Guideline for the management of chronic asthma in children - 2000 update

Objective. To increase awareness of asthma and diagnose asthma early in chi ldren. To make recommendations regarding management of chronic childhood as thma in a country with diverse cultural, sodo-economic and educational char acteristics. The guideline should be used by health professionals involved in the treatment of asthma at all levels of care. Options. Various management options were considered. Ideal treatment includ es use of the new generation inhaled corticosteroids (fluticasone, budesoni de), housedust mite intervention for asthma control using impermeable cover s for pillows and mattresses, and if needed use of inhaled longacting beta( 2) agonists (LABAs) and leukotriene receptor antagonists(LRAs). Alternative therapeutic approaches for situations where resources are limited include simple housedust mite control measures (e.g. airing mattresses and bedding) , avoidance of exposure to passive smoking, use of lower doses of beclometh asone than recommended by other guideline documents and/or sustained-releas e (SR) theophylline as preventer treatment and use of plastic bottles as ch eap spacer devices. Outcomes. The main potential outcomes considered were: to; reduce morbidity and mortality by correct diagnosis of asthma, to achieve the best quality of life for the child with asthma, to minimise side-effects from medication and to prevent development of permanently abnormal lung function. Evidence. Current international guideline documents for diagnosis and manag ement of childhood asthma were evaluated. Clinical studies before 1998 pert aining to the various aspects of management of childhood asthma were review ed, including controlled studies on the use of inhaled corticosteroids in c hildren with asthma, randomised controlled trials on the use of LRAs and tw o studies evaluating the efficacy of LABAs. Current data on the antiinflamm atory effects of SR theophylline were also reviewed as well as a randomised controlled trial on the benefits of SR theophylline as adjunct treatment i n childhood asthma. The benefit of simple spacer devices, based on well-con ducted local studies (published in an international peer-reviewed journal) was also considered. Values. The South African Childhood Asthma Working Group (SACAWG) committee members, appointed by the Allergy Society of South Africa (ALLSA) were sel ected to represent the interests of health professionals involved in the ca re of childhood asthma and to co-opt other colleagues with expertise releva nt to the guideline. The committee was divided into six task groups headed by a chairperson - each task group had to review critically the previous SA CAWG guideline (for deficiencies and obstacles to implementation), review c urrent trends in asthma management (evidence-based where available) and sub mit proposals and recommendations to their respective chairperson. The chai rperson then compiled a report for discussion by the SACAWG executive commi ttee. The executive group convened a meeting to discuss the recommendations and obtain consensus. An editorial board was appointed to compile the fina l report. Cultural factors, patient preferences, cost, availability and edu cation were considered important. Benefits, harms and costs. Proper treatment should enable most children wit h asthma to lead normal or near-normal lives. The guideline could be implem entable at all levels of tare. The risk of systemic effects due to inhaled corticosteroids should be minimised in children with mild to moderate persi stent asthma (risk of systemic effects is more likely at daily beclomethaso ne doses exceeding 400 mu g or the equivalent dose of other inhaled cortico steroids). Promotion of simple environmental control measures and use of in haled beclomethasone and/or SR theophylline should make treatment more wide ly available and more affordable and improve adherence to treatment. Altern ative cheap plastic bottle spacer devices will increase availability and as sist with overcoming the problem of incorrect inhaler technique. Recommendations. Asthma must be diagnosed in children with recurrent wheezi ng or tough that responds to a bronchodilator. In young children (< 3 years ), recurrent wheezing may be due to other causes such as viral-induced whee zing, gastro-oesophageal reflux, pulmonary tuberculosis and congenital abno rmalities (cardiac or respiratory). Inhaled corticosteroid (ICS) should be first-line treatment for children with persistent asthma. If needed, adjunc t controller therapy (SR theophylline, LABAs or LRAs) should be used for th eir steroid-sparing effect. Spacer devices should be used in all children o n TCS to reduce the risk of local adverse effects and improve drug delivery to the lungs (this may enable use of lower doses of ICS). Simple environme ntal control measures should he implemented when feasible. Validation. SACAWG's recommendations will be reviewed by ALLSA, This guidel ine differs from those of other societies or organisations that have recomm ended the use of much higher doses of ICS. It also pays due regard to cultu ral, socio-economic and educational factors in South Africa. Recommendation s were developed by SACAWG and endorsed by the South African Pulmonology So ciety and the South African Medical Association (SAMA). Financial sponsors. A meeting of the SACAWG executive committee to discuss the task group reports was sponsored by an educational grant from Zeneca Ph armaceuticals. The cost of production and dissemination of the guideline as well as secretarial assistance were borne by ALLSA.