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Inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12 years

Scope of the guidance

This EGP Update item draws on several guidelines: NICE technology appraisal guideline 131 and BTS & SIGN British guideline on the management of asthma (see below).  It looks at the use of inhaled corticosteroids to treat children with chronic asthma.  Other related guidance includes NICE technology appraisal guidance 38: 'inhaler devices for routine treatment of chronic asthma in older children (aged 5-15 years)’, and NICE technology appraisal guidance 10: 'guidance on the use of inhaler systems (devices) in children under the age of 5 years with chronic asthma' (see Further Reading).

Source

British Thoracic Society and Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. Edinburgh: BTS & SIGN; 2008.

http://www.sign.ac.uk/pdf/sign101.pdf

National Institute for Health and Clinical Excellence. Inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12 years. NICE Technology Appraisal Guidance 131. London: NICE; 2007.

http//www.nice.org.uk/nicemedia/pdf/TA131guidance.pdf

Key points

1. Background

• Asthma is the most common chronic disease in children in the UK, with about 10% of children being diagnosed with asthma and as many as 20% being wheezy at some point.
• Asthma causes airflow obstruction and airway hyper-responsiveness in the lung. 
• Symptoms can be triggered by a number of factors including infection, allergy, smoke or exercise.
• Inhaled corticosteroids are used to treat chronic asthma to help to reduce inflammation and swelling in the airways.
• Deaths in children as a result of asthma are rare.
• Asthma can impact on the quality of a child’s life; some children do not participate in physical activity or play with animals. There is an increase in school absences and sleep disturbances for children with asthma.

2. Diagnosis

• Diagnosing asthma can be difficult, especially in young children.
• Suspect asthma in a child where you hear wheezing on auscultation; though most wheezing episodes in infancy are precipitated by viral respiratory infections.
• The four cardinal symptoms of asthma are: shortness of breath, cough, chest tightness and wheeze.
• Respiratory symptoms between acute attacks suggests a diagnosis of asthma.  Having a personal or family history of atopic conditions such as eczema or hayfever is also linked to asthma.

• Exclude other causes of recurrent respiratory symptoms e.g.:

            cystic fibrosis

            immunosuppression and recurrent infections

            bronchiectasis

            gastro-oesophageal reflux

            (see BTS and SIGN guidelines in Further Reading for full list of other causes).

• You might confirm your diagnosis of asthma by assessing the child’s response to bronchodilators, inhaled corticosteroids or oral steroids.
• Allergy testing (if available) can help to identify allergens in the obviously atopic child, but false positives and false negatives are common.

3. Review Control

• Most children with asthma are symptom-free most of the time, with occasional episodes of shortness of breath. But some children frequently cough and wheeze and may have severe attacks during viral infections, after exercise, or after exposure to allergens or cigarette smoke.
• All people with asthma (including children) should have annual reviews in primary care as part of the Quality and Outcomes Framework.  Check the child’s inhaler technique at the annual review as well as their concordance with treatment and symptom control. Address any concerns of the child or parents in relation to therapies used.

4. Treatment

• Non-pharmacological management options include avoiding allergens e.g.:
  • if the child is sensitive to house dust-mite then the parents could try removing carpets, washing bed linen at high temperature or using complete barrier bed coverings although there is no evidence that chemical and physical methods to eradicate house dust mite are effective. 
  • if the child is allergic to a pet, some experts suggest that removing the pet from the house can improve symptoms, though trials have failed to show benefits of doing so.
  • smoking should be discouraged in the house as it contributes to the severity of the asthma – so try and motivate the parents or carers to stop smoking themselves and insist on other smokers going outside.

• Use pharmacological treatment to control symptoms (including nocturnal symptoms and exercise-induced asthma), prevent exacerbations and get the best possible respiratory function, whilst minimising side effects.
• Employ a stepwise approach to treatment: start at the most appropriate step for the severity of the asthma, to gain early control of symptoms and optimise respiratory function.

        Step 1 – mild intermittent asthma: treat with an inhaled short-acting beta-2 agonist, as required. 

        Step 2 – add a regular ‘preventer’ therapy with inhaled steroid.  Move to this step when a child:

         has had exacerbations of asthma in the last two year

         is using an inhaled beta-2 agonist three times a week or more

         is symptomatic three times a week or more

         is waking at night once a week because of asthma

See below for inhaled steroid recommendations.

        Step 3 – add-on therapy, so that a third drug is introduced.  Reassess the child’s response to the additional therapy after a few weeks, and decide whether to continue the drug or swap for another.

         For children try add-on therapy before increasing the dose of inhaled steroid beyond 400 micrograms of beclometasone daily (or equivalent).

         For children older than 5 years add in long-acting beta-2 agonists.

        Other drugs you could try for children aged 5-12 years old include leukotriene receptor antagonists and theophyllines.  Antihistamines and ketotifen are ineffective as sodium cromoglycate probably is too.

         In children aged 2−5 years, a leukotriene receptor antagonist should be tried first.

         For children younger than 2 years, refer to a respiratory paediatrician.

        Step 4 – if control remains inadequate despite three drugs: increase the daily dose of inhaled steroid to 400 or 800 mcgs per day for children aged 5–12 years; refer all children requiring 800mcg per day to a respiratory paediatrician

        Step 5 – involves continuous or frequent courses of oral steroids being introduced. Before proceeding to this step, you should refer the child to a respiratory paediatrician.

• Stepping down: step down therapy once a child’s asthma is well-controlled.  Regular reviews should take into account the severity of the asthma, side-effects and any patient preferences, when deciding which medication to cut down or stop.

5. Treatment with inhaled steroids

• Three inhaled steroids are licensed for use in children:

            beclometasone dipropionate

            budesonide

            fluticasone propionate.

• All are available as metered-dose inhalers (press-and-breathe or breath actuated) and dry powder inhalers. 
• NICE recommends a ‘press-and-breathe’ metered-dose inhaler with a spacer device as the first choice of device for children aged 5−15 years taking inhaled steroids. If you think that the child will not be able to manage a press-and-breathe inhaler, consider other devices. 
• Inhaled steroids are also available in combination with long-acting beta-2 agonists in a more expensive, single combination device. The decision whether to use a combination device or as two drugs in separate devices, should be based on the individual child and their asthma, taking into consideration therapeutic need and the likelihood of the child adhering to the treatment regime.

6.  Side-effects from inhaled steroids include:

• Local –
• dysphonia
• oropharyngeal candidiasis
• cough
• irritation of the throat
• reflex bronchospasm

• Systemic – (these start to be seen at daily doses of 400 micrograms of beclometasone and above)
• adrenal gland suppression
• osteoporosis
• skin thinning and ready bruising
• cataract formation and glaucoma
• growth retardation in children and adolescents – so you should monitor a child’s height on a regular basis (underuse of medication and symptomatic asthma often result in children of lower height than those on relatively high doses of steroids).

Practical tips for the busy GP >>

EGP 1. May 2008