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Personal Practice Indian Pediatrics 2002; 39:731-738 |
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Asthma and the School Going Child |
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Parang N. Mehta
School going children afflicted with asthma face multiple problems because of various restrictions, necessity to take medication in school, and above all, being seen as ‘sick’ by their peers. Asthma is the most common chronic disease of children, and its prevalence is increasing(1). It is also greatly underdiagnosed. An American study among urban schoolchildren found 14% to have undiagnosed asthma(2). A recent study in Delhi found that 16% of schoolchildren had asthma(3). Rural schoolchildren also suffer from asthma, though less commonly(4). Asthma is a common cause of school absenteeism, which hinders education as well as the child’s participation in other school activities(5). Recent advances in our understanding of the disease, and the development of newer drugs and delivery systems, have made asthma control better and easier that at any time in the past. Problems related to school attendance Physical education and sports are part of school. Apart from these, there are often games and other exertion during recess and free periods, which are unpredictable. Children with poorly controlled asthma can have problems, as exercise induced bronchospasm (EIB) can leave them breathless and unable to participate. Schools may expose the child to aeroallergens at high concentrations. This is significant as a child usually spends several hours a day in the classroom. Tobacco smoke, cat and dog dander, cockroach antigen, house dust mite allergen, and dampness are found to worsen asthma(6,7). These allergens are often present in high concentrations in classrooms. Schoolchildren can be cruel to anyone seen as "different". A child with acute asthma will sometimes go without medicines in order to avoid the teasing and taunting of his classmates. Regular anti-inflammatory medications must be planned to avoid doses during school hours. Acute asthma care is a problem in young children, as teachers are usually not willing to take on what they see as medical responsibilities. Pharmacotherapy The treatment of asthma has been simplified and standardized by the availability of guidelines(8). Asthma is classified into four types(8) based on the frequency of symptoms and lung function (Table I). Asthma medication is now divided into two classes - agents for long-term control, used to achieve and maintain control of persistent asthma (controllers), and quick-acting relief medications used to treat symptoms and exacerbations (relievers). All treatment recommendations in this article are based on the 1997 National Heart Lung and Blood Institute document, "Guidelines for the diagnosis and management of asthma"(8), unless stated otherwise. A child with mild, intermittent asthma requires no ongoing medication. A reliever medicine, such as inhaled salbutamol, should be with the child for use whenever acute symptoms are experienced. A child with mild, persistent asthma requires long term anti-inflammatory treatment. Sodium cromoglycate and low dose inhaled steroids are both appropriate. The child must also carry a reliever medicine for use in emergencies. Table I- Classification of Asthma(8)
FEV1: forced expiratory volume at 1 second; PEF: peak expiratory flow rate A child with moderate, persistent asthma needs low or medium doses of regular inhaled corticosteroids. These drugs not only reduce exacerbations, but prevent deterioration in lung function. Addition of a long acting beta agonist can reduce the requirement for inhaled corticosteroids. Though regular administration of a long acting beta agonist may control symptoms, it should never be used alone. Children with severe asthma need high doses of inhaled steroids, a long acting beta agonist and sometimes oral steroids for good control. In these children, achieving the goals of asthma therapy (Table II) is challenging, but not impossible. Inhaled short acting beta agonists Salbutamol and terbutaline are both available as metered dose inhalers. Salbutamol is available also as a pocket sized dry powder inhaler, which is convenient to carry to school. School going children are able to control their symptoms with these drugs, but require monitoring. The child who uses these drugs frequently has poor control of his asthma, and needs reevaluation. Salbutamol and terbutaline also provide protection against EIB. This effect lasts only 2-3 hours, so the child must carry the medication to school, and inhale a dose shortly before participation in sports. These preparation are thus an unsatisfactory choice for this indication.
Inhaled long acting beta agonists Salmeterol and formoterol are both available now, and are good additions to inhaled steroids for treatment of moderate or severe asthma. These drugs also protect against allergen and EIB. Their prolonged action (9-12 hours) allows the child to take a single morning dose for protection against allergen and exercise induced symptoms through the day. It also avoids the need to administer the medication in school. Both these medications are potent bronchodilators, and can suppress the manifestations of worsening asthma. They should, however, not be used alone; concurrent anti-inflammatory therapy is essential. Inhaled steroids These drugs are the cornerstone of long term asthma control. Beclomethasone, budesonide and fluticasone are available in India. The dose of inhaled steroid should be adjusted according to the patient’s symptoms, peak flow measurements and usage of rescue medication. The lowest dose that maintains good control of asthma is the right dose. Parents and children need frequent motivation and explanation about continuing these drugs even when asymptomatic. Sodium cromoglycate This has been the traditional first choice maintenance treatment for mild persistent asthma. It is a safe drug and is effective in children with mild atopic asthma. It can also be used for prophylaxis against EIB. The medication should be given four times a day, including one dose at school. Multiple daily doses decrease adherence to medication among children. Cromoglycate is more expensive than inhaled steroids, and its efficacy in patients with moderate asthma is questionable(9). Montelukast This is a leukotrienne antagonist, which has recently been approved for use in children. It is useful for long term anti-inflammatory therapy in mild, persistent asthma and in EIB. In the more severe forms of asthma, it has a steroid sparing effect. It is effective as a single daily dose, taken as a chewable tablet. This eliminates the need for any dosing in school and the dose taken at night will protect against EIB through the next day. Montelukast is available as 10 mg tablets for adults and 5 mg tablets for children. The usual dose for children over six years of age is 5 mg once a day. Being an oral drug, it may be acceptable to parents who refuse inhaled therapy. Asthma control plans Written plans are vital for children with asthma. These should be prepared by the treating doctor, and well understood by the parents (and child, if old enough). The parents should also discuss these plans with the child’s class teacher. Children should have two plans - one for regular asthma control, and one for acute exacerbations and emergencies. With the current drugs available, the regular (controller) medicines can be given at home in a single or twice daily dose regimen. The child should carry a clear plan regarding treatment in acute emergencies. Drugs should be readily available and the teachers should have some familiarity regarding administering inhaled medications. The acute management plan should include the address and telephone numbers of the parents and pediatrician. Ideally, schools should have their own asthma management plans, for use in sick children. However, school would probably not like to take responsibility for medical care of an illness which might be life threatening. Devices for inhaled therapy Metered dose inhalers (MDIs) are a popular means of administering inhaled therapy. Rescue drugs (short-acting beta agonists) are commonly prescribed as MDIs, since they provide quick relief from acute symptoms. A MDI requires coordination between actuation and inhalation, and many school age children are unable to use one effectively. Spacers are valuable if a metered dose inhaler is to be used. Spacers obviate the need to coordinate breathing and actuation of the metered dose inhaler, increase drug delivery to the lungs, and reduce side effects. However, they are bulky and cumbersome, and some children may not like to carry them to school. Dry powder inhalers contain the active drug as a dry powder in a capsule. The child’s own airflow carries the medication into the lungs and no coordination is required. Children above 6 years can generally use these devices comfortably, and being small-sized, they are well suited for school children. During an acute attack, however, the child may not be able to generate the inspiratory flow required to use this device effectively. The choice of the device is as important as the choice of drug. A device the child is unable to use will be associated with failure of therapy. A device the child does not like will result in poor adherence to treatment. A MDI without spacer is usually not effectively coordinated by children, and the ‘freon effect’ (arrest of inspiration owing to cold sensation in throat caused by propellant) interferes with proper drug delivery. Monitoring the disease Monitoring the disease is an important component of the long term management of asthma. It helps to regulate drug therapy, identify triggers, and anticipate acute exacerbations. The following things should be assessed: (i) signs and symptoms of asthma, their frequency and severity; (ii) pulmonary function; (iii) school absenteeism; (iv) acute exacerbations, emergency visits and hospitalizations; and (v) use of medicines, especially inhalers for acute symptoms. Parents should be encouraged to maintain a diary. The most commonly used device to estimate lung function is the peak expiratory flow rate meter, also called the peak flow meter. These are inexpensive, easy to use and maintain. A peak flow meter can be used in children older than six years. The parents are advised to record morning and evening peak flow reading in the diary. Reviewing this record during clinic visits gives valuable information about disease control and effectiveness of drug therapy. It simplifies decisions about stepping up or stepping down therapy. Some children have frequent acute asthma attacks, even on regular preventive therapy. Carrying a peak flow meter to school and using it when acute symptoms occur can warn of impending danger. Any peak flow reading less than 50% of the child’s personal best is an indication for prompt medical care. Nocturnal asthma Asthma is usually worse at night. Children with asthma have disturbed sleep and suffer the consequences during daytime including daytime sleepiness, depression, reduced concentration, poor visual coordination, and diminished attention and memory(10,11). Inadequate attention is given to this factor in the management of children with asthma. These effects often lead to less than optimal academic performance, which contributes to their poor self image. It is vital to control nocturnal asthamatic symptoms, not only to improve respiratory function but also to promote better quality sleep and psychological well being. For children who are otherwise well controlled but have nocturnal symptoms, long acting beta agonists(formoterol or salmeterol) are recommended(12). Other alternatives are slow release theophylline, increased doses of inhaled steroid or slow release salbutamol or terbutaline. Exercise induced asthma Some children with asthma develop cough or wheezing during participation in physical education, sports or even while playing during recess. EIB is usually a sign of poor control of asthma and indicates the need for more aggressive treatment. A few children have no manifestations of asthma other than EIB. EIB is difficult to diagnose. Teachers and parents may report that the child goes to play regularly. Closer questioning may reveal, however, that the child always takes on the role of goalkeeper or umpire. A detailed history helps to uncover exercise intolerance in the child with asthma. As many of 90% of children with asthma may have EIB, which often goes unrecognised(13,14). Managing EIB is an important part of asthma care. While young children are most upset by their cough and wheezing, older children are upset about their inability to participate in sports. Games and sports are vital to childhood, and controlling the asthma to allow the child a full range of activity is essential. Long acting beta agonists, taken once in the morning, provide day long protection against EIB(15-17). Prolonged use of these drugs is associated with decreased duration of their protective effects(16,18). Anti-inflammatory therapy should also be given to these children; regular use of beta agonists should never be prescribed alone. An alternative is the oral drug montelukast, which confers prolonged protection against EIB(19). This drug may be used alone in mild disease, or for those who have symptoms only on exercise. Barriers to proper management Peer group pressure. Being "different" marks out a child for teasing and ridicule by his schoolmates. Many children will avoid taking treatment in school to avoid the taunting of their friends. Ignorance of school authorities Some schools will not allow the use of medications in their premises, especially inhaled ones. This can be a serious issue for the child with acute symptoms. Poor understanding of the disease Misunderstanding of the disease by the child and parents, and misconceptions about medication interfere with management. Teacher Education It is not a teacher’s job to diagnose and treat asthma. However, since teachers deal with children with asthma in school, they should be aware of the condition. Teachers have a poor understanding of childhood illnesses, including asthma, and they receive no instructions on medical issues during their training(20). This often makes them reluctant to participate in asthma care. Pediatricians, and their associations, should take lead in arranging educational programs for teachers. This training should focus on: (i) basic understanding of asthma; (ii) recognizing danger signs: (iii) helping children take inhaled therapy; and (iv) emergency management of asthma. Environmental control A major problem in tropical climates is moisture. Damp building are associated with house dust mites, cockroaches, and molds and spores, which are known to worsen asthma. Moisture and mold problems have been shown to be linked to higher rates of respiratory infection, cough and asthma(21,22). Other problems are smoking, stray animals entering the classroom when the school is closed, perfumes, air sprays and poor ventilation. Schools should take an initiative to provide an appropriate environment (Table III). Patient education Teaching the older child about the disease and its control is crucial. Knowledge empowers patients, especially in a chronic disease like asthma. The child must know about the types of medications and their use during emergencies. The importance of adherence to regular medications should be emphasized on each visit. The danger signs of an impending severe exacerbation should be described. An essential part of patient education is training in the use of inhalation therapy devices. Improper technique in the use of MDIs and dry powder inhalers can be the cause of inadequate drug delivery to the lungs, and poor asthma control in spite of an appropriate treatment plan. Inhaler technique must be checked frequently and corrected as required. Good communication is the key to good outcomes and patient satisfaction in a chronic illness like asthma. Important components are friendly behavior, attentiveness, acknowledging patient fears and concerns, and providing encouragement and praise. Adherence issues Poor adherence is a fact of life for doctors treating children with asthma. One study(23), using sophisticated measuring instruments found that children took less than 50% of prescribed doses of inhaled steroids and beta agonists, and over reported their own adherence. School children especially adolescents often do not comply with therapy because of poor understanding, fear of side effects, lack of perception of immediate relief, concerns over safety, need for multiple medications, lack of ease of use and a wish to be just like everyone else. Pediatricians and health providers should encourage patients to adhere to required therapy and prevent frequent exacerbations and deterioration of lung function. One important way is to involve the older child in planning therapy. The goal of attaining adequate peak flow rates may have little meaning for them; their goal may be to play competitive badminton. Using such starting points to develop a treatment plan will achieve more satisfying outcomes. Adherence to prescribed therapy also depends on the child (and parents) understanding the severity of the disease and risks of improper therapy. Unless the child and family realize the grave nature of the illness, adherence will be poor. Patients and parents must be told clearly that exacerbations of asthma might be life threatening, if not managed properly. Funding: None. Competing interests: None stated.
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