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Severe Asthma in Paediatrics and Adolescence

Child with an inhaler from toolkit page on paediatric asthma
Severe asthma specifically refers to those with treatment-resistant asthma and is very rare in children. However, ``difficult to treat`` asthma is common. This Toolkit section will help to differentiate between the two.
Reasons for not including children under 5 years in the scope of this Toolkit
Reasons for not including children under 5 years in the scope of this Toolkit
 Note: The paediatrics toolkit section is designed for children older than 5 years of age

There are several factors that make diagnosing asthma particularly difficult in preschool children. Issues that complicate objective diagnosis include:

  • Preschool children are unable to perform reliable spirometry
  • Natural history of wheezing at preschool age is much more variable, with the majority of symptoms resolving over time
  • The likelihood of alternative diagnosis for ‘wheeze’ in preschool is relatively high, particular in cases of severe symptoms (e.g. airway malacia, anatomical obstructions lung malformations, reduced immune function, reflux and aspiration disease, cystic fibrosis, primary ciliary dyskinesia)
  • Evidence for inhaled corticosteroid efficacy is largely lacking for pre-school children

Asthma continues to claim the lives of Australian children each year, many of whom have not been identified as having severe asthma. It also contributes significantly to morbidity, hospitalisation, school absence and children missing out on normal social and sporting activities. Up to 80% of child and adolescent deaths from asthma are considered to be preventable with appropriate asthma management and education (Fitzgerald et al. 2015).

LAY OVERVIEW

Asthma claims the lives of Australian children and teenagers each year. Many of these children were not known to have severe asthma and their deaths could have been prevented with the proper health care.  Also, many children suffer from illness, hospitalisation, and absence from school or are unable to participate in sports and social activities due to severe asthma.

Risk Factors for Death due to Asthma in Children

Adolescent Male

Poor Socioeconomic Status

Psychosocial and Child Protection Issues

Previous Intensive Care Unit Admission

Exposure to Tobacco Smoke

Hospital Admission in Previous Year

Persistent Asthma Symptoms

Lack of Asthma Action Plan

Diagnosis, Assessment & Management in Paediatrics:
Medication in Paediatrics:
Adolescents
Diagnosis, Assessment & Management in Paediatrics:

Involves:

  • Confirming a diagnosis of severe asthma
  • Identifying co-morbidities or alternative diagnoses
  • Identifying and managing contributing factors
  • Ensuring treatment compliance
  • Initiating treatment/review process.

All aspects must occur in a holistic manner, involving family members, considering the household and school environment, and ensuring any associated psychological issues are also acknowledged and managed appropriately.

Management in Paediatrics
Assessment in Paediatrics
Alternative Diagnosis & Co-Morbidities in Paediatrics
Psychosocial Issues in Paediatrics
Medication in Paediatrics:

Children with difficult-to-treat or severe asthma should be referred to a paediatrician with experience managing asthma. High-dose asthma treatments can have detrimental short and long-term consequences and thus treatments should be targeted and rationalised following appropriate investigations and education. For more information see Medications

Adolescents

Adolescents and young adults (aged 14-24 years) may present with a number of specific problems which need to be understood and addressed for optimised asthma management. This age group are under-represented in hospital admissions, but over-represented in asthma mortality rates. For more information see Asthma in the Adolescent Population

Key Points

  • Children still die from asthma in Australia each year, many of these deaths are considered preventable
  • Difficult-to-treat asthma is common, but true severe treatment-refractory asthma is rare, in the paediatric population
  • Differentiating between these diagnoses is possible, but can be time consuming
  • Psychosocial aspects must be considered
  • Adolescents and young adults present specific problems
  • Side-effects of medications must also be considered
Paediatrics Adults
Lung function testing for diagnosis Can be difficult particularly in young children. Response to treatment may be used as diagnostic tool Should be used as diagnostic tool
Treatments ICS first line. Many combination ICS/LABA and monoclonal antibodies are only licensed for >12 years-old ICS first line. Add LABA if poorly controlled +/- add on treatments
Atopy frequency +++ ++
Family history of asthma +++ ++
Natural history Approx 2/3 will grow out of symptoms May develop early or later in life
Co-morbidities Consider alternative diagnoses, comorbidity and psychosocial factors

(See Paediatrics – Alternative Diagnoses & Co-Morbidities and Psychosocial Issues)

 Significant comorbid disease is common

(See Comorbidities)
Read more

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