichshould be to achieve and maintain control for prolongedperiods, with due regard to the safety of treatment,potential for adverse effects, and the cost of treatmentrequired to achieve this goal.ASTHMA MEDICATIONS(Detailed background information on asthmamedications for children of all ages is included inChapter 3.)Inhaled therapy is the cornerstone of asthma treatment forchildren of all ages. Almost all children can be taught toeffectively use inhaled therapy. Different age groups requiredifferent inhalers for effective therapy, so the choice ofinhaler must be individualized (Chapter 3, Figure 3-3).Controller MedicationsInhaled glucocorticosteroids: Treatment with inhaledglucocorticosteroids in children 5 years and younger withasthma generally produces similar clinical effects as inolder children, but dose-response relationships havebeen less well studied. The clinical response to inhaledglucocorticosteroids may depend on the inhaler chosenxi
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