Updates in Diagnosis and Management Asthma in Preschool Children

(1)

Updates in Diagnosis and Management Asthma in Preschool Children

Heda Melinda

(2)

This meeting is organized by Respirology Working Group of Indonesian Pediatric Society and supported by Astra Zeneca Indonesia

I have no conflict of interest to declare

DISCLAIMER

(3)

OUTLINE

ü Introduction ü Case study

ü Clinical Presentation

ü Timeline of Asthma in Preschool Children in Global Initiative for Asthma (GINA)

ü Classification of Asthma in Preschool Children

ü Asthma Predictive Index (API) for define RISK of ASTHMA IN YOUNG CHILDREN

ü Diagnosis of Asthma in Preschool Children According to National Pediatric Asthma Guideline (PNAA)-2022

ü Management of Asthma in Preschool Children According to National Pediatric

Asthma Guideline (PNAA)-2022

(4)

Anak laki-laki, usia 3 tahun 8 bulan, BB 14,150 (!3 Mei 2022)---- PRASEKOLAH

Keluhan Utama

: Riwayat batuk dan sesak

Riwayat anak mengalami batuk terutama dimalam hari, mengi (+), dan kadang disertai sesak dalam 12 bulan terakhir

Bersin - bersin dipagi hari disertai menggosok-gosok hidung

Riwayat Kesehatan

•

5 Mei 2022 (usia 2th)à Rawat inap di RS Cahaya Bunda Cirebon, SpA, diagnosis bronkitis asma

• IGD RS, 17 Januari 2023, anak mengalami bengkak pada mata yang dirasakan gatal

setelah bermain tepung di sekolah, terapi Deksametason (SCS) IV dan obat pulang oral SCS (triamcinolone)

• 29 Januari 2023à nafas anak tampak cepat dan terdengar mengi, berobat ke RS-à SERANGAN TIDAK

• TERTULIS?? Nebulisasi salbutamol dan NS 3%. Obat pulang procaterol 2 x 2,5mL

• IBU: asma

• Riwayat imunisasi lengkap hingga usia ini

C A S E S T U D Y

(5)

Pemeriksaan Penunjang

IgE Total : 1.384 (N : 0 - 29,2)

IgE Spesifik Debu Rumah: 1,07 (N : <0.35) IgE Spesifik Tungau Debu : >100 (N : <0.35) IgE Spesifik Susu: <0.1

IgE Spesifik Kuning Telur: 16,8 (N : <0.35) IgE Spesifik Putih Telur: 31,9 (N : <0.35) Vitamin D 25-OH total: 38,0 (sufisiensi)

Hasil Pemeriksaan Laboratorium 31 Mei 2023 Hasil Pemeriksaan Panel Alergi

Dermatophagoides pter. (d1) : 3.50 kU/l (3) Dermatophagoides microceras (d4): 6.15 kU/l (3)nBos d6 (BSA) (e204): 35.00 kU/l (4)

Wheat flour (f4): 73.89 kU/l (5) Gluten (f79): 75.72 kU/l (5) Peanut (f13): 6.81 kU/l (3) Soybean (f14): 2.05 kU/l (2) Almond (f20) : 61.02 kU/l (5) Egg White (f1) : 62.25 kU/l (5) Cow's milk (f2) : 22.75 kU/l (4)

Alpha Lactalbumin (f76): 2.50 kU/l (2) Beta-lactoglobulin (f77): 0,54 kU/l (1) Lamb meat (f88): 3,17 kU/l (2)

Eosinophil 5%

(6)

Diagnosis

ICS +LABA pMDI 25/50 (spacer) mulai Mei 2022 dengan dosis awal 2 x 1 inhalasi Step down à 12 September 2022, Seretide 1 x 1 inhalasi (sd Okt, dan Nov dan Des 2022 tak kontrol, obat pengendali (maintenance ) msh digunakan

Jan 2023 -- terjadi serangan asma ringan-sedang----terapi pengendali/maintenance

Diagnosis

Asma terkendali, terapi maintenance rencana stop, tanpa serangan asma + Rhinitis Allergica (terkendali)

29 Juli 2023 à IGD à asma serangan ringan-sedang—(masih terapi maintenance)

Most have asthma (tanpa terapi maintenance) dan Allergic Rhinitis

Tata Laksana

(7)

Clinical Presentations

Asthma Emergencies

Severe asthma attacks can be life-threatening and require emergency room treatment

Signs and symptoms of asthma emergency in children under aged five include:

• gasping for air

• breathing in so hard that the abdomen is sucked under the ribs

• Trouble speaking because of restricted breathing

Laboratory Test

Blood test if needed to identify elevated white blood test in response to infections; asthma is moderate to severe

Chest X-ray: may also be used to rule out other conditions Allergy test: skin test or blood test

(8)

A history of respiratory symptoms such as wheeze, shortness of breath, chest tightness, and cough that vary over time and in intensity, together with variable expiratory airflow limitation.

www.ginasthma.org;2020

Asthma is a heterogenous disease, usually characterized by chronic inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and intensity, together with variable expiratory airflow limitation.

Definition: by concensus; before controller commenced.

www.ginaasthma.org; 2021

Asthma is not one disease

Asthma is a syndrome composed of multiple phenotypes

Asthma is more complex than indicated

NEED OBJECTIVE TOOLS

Asthma definition is complex

• A disease that includes the symptoms of wheeze, cough and breathing difficulty together with reversible airways obstruction, airway inflammation and bronchial

hyperresponsiveness.

• Asthma is a heterogenous and variable

condition and frequently not all the above are present in each individual patient at the same time

GINA 2020 NHLBI 2020 ERS TASK FORCE-2021

GINA 2021

(9)

Diagnosing and managing asthma in preschool children can be difficult

Asthma often starts before six year of age, however, still uncertainty WHEN and HOW preschoolers with symptoms suggestive asthma can be diagnosed as ASTHMA

In infants and young children:

The primary symptoms— coughing and wheezing maybe caused by other conditions Standard diagnostic test to test used to measure how well children is breathing

cannot be used easily in children under five

Some treatments available to older children for managing older children are not recommended for infants and preschool children

For those reasons,

managing asthma for children under five requires careful and frequent monitoring (written asthma action plan to monitor symptoms and adjust treatment as necessary)

Ducharme FM et al. Can Rspir J. 2015;22(6):348. doi:10.1155/2015/76141

(10)

• GINA Report is NOT A Guideline

• GINA Report is updated every 12

months following a twice-yearly review of recent publications by the scientific commitee

• Published Dec/Jan

• 45 countries involved in GINA Assembly

Global Initiative for Asthma (GINA)

United States

United Kingdom Argentina

Australia

Brazil Canada Austria

Chile

Belgium

China

Denmark Colombia

Croatia Germany

Greece Ireland

Italy

Syria

Hong Kong ROC

Japan

India

Korea

Kyrgyzstan Moldova

Macedonia

Malta

Netherlands New Zealand

Poland

Portugal

Georgia

Romania

Russia

Singapore Slovakia

Slovenia Saudi Arabia

South Africa

Spain Sweden

Thailand

Switzerland

Ukraine

Taiwan

Venezuela

Vietnam Yugoslavia

Albania

Bangladesh

France

Mexico

Turkey ^Czech

Republic

Lebanon Pakistan

GINA Assembly

Israel

Philippines

Cambodia Mongolia

Egypt

www.ginaorg.

(11)

Timeline of Asthma Under-five in GINA Guideline

2011

The First Asthma Under-five GINA

separated from the main guideline

The First GINA Report1995

2023 The Latest

Updated Asthma Under- five GINA

2014

The First Asthma Under- five GINA as a chapter

(12)

2014

Asthma in Children ≤5 Years

(13)

2015 2016 201720182020 2022

(14)

Definition and Diagnosis Asthma Exacerbation in Children Aged ≤ 5 tahun (GINA 2019, 2020, 2021, 2022, 2023)

GINA 2019 GINA 2020 GINA 2021 GINA 2022 GINA 2023

Definisi Perburukan akut atau subakut dalam pengendalian gejala yang

menyebabkan distres atau mengancam kesehatan dan

memerlukan kunjungan ke penyedia layanan kesehatan atau memerlukan pengobatan dengan kortikosteroid sistemik

Definisi sama Definisi sama Definisi sama Definisi sama

Gejala awal eksaserbasi dapat berupa salah satu berikut:

• Awitan gejala infeksi saluran respiratori

• Peningkatan gejala mengi akut atau sub-akut dan sesak napas

• Peningkatan batuk, terutama saat anak tertidur

• Letargi atau berkurangnya toleransi olahraga

• Gangguan aktivitas sehari-hari, termasuk makan/minum

• Respons yang buruk terhadap obat

Sama Sama Sama Sama

www.ginaasthma.org Slide Heda Melinda

(15)

Asthma in Children ≤6 Years A diagnosis of asthma in young children with history of

wheezing is likely if the have

• Wheezing or coughing that occurs with exercise, laughing or crying, or in the absence of an apparent respiratory tract infection

• A history of other allergic disease (eczema or allergic rhinitis), allergic sensitization or asthma in first degree relatives

• Clinical improvement during 2-3 months of controller treatment, and worsening after cessation

ginasthma.org

Canada Paediatric Society. Paediatr Child Health. 2013:10(18):544-9 Indonesian Pediatric Allergy Immunology Working Group, 2014

History of allergy in first degree relative (minimal 1 of parent or siblings) such as atopic dermatitis, food allergy, asthma, allergic rhinitis

(16)

Probability of Asthma Di agnosis

ginasthma.org

It may be challenging to make confident diagnosis of asthma in children 5 years and younger

wheezing and cough are also common in children without asthma, particularly in preschoolers

A probability-based approach, based on pattern of symptoms avoid either over- or under- treatment

(17)

ginasthma.org

Differential Diagnosis Typical Characteristic

Differential Diagnosis of Asthma in Preschool Children

(18)

ASTHMA TREATMENT IN PRESCHOOL CHILDREN

Treatment Goals

• Treat inflammation in the airways, usually with daily medication, to prevent asthma attacks

• Use short-acting drugs to treat asthma attacks

• Avoid or minimize the effect of asthma triggers

• Maintain normal activity levels

(19)

Initial Assessment of Acute Asthma Exacerbation in Children ≤6 Years

ginasthma.org

(20)

ginasthma.org

Management of Acute

Asthma or Wheezing in

Children ≤6

(21)

Initial Emergency Department Management of Asthma Exacerbations in Children ≤6 Years

ginasthma.org

(22)

ginasthma.org

(23)

Low Daily ICS for Children 5 Years and Younger

ginasthma.org

(24)

Assessment of Asthma Control in Children ≤6 Years

ginasthma.org

(25)

Inhaler Device

A pressured metered dose inhaler (pMDI) with a valved spacer (with or without a face mask, depending on the child age) is the preferred delivery system

ginasthma.org

(26)

How to keep asthma in preschool is under control ?

• Create an asthma action plan

• Your child’s name and age

• Physician and emergency contact information

• The type, dose and timing of long-term medications

• The type and dose of rescue medication

• A list of common asthma triggers for your child ans tips for avoiding them

• A system for rating normal breathing, moderate symptoms and severe symptoms

• Intructions for what to do when symptoms occur and when to use rescue medication

• Monitor and record

• The time, duration and circumstances of an asthma attack

• Treatment responses to asthma attacks

• Medication side effects

• Changes in your child’s symptoms

• Changes in activity levels or sleep patterns

• Control asthma triggers

• Cleaning thoroughly to control dust and pet dander

• Checking pollen count reports

• Removing cleaning products or other household products that may be an irritant

• Administering allergy medicine as directed by your doctor

• Teaching your child hand washing and other habits to minimize colds

• Teaching your child to understand and avoid triggers

(27)

Ducharme FM et al. Can Rspir J. 2015;22(6):348. doi:10.1155/2015/76141

Canadian Thoracic Society and

Canadian Paediatric Society

(28)

Age 1-5 years presenting with:

Current signs of airflow obstruction

• >1 documented* asthma-like exacerbation^✞ AND

• No red flags for an alternative diagnosis (Table 2)

Therapeutic trial

Mild exacerbation^⍑

SABA^ℑ

Moderate or severe exacerbation^⍑

SABA and OCS^ℑ

Clear improvement No/unclear improvement^**

1^st episode -> Suspected asthma ^{✞ ✞}

> 2 episodes -> Asthma

Unclear diagnosis

Consider co-morbidity or an alternative diagnosis Watchful observation

Referral to an asthma specialist if persistent symptoms and/or moderate to severe exacarbations

No Current signs of airflow obstruction

• >2 reported episodes of asthma-like symptoms AND

• No previously documented* signs of airflow obstruction

• ORNo previously documented* improvement to asthma therapy

AND

Frequent symptoms # or >1 moderate to severe ^ℑasthma- like exacerbation^✞?

Monitor and reassess when symptomatic + 3-moth therapeutic

trials^ℑwith as-needed SABA

Therapeutic trials^ℑof medium dose ICS for 3 months with as needed

SABA

Documented* signs of airflow obstruction AND

Convincing response to SABA No/unclear

improvement ** Clear

improvement***

Asthma Stop trial (de-

challenge) Deterioration

Mild infrequent symptoms and

exacarbations

Asthma

AND IF

No Yes

No

No Yes

Yes

Release when symptomatic an/or at 3 months

Release at 6 weeks and 3 months

Yes

Canadian Resp J 2015

*Documentation by a physician or trained health care practitioner

†Episodes of wheezing with/without difficulty breathing

‡Severity of an exacerbation documented by clinical assessment of signs of airflow obstruction, preferably with the addition of objective measures such oxygen saturation and respiratory rate, and/or validated score such as the Pediatric Respiratory Assessment Measure (PRAM) score

‡‡≥8 days/month with asthma-like symptoms

**A conclusive therapeutic trial hinges on adequate dose of asthma medication, adequate inhalation technique, diligent documentation of the signs and/or symptoms, and timely medical reassessment; if these conditions are not met, consider repeating the treatment or therapeutic trial

***Based on 50% fewer moderate/severe exacerbations, shorter and milder exacerbations, and fewer, milder symptoms between episodes. ICS Inhaled corticosteroid

(29)

SABA^ℑ

SABA and OCS^ℑ

Unclear diagnosis

AND

SABA

improvement***

exacarbations

Asthma

AND IF

No Yes

No

No Yes

Yes

(30)

SABA^ℑ

SABA and OCS^ℑ

Unclear diagnosis

AND

SABA

improvement***

exacarbations

Asthma

AND IF

No Yes

No

No Yes

Yes

(31)

ASTHMA IN ≤5 YEARS (Section 2)

CHAPTER 6 IN GINA 2014

2014

(32)

2015

2015 Update

A new flow-chart has been provided for management of acute asthma

exacerbations or wheezing episodes

(33)

2017 Update

Prolonged cough in infancy, and cough without cold symptoms, are associated with later parent-reported physician-

diagnosed asthma, independent of infant wheeze.

Effects of ICS on growth velocity are seen in pre-pubertal children in the first 1-2

years of treatment, this is not progressive or cumulative. (difference of only 0.7%

adult height)

1.

2.

(34)

1. In a multi-center study, blood eosinophils and atopy predicted greater short-term response to moderate dose ICS than to LTRA

New relevant low dose ICS dose based on age- group

2018 Update

2.

(35)

1. Additional suggestions are provided for investigating a history of wheezing

2019 Update

(36)

For exacerbations, OCS are not generally recommended except in emergency

department and hospital settings.

2019 Update

2.

3.

Recent studies suggest that clinical and/or

inflammatory features may predict better short- term response to ICS but more studies are needed.

Early referral is recommended if the child fails to respond to controller treatment

(37)

1. Assessment criteria have been revised with

respiratory rate added, retractions removed and pulse rate-revised lower

2020 Update

(38)

In children ≤ 5 years with intermittent viral

wheezing and no or few interval respiratory

symptoms, consideration of intermittent short

course ICS has been

added to the treatment figure

2022 Update

1.

www.ginasthma.org

(39)

GINA Updated 2022 GINA Updated 2023

NOT CHANGED

(40)

2023

(41)

(42)

(43)

(44)

A Clinical Index to Define Asthma Risk

Major Criteria Minor Criteria

1. Parenteral medical history of

asthma 1. Medical history of rhinitis allergy 2. MD eczema 2. Wheezing apart from colds

3. Eosinophilia (≥ 4%)

Loose Index • At least 1 major criteria or

• 2 minor criteria Stringent

Index

• Early frequent wheezing plus at least:

• 1 major criteria or

• 2 minor criteria

Positive Loose Index

• 2.6-5.5 times more likely to have asthma

Positive Stringent Index

• 4.3-9.8 times more likely to have asthma

(45)

Modified Asthma Predictive Index (mAPI) Primary ≥ 4 wheezing episodes in a year

and

Secondary At least 1 major: OR At least 2 minior:

Parenteral physician-

diagnosed asthma Wheezing unrelated to colds Physician-diagnosed atopic

dermatitis Eosinophils ≥ 4% in

circulation Allergic sensitization to at

least one aeroallergen Allergic sensitization to milk, egg, or protein

Positive mAPI

• 4.9-55 times more

likely to have asthma

(46)

Several asthma prediction models have been proposed to improve the early diagnosis and management of asthma-like symptoms.

The Prevention and

Incidence of Asthma and Mite Allergy (PIAMA) Risk Score

An instrument to predict asthma at school age in children who present with asthma-like

symptoms before age 4 years

(47)

Modified PIAMA Risk Score for

Predicting Asthma in Preschool Children

Male Sex 2

Medium/ low parental education 1

Parental asthma 4

Preterm Birth (<37 week) 1 Wheezing Frequency

1–3 times/y 4

>4 times/y 7

Wheezing/dyspnea apart from colds 2

Eczema 6

Range Total Score 0–23

0–7 : <5%

8–15 : 6%–22%

16–23: 25%–50%

Total Score

de Groend, et al. Predicting asthma in preschool children with asthma-like symptoms: Validating and updating the PIAMA risk score. Am Acad Allergy, Asthma & Immunol. 2013.

(48)

Children aged between 0-4 years Four Major Aims

1. To estimate the prevalence of respiratory disorders in young children and to determine whether secular trends in asthma and wheeze described for adults and schoolchildren were also evident for preschool children;

2. To study the contribution of potential risk factors on incidence and persistence of wheeze and other respiratory disorders taking into account different age-exposure windows;

3. To study wheezing disorders in children of South Asian origin, the predominant British ethnic minority and

4. To study the natural history of wheeze and chronic cough and to determine how many disease phenotypes exist within the ‘asthma’

spectrum in childhood. Kuehni CE, et al. Cohort Profile: The Leicester Respiratory Cohorts. Intern J Epid. 2007;36:977-985

(49)

(50)

Among all available asthma predictive tools, only

API, PIAMA, and the Leicester--VALIDATED

Colicino S, et al. Validation of childhood asthma predictive tools: A systematic review. Clin Exp Allergy.2019;49:410–18.

(51)

In children aged ≤ 5 years, infant and preschool asthma is diagnosed according to the response to short acting beta2 agonists or the effect of a

therapeutic trial during 1 month with controller treatment and worsening after treatment

cessation

(52)

Low dose ICS for Asthma in Children <5 year

www.gina2023 52

(53)

About 80% of children with asthma experience their first

symptoms in preschool age, but are often not diagnosed as asthma.

Establishing a diagnosis of asthma in preschool children is challenging because in this age group recurrent coughing

and wheezing are often caused by diseases other than asthma, and supporting asthma diagnosis with a spirometry cannot be done.

For preschool children, the guideline refers to children aged 0-

<6 years

NATIONAL PEDIATRIC ASTHMA GUIDELINE (PANDUAN NASIONAL ASMA ANAK=PNAA)-2022

PNAA 2022

(54)

Diagnosis of Asthma in Preschool Children

Symptoms: coughing, wheezing, shortness of breath, difficulty breathing, or a combination of these symptoms.

● With recurrent (episodic) characteristics, tends to worsen at night (nocturnal),

triggered by certain triggers, and can improve with or without treatment (reversible).

● More likely to be asthma, especially when symptoms occur without respiratory infection

Risk factors for asthma: family history of asthma or allergy, history of food allergy, or atopic dermatitis

Good response to therapeutic trials: controller therapy (low dose IC) daily and SABA inhalation when shortness of breath given for 3 months

Other differential diagnoses have been ruled out or are unlikely.

Pedoman Nasional Asma Anak (PNAA) Edisi Ketiga UKK Respirologi IDAI; 2022

PNAA 2022

(55)

Classificatio n

Degree of Asthma Description

Intermittent Episodes of asthma symptoms once a

month or less often

Mild persistent Symptomatic episodes ≥2 times a

month, but not >1 time a week

Moderate persistent Symptomatic episodes > 1 time a week, but not every day

Severe persistent Asthma symptom episodes almost every day

Classification of asthma in preschool children based on frequency of symptoms

PNAA 2022

(56)

Classification

Criteria Controlled Partially controlled Uncontrolled

In the last 4 weeks has the child experienced:

● Daytime asthma symptoms for more than a few minutes >1 time a week

● Wake up at night because of asthma

● Use of reliever

medication >2 times a week

● Activity limitation due to asthma symptoms

all criteria are

absent 1-2 criteria 3-4 criteria

Classification of asthma in preschool children based on degree of control

PNAA 2022

(57)

Classification

Criteria Mild-moderate Severe/life-threatening*

consciousness Not disturbed Agitation, confusion, or drowsiness Peripheral oxygen saturation

on admission (prior to therapy) >95% <92%

Speaking** Sentence Word

Pulse rate < 100 x/min > 180 x/min (0-3 years old)

>150 x/min (4-5 years old)

Respiratory rate ≤40 x/min >40 x/min

Central cyanosis none Most likely

Intensity of wheezing vary breathing sounds may be weak or inaudible

Classification and Criteria for the Degree of Asthma Attacks in Preschool Children

* The presence of one of the signs and symptoms indicates a severe/life-threatening attack.

** Depending on the child's speech ability based on age

PNAA 2022

(58)

Long-term Management of Asthma in Preschool Children

without controller

Consider intermittent ICS when respiratory viral infections occur

Low-dose IC or LTRA

or

Intermittent ICS when there is a viral

respiratory infection

Double low dose ICS or

Low dose IC + LTRA

Consider referral to consultant

respirologist

Continue controller and refer to

consultant respirologist

or

● increase ICS dose

● or add LTRA

● or ICS-LABA High-dose

intermittent IC in the presence of viral respiratory tract infections

Reliever: SABA if necessary Step 1

Step 2

Step 3

Step 4

PNAA 2022

(59)

Long-term Management of Asthma in Preschool Children

Assessing response and adjusting therapy

●

Re-visits are conducted at 2-4 weeks from the start of treatment to assess treatment response.

●

If the response is good, repeat visits can be done but monthly to evaluate the degree of asthma control, risk factors for adverse outcomes, and side effects.

●

Treatment is adjusted according to the child's condition at the time of the revisit, and may be downgraded or upgraded

PNAA 2022

(60)

Down grading

● Downgrading asthma therapy can be done if the child is free of asthma symptoms for 2-3 months.

● If therapy is downgraded or discontinued, schedule a follow-up visit 3-6 weeks later to check for recurrence of symptoms, as relapse may occur and control therapy should be up-graded or reintroduced.

Upgrading

If the child is receiving controller medication, the therapeutic response should be assessed monthly. In each treatment tier, the tier can be upgraded after at least 3 months of controller use.

Consider the following before upgrading to a higher tier

● Ensure that symptoms are indeed due to asthma and not to other diseases or comorbidities.

Refer to a consultant respirologist if there is any doubt.

● Observe and correct technique of inhaler use

● Ensure regularity of medication use according to prescribed dose

● Control environmental exposure and precipitating factors such as allergens (house dust mites, dust, cockroaches, pets, inhalation of other substances, food allergens) or cigarette smoke, acute upper respiratory tract infections (rhinitis, sinusitis, and other respiratory tract viral infections), obesity, and excessive physical activity in exercised- induced asthma (EIA).

● Consider replacing therapy with a "preferred" medication at the same level.

If these things have been done and asthma symptoms are still uncontrolled and/or attacks continue to occur, then the level of therapy is increased.

(61)

Practical Approach

In a preschooler with recurrent wheezing, the possibility of an underlying allergy should be assessed (by skin prick testing or determination of specific IgE)

If allergy (viral-induced wheezing) is not present, usually little maintenance treatment is needed, the wheezing should be considered as nonallergy.

Most of the children will grow out of it.

Treatment should be focused on treating the symptoms such as beta-agonist. If the symptoms frequently occur, consider a leukotriene-receptor antagonist or starting ICS

In contrast, if allergy is present (positive skin prick test or positive specific IgE), there is an increased risk that the child will continue wheezing beyond preschool age. ICS is necessary to control the underlying inflammation and to prevent symptoms

(62)

Take Home Messages

• Diagnosing and managing asthma in preschool children can be difficult In infants and young children:

The primary symptoms— coughing and wheezing maybe caused by other conditions

Standard diagnostic test to test used to measure how well children is breathing cannot be used easily or accurately in preschool children

Managing asthma for children under five requires careful and frequent monitoring (written asthma action plan to monitor symptoms and adjust treatment as necessary)

• We can predict risk for preschool children for having asthma by using Asthma Predictive Index (API)

• Treatment should be taken into account individually, depend on degree of asthma severity or severity of asthma exacerbation focused on treating the symptoms such as beta-agonist.

If the symptoms frequently occur, consider a leukotriene-receptor antagonist or starting ICS

In contrast, if allergy is present (positive skin prick test or positive specific IgE), there is an increased risk that the child will continue wheezing beyond preschool age.

ICS is necessary to control the underlying inflammation and to prevent symptoms; trial ICS may be considered

(63)

Thank you

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