G IN A lobal itiative for sthmawww.ginasthma.org

Global Strategy for the Diagnosis and Management of Asthma in Children 5 Years and Younger

May, 2009

Global Strategy for Asthma Management and Prevention in Children 5 Years and YoungerBurden of Asthma in ChildrenThe most common chronic disease of childhoodThe leading cause of childhood morbidity from chronic disease as measured by emergency department visits, hospitalizations, and school absencesTypically begins in early childhood, with earlier onset in males than femalesAtopy is present in the majority of children over 3 years of age with asthma

Global Strategy for Asthma Management and Prevention in Children 5 Years and YoungerWriting Committee Allan Becker, Manitoba, Canada Soren Pedersen, Kolding, Denmark Robert Lemanske, Madison, Wisconsin US Peter Sly, Perth, Western Australia Manuel Soto-Quiros, San Jose, Costa Rica Gary Wong, Hong Kong, ROC Heather Zar, Cape Town, S. Africa

Global Strategy for Asthma Management and Prevention in Children 5 Years and YoungerReferencesWriting committee searched published literature by PubMed (NLM) 110 key references selected for citationEvidence levels assigned according to methodology used in previous GINA documentsText and publication list will be updated annually

Global Strategy for Asthma Management and Prevention in Children 5 Years and YoungerEvidence Category Sources of Evidence

A Randomized clinical trials Rich body of data B Randomized clinical trials Limited body of data C Non-randomized trials Observational studies D Panel judgment consensus

Hans Bisgaard, Copenhagen, DenmarkJacque de Blic, Paris, FranceJohan De Jongste, Rotterdam, The Netherlands.Renato Stein, Rio Grande do Sul, BrazilStan Szefler, Denver, CO, USAGran Wennergren, Gteborg, SwedenCarlos E. Baena-Cagnani, Cordoba, ArgentinaChunxue Bai, Shanghai, ChinaHisbello da Silva Campos, Rio De Janeiro, RJ BrazilMotohiro Ebisawa, Kanagawa, JapanAziz Koleilat, Beirut, LebanonLe Thi Tuyet Lan, Ho Chi Minh City, Viet NamPatrick Manning, Dublin, IrelandHugo E. Neffen, Santa Fe, ArgentinaLexley M Pinto Pereira, Trinidad, West IndiesPetr Pohunek, Czech RepublicYoung Soo Shim, Seoul, KoreaHaluk Turktas, Ankara, TurkeyBulent Karadag, Ankara, TurkeyBulent Sekerel, Istanbul, TurkeyHasan Yuksel, Manisa, TurkeyChen Yu Zhi, Beijing, P.R.ChinaShigemi Yoshihara, Dokkyo, JapanEva Mantzouranis, Heraklion, Crete, GreeceYousser Mohammad, Lattakia, SyriaGazal Dib, Lattakia, SyriaSamira Mohammad, Lattakia, SyriaFatmeh Dmeiraoui, Lattakia, SyriaGlobal Strategy for Asthma Management and Prevention in Children 5 Years and YoungerReport Reviewers

+ GINA Science Committee and Executive Committee

Global Strategy for Asthma Management and Prevention in Children 5 Years and YoungerRisk factors associated with development of asthmaDiagnosisManagement and pharmacologic treatment

Global Strategy for Asthma Management and Prevention in Children 5 Years and YoungerRisk factors associated with development of asthmaDiagnosisManagement and pharmacologic treatment

Risk Factors Associated with Development of Asthma

Aeroallergens - House dust mites - Companion animal allergens - Cockroaches - FungiMaternal diet during pregnancy and/or lactation Pollutants Microbes and their products Psychosocial factors Other risk factors

Risk Factors Associated with Development of Asthma

Avoid maternal smoking during pregnancyAvoid exposing children to atmospheric pollution and particularly tobacco smoke Avoid unnecessary use of antibiotics in young childrenProvide a calm and nurturing environmentRecommendations

Global Strategy for Asthma Management and Prevention in Children 5 Years and YoungerRisk factors associated with development of asthmaDiagnosisManagement and pharmacologic treatment

Diagnosis of Asthma in Children 5 Years and YoungerAsthma diagnosis in this age group is difficult Respiratory symptoms (wheezing and cough) also common in children without asthmaNot possible to routinely assess airflow limitation (spirometry)

Diagnosis of Asthma in Children 5 Years and YoungerA diagnosis of asthma can often be made based on symptom patterns (wheeze, cough, breathlessness) and on a careful clinical assessment of family history and physical findings.Typical symptom pattern: Symptoms occur recurrently, during sleep, or with triggers such as activity, laughing or crying The presence of atopy or allergic sensitization provides additional predictive support.

Diagnosis of Asthma in Children 5 Years and YoungerNo tests provide a diagnosis with certainty but the following may be useful adjuncts in a diagnostic decision:Therapeutic trial with inhaled glucocortiosteroid and rapid-acting 2-agonists for 8-12 weeks Tests for atopyLung function testing is of limited use because of practical difficulties obtaining reliable results.

Differential Diagnosis of Asthma in Children 5 Years and Younger Infections, e.g. - Recurrent respiratory tract infections - Chronic rhino-sinusitis- Tuberculosis Congenital problems, e.g. - Tracheomalacia- Immune deficiency- Congenital heart disease Mechanical problems, e.g.- Gastroesophageal reflux

Global Strategy for Asthma Management and Prevention in Children 5 Years and YoungerRisk factors associated with development of asthmaDiagnosisManagement and pharmacologic treatment

Clinical Control of Asthma in Children 5 Years and YoungerFor children with a confirmed diagnosis of asthma, control can be achieved with a pharmacologic intervention strategy developed in partnership between the family/caregiver and the health care practitioner. Inhaled therapy constitutes the cornerstone of asthma treatment in this young age group.

> 2 days/weekNeed for reliever/rescueNocturnal symptoms or awakeningNone(less than twice/week, typically for short periods of the order of minutes and rapidly relieved by use of a rapid-acting bronchodilator)Limitations of activities>Twice a weekDaytime symptoms:wheezing, cough,difficult breathing Uncontrolled(>3 features of partly con- trolled present in any week)Partly controlled(any measure present in any week)ControlledCharacteristicLevels of Asthma ControlNone(child is fully active,plays and runs withoutlimitation or symptoms)None(including no nocturnalcoughing during sleep)< 2 days/week(typically for short periods of the order of minutes and rapidly relieved by use of a rapid-acting bronchodilator(coughs during sleep or wakes with cough, wheezing,and/or difficult breathing)Any> 2 days/weekAny(cough, wheeze or difficulty breathing,during exercise, play or laughing)(typically last minutes or hours or recur, but partially or fully relieved by a rapid-acting bronchodilator>Twice a weekAny(cough, wheeze or difficulty breathing,during exercise, play or laughing)(coughs during sleep or wakes with cough, wheezing,and/or difficult breathing)AnyGlobal Strategy for Asthma Management and Prevention in Children 5 Years and YoungerAny exacerbation should prompt review of maintenance treatment

Choosing an Inhaler DeviceA pressurized metered-dose inhaler (MDI) with a valved spacer (with or without a face mask, depending on the childs age) is the preferred delivery system

Choosing an Inhaler Device Age groupPreferred deviceAlternative deviceYounger than 4 yearsPressurized metered-dose inhaler plus dedicated spacer with face maskNebulized with face mask 4-5 yearsPressurized metered-dose inhaler plus dedicated spacer with mouth piecePressurized metered-dose inhaler plus dedicated spacer with mouth piece, or

Nebulizer with mouthpiece or face mask

Global Strategy for Asthma Management and Prevention in Children 5 Years and YoungerPharmacotherapy - LiteraturePlacebo-controlled studies of inhaled gluco-corticosteroids in children 5 years and younger with asthma provide statistically significant clinical effects on (Evidence A): number of symptom-free days reduced symptoms need for additional medication caregiver burden systemic glucocorticosteroid use exacerbations (..continued)

Global Strategy for Asthma Management and Prevention in Children 5 Years and YoungerPharmacotherapy - LiteratureRapid-acting inhaled 2-agonists are the most effective bronchodilators available and therefore the preferred reliever treatmentBecause of the side effects associated with prolonged use, oral glucocorticosteroids in young children with asthma should be restricted to the treatment of acute severe exacerbations, whether viral-induced or otherwise (Evidence D)

Several trials have found little or no effect of intermittent treatment of wheezing episodes with:

Oral glucocorticosteroids Montelukast Inhaled glucocorticosteroids

Environmental controlAs needed rapid-acting 2-agonistsControlled on as neededrapid-acting 2-agonistsPartly controlled on as needed rapid-acting 2-agonistsUncontrolled on 2-agonists prn. or partly controlled on a low-dose inhaled glucocorticosteroidController optionsLeukotriene modifierLow-dose inhaled glucocorticosteroid plus leukotriene modifierDouble low-doseinhaled glucocorticosteroid

Asthma Management Approach Based on Control for Children 5 Years and YoungerOral glucocorticosteroids should be used only for treatment of acute severe exacerbations of asthma.Green shaded boxes represent the preferred treatment options.

Global Strategy for Asthma Management and Prevention in Children 5 Years and Younger

* Doses found to be without adverse systemic effects in clinical trials

Low daily doses of inhaled glucocorticosteroids*DrugDaily doseBeclomethasone dipropionate100 gBudesonide pMDI+spacerBudesonide nebulized200 g500 gCiclesonideNSFluticasone propionate100 gMometasone furoateNSTriamcinolone acetonideNS

Early symptoms of an acute exacerbation:Increase in wheeze or shortness of breathIncrease in coughing, especially at nightReduced exercise toleranceImpairment of daily activities, including feedingA poor response to reliever medicationAcute Exacerbations of Asthma in Children 5 Years and Younger

An action plan should be provided to the family members and caregivers to:Recognize an asthma attack and initiate treatment Recognize a severe episodeIdentify when urgent treatment is necessaryProvide specific recommendations for follow-up careAcute Exacerbations of Asthma in Children 5 Years and Younger

A pressurized metered dose inhaler with a valved spacer (with or without a face mask depending on the childs age) is the preferred delivery system (Evidence A).A low-dose inhaled glucocorticosteroid is recommended as the preferred initial treatment to control asthma (Evidence A).If low-dose inhaled glucocorticosteroid does not control symptoms, and the child is using optimal technique and is adherent to therapy, doubling the initial dose of glucocorticosteroid may be the best option (Evidence C). (.continued)Global Strategy for Asthma Management and Prevention in Children 5 Years and YoungerKey Messages: Pharmacologic Therapy

When doubling the initial dose of inhaled glucocorticosteroid fails to achieve and maintain asthma control, the childs inhalation technique and compliance with the medication regimen should be carefully assessed and monitored. Use of oral glucocorticosteroids should be restricted to the treatment of acute severe exacerbations, whether viral-induced or otherwise (Evidence D).To avoid under and over-treatment continued need for asthma treatment should be regularly assessed (e.g., every three to six months).Global Strategy for Asthma Management and Prevention in Children 5 Years and YoungerKey Messages: Pharmacologic Intervention

Available at www.ginasthma.orgGlobal Strategy for Asthma Management and Prevention in Children 5 Years and YoungerFull ReportPocket Guide

Additional Slides The following slides represent alternative presentations

Diagnosis of Asthma in Children 5 Years and YoungerSymptom patterns (wheeze, cough, breathlessness) which occur recurrently, during sleep, or with triggers such as activity, laughing or crying are consistent with a diagnosis of asthma.

Diagnosis of Asthma in Children 5 Years and YoungerThe presence of atopy or allergic sensitization provides additional predictive support, as early allergic sensitization increases the likelihood that a wheezing child will have asthma.

Need for reliever/rescueNocturnal symptoms or awakeningLimitations of activitiesDaytime symptoms:wheezing, cough,difficult breathing CharacteristicGlobal Strategy for Asthma Management and Prevention in Children 5 Years and YoungerLevels of Asthma Control(coughs during sleep or wakes with cough, wheezing,and/or difficult breathing)Any exacerbation should prompt review of maintenance treatment

Clinical Control of Asthma in Children 5 Years and YoungerAsthma is controlled (all of the following): No (or minimal)* daytime symptomsNo limitations of activity (Child is fully active, plays and runs without limitations of symptoms) No nocturnal symptoms (including no nocturnal coughing during sleep) No (or minimal) need for rescue medication_________* Minimal = twice or less per week

Clinical Control of Asthma in Children 5 Years and YoungerAsthma is uncontrolled:Daytime symptoms >2 times/week (last minutes or hours or recur) Any limitations of activity (May cough, wheeze or have difficulty breathing during exercise, vigorous play, or laughing) Any nocturnal symptoms (typically coughs during sleep or wakes with cough, wheezing, and/or difficult breathing) Need for rescue medication > 2 days/week

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