Guideline for the management of chronic asthma in children - 2009 update

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Abstract

OBJECTIVE: To revise the guideline for the diagnosis and management of chronic asthma in children in view of the following considerations: the existing South African Childhood Asthma Working Group (SACAWG) guideline was produced 10 years ago; diagnosis of asthma in young children remains a challenge; evidence-based treatment is the new paradigm; new treatment approaches to achieving and maintaining control; therapeutic roles of several medications have evolved; more studies and data on treatment in young children; new medications and formulations; a change of emphasis in assessing asthma control to guide treatment changes. The main aim of the guideline is to promote a better standard of treatment based on understanding of the pathophysiology and pharmacotherapy of asthma, and encouraging uniformity in asthma management. EVIDENCE: A detailed literature review by a working group of clinicians from relevant disciplines. The strategies recommended are classified according to the evidence category in Appendix B, and denoted as Evidence A, B, C and D. RECOMMENDATIONS: These include an appropriate diagnostic approach, environmental control measures, treatment options, definition of asthma control, and strategies to achieve control. ENDORSEMENT: The guideline document was endorsed by the South African Thoracic Society (SATS), the National Asthma Education Programme (NAEP), the South African Paediatric Association (SAPA) and the South African Academy of Family Practice.

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Most cited references 130

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Long-term inhaled corticosteroids in preschool children at high risk for asthma.

Theresa W. Guilbert, Wayne J. Morgan, Robert Zeiger … (2006)

It is unknown whether inhaled corticosteroids can modify the subsequent development of asthma in preschool children at high risk for asthma. We randomly assigned 285 participants two or three years of age with a positive asthma predictive index to treatment with fluticasone propionate (at a dose of 88 mug twice daily) or masked placebo for two years, followed by a one-year period without study medication. The primary outcome was the proportion of episode-free days during the observation year. During the observation year, no significant differences were seen between the two groups in the proportion of episode-free days, the number of exacerbations, or lung function. During the treatment period, as compared with placebo use, use of the inhaled corticosteroid was associated with a greater proportion of episode-free days (P=0.006) and a lower rate of exacerbations (P<0.001) and of supplementary use of controller medication (P<0.001). In the inhaled-corticosteroid group, as compared with the placebo group, the mean increase in height was 1.1 cm less at 24 months (P<0.001), but by the end of the trial, the height increase was 0.7 cm less (P=0.008). During treatment, the inhaled corticosteroid reduced symptoms and exacerbations but slowed growth, albeit temporarily and not progressively. In preschool children at high risk for asthma, two years of inhaled-corticosteroid therapy did not change the development of asthma symptoms or lung function during a third, treatment-free year. These findings do not provide support for a subsequent disease-modifying effect of inhaled corticosteroids after the treatment is discontinued. (ClinicalTrials.gov number, NCT00272441.). Copyright 2006 Massachusetts Medical Society.

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Intermittent inhaled corticosteroids in infants with episodic wheezing.

Frederik Buchvald, Liselotte Halkjaer, Mette Northman Hermansen … (2006)

We hypothesized that asthma is preceded by a stage of recurrent episodes of wheezing during the first years of life and that inhaled corticosteroid therapy during symptomatic episodes in this early phase may delay progression to persistent wheezing. We assigned one-month-old infants to treatment with two-week courses of inhaled budesonide (400 mug per day) or placebo, initiated after a three-day episode of wheezing, in this single-center, randomized, double-blind, prospective study of three years' duration. The primary outcome was the number of symptom-free days; key secondary outcomes were the time to discontinuation due to persistent wheezing and safety, as evaluated by height and bone mineral density at the end of the study. We enrolled 411 infants and randomly assigned 294 to receive budesonide at a first episode of wheezing. The proportion of symptom-free days was 83 percent in the budesonide group and 82 percent in the placebo group (absolute difference, 1 percent; 95 percent confidence interval, -4.8 to 6.9 percent). Twenty-four percent of children in the budesonide group had persistent wheezing, as compared with 21 percent in the placebo group (hazard ratio, 1.22; 95 percent confidence interval, 0.71 to 2.13)--a finding that was unaffected by the presence or absence of atopic dermatitis. The mean duration of the acute episodes was 10 days in both groups and was independent of respiratory viral status. Height and bone mineral density were not affected by treatment. Intermittent inhaled corticosteroid therapy had no effect on the progression from episodic to persistent wheezing and no short-term benefit during episodes of wheezing in the first three years of life. (ClinicalTrials.gov number, NCT00234390.). Copyright 2006 Massachusetts Medical Society.

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Early identification of atopy in the prediction of persistent asthma in children.

Peter Sly, Attilio Boner, Bengt Björkstén … (2008)

The long-term solution to the asthma epidemic is thought to be prevention, and not treatment of established disease. Atopic asthma arises from gene-environment interactions, which mainly take place during a short period in prenatal and postnatal development. These interactions are not completely understood, and hence primary prevention remains an elusive goal. We argue that primary-care physicians, paediatricians, and specialists lack knowledge of the role of atopy in early life in the development of persistent asthma in children. In this review, we discuss how early identification of children at high risk is feasible on the basis of available technology and important for potential benefits to the children. Identification of an asthmatic child's atopic status in early life has practical clinical and prognostic implications, and sets the basis for future preventative strategies.

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Author and article information

Contributors

C Motala: Role: ND

R J Green: Role: ND

A I Manjra: Role: ND

P C Potter: Role: ND

H J Zar: Role: ND

Journal

Journal ID (publisher): samj

Title: SAMJ: South African Medical Journal

Abbreviated Title: SAMJ, S. Afr. med. j.

Publisher: Health and Medical Publishing Group (Cape Town )

ISSN: 2078-5135

Publication date (Print): December 2009

Volume: 99

Issue: 12

Pages: 898-912

Affiliations

[1 ] South African Childhood Asthma Working Group

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Publisher ID: S0256-95742009001200024

SO-VID: 47b44e26-6c4d-47dc-bc6f-b737d66c4609

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http://creativecommons.org/licenses/by/4.0/

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SciELO South Africa

Self URI (journal page): http://www.scielo.org.za/scielo.php?script=sci_serial&pid=0256-9574&lng=en

Guideline for the management of chronic asthma in children - 2009 update

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Most cited references 130

Long-term inhaled corticosteroids in preschool children at high risk for asthma.

Intermittent inhaled corticosteroids in infants with episodic wheezing.

Early identification of atopy in the prediction of persistent asthma in children.

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