aAsthma is not always a quick and easy diagnosis in children. According to a 2014 task force compiled by the American Thoracic Society and the European Respiratory Society, severe asthma can be diagnosed in children if the child’s symptoms require high-dose treatment. Inhaled corticosteroids Plus a second “control” medication for a full year, and/or systemic corticosteroids for half a year or longer. In other words, its diagnostic criteria are based on the difficulty of treating its symptoms.
Jonathan Gavin, co-director of the Asthma Program at Boston Children’s Hospital and assistant professor of pediatrics at Harvard Medical School.
In some children with severe asthma, the condition causes daily breathing problems but a few episodes of exacerbations. In other cases, this trend reverses; Long periods of asymptomatic life are broken down by rare but serious flare-ups. In fact, a young person’s lung function may appear normal and healthy between flare-ups, which experts say is one difference between severe asthma in children versus severe asthma in adults.
Severe asthma has another distinguishing feature: it tends to appear very early in life. Dr Andrew Bush, asthma specialist and director of the Imperial College London Paediatrics and Child Health Centre. In some cases, he says, asthma may become severe and not be controlled until later in childhood. But it is very rare for a child who does not show signs of asthma to develop this condition after the first years of life. “There are cases that seem to start showing up later, but if you look back, you’ll find that most of them have forgotten the symptoms when they were younger children,” Bush explains.
While severe asthma in children is defined by its resistance to treatment, there are some new medications that can bring the condition under control and prevent the need for systemic corticosteroids or other aggressive treatments, which may be particularly dangerous to children’s growth and development. However, experts say that long before these drugs are published, important diagnostic work needs to be done to detect whether a child’s asthma is really severe.
Asthma is one of the most common medical conditions in young adults. By some estimates, 1 in 10 American children under the age of 15 – roughly 6 million – have asthma. Experts agree that childhood asthma rates have risen dramatically over the past 40 years (although there is evidence that this increase has slowed dramatically in recent years).
When it comes to severe asthma in children, there is more room for difference. While some estimates put its prevalence, roughly, between 2% and 5% of all childhood asthma cases, experts say it’s hard to know for sure. This is because many children with symptoms that are difficult to control may suffer due to poor adherence to medication and regular contact with them allergens, or other factors. “More than half of the kids who pointed out to me that they might have severe asthma actually had a problem with environmental exposure or with how they used their inhaler — that kind of thing,” Bush says. These situations are sometimes called “hard-to-treat” asthma.
In other cases, a child’s breathing problems may be the result of conditions other than asthma, which explains why medications aren’t helpful. For example, induced laryngeal obstruction is a temporary and reversible narrowing of the larynx that can mimic asthma symptoms. Chronic infection can also cause asthma-like symptoms. To diagnose acute asthma, it must be ruled out.
While it is difficult to determine the exact prevalence of severe childhood asthma, experts agree that the condition accounts for a large portion of asthma care expenses. According to a 2017 study in Journal of Allergy and Clinical Immunologyof the $10 billion spent each year on childhood asthma in the United States, up to half of that money is used to treat children with severe asthma, whether it’s for hospitalizations, medications or clinic visits.
Causes, presentation and diagnosis
Why do children get severe asthma? The usual suspects – environmental exposures coupled with genetic susceptibility – are a safe bet. But elucidating the specific causes of severe asthma is a challenge. “The pathogenesis of asthma is really complex in children, and there may be many mechanisms responsible,” says Dr. Marielle Bennenburg, chair of the department of pediatric respiratory medicine and allergology at Erasmus University Medical Center in the Netherlands.
Pijnenburg says that allergens, viral infections and diet air pollutionAnd the Tobacco smokeAnd the Microbiome disorders They are all viewed as potential contributing factors. But bridging the current knowledge gaps will be difficult. “Looking at the lungs and finding out what’s going on requires invasive, useless testing in children,” she says.
When it comes to the presentation of the disease, for many children, the first symptoms appear very early in life – at 1 or 2 years of age. Says. Among those children with severe asthma, he says, several factors predict this development: exposure at home to tobacco smoke before age 3, sensitivity to multiple allergens, and episodes of severe wheezing requiring hospitalization.
While the first symptoms usually begin at a very young age, it can be difficult to assess lung function or other diagnostic criteria associated with asthma in young children. Thus, in most cases, it is difficult to know if severe asthma is present until children reach school age – at least 5 or 6 years old.
Again, this diagnosis requires a lot of work in the exclusion process. It is becoming increasingly common for a young person’s care team to perform an assessment at home. “Someone goes to the child’s home to see if there are dust mites or mold or pets present, or if a parent smokes,” Beigning explains. She says one of the things that distinguishes severe childhood asthma from severe adult asthma is the prevalence of allergens. While about half of adults with severe asthma have allergies that make the condition worse, this rises to 80-85% of children with severe asthma. Identifying and trying to get rid of the allergen is a critical step.
It is also becoming common for children with severe asthma symptoms to receive evaluation from a multidisciplinary care team that includes a pulmonologist, but also an allergist and even a counselor or mental health professional. “Children with asthma can experience frightening attacks where they are already having difficulty breathing, and by the time we see them, they have been admitted to the hospital or intensive care unit, and they have had a lot of tingling and pressure that can lead to heartburn,” Gavin says. Anxiety creates distress, which can worsen asthma symptoms and also be difficult to manage.
Once these contributing or aggravating factors have been evaluated and optimally resolved, and assuming other tests confirm the presence of asthma, a diagnosis of severe asthma is guaranteed if the young person continues to have severe symptoms or attacks.
How severe is asthma treatment?
Asthma specialists talk a lot about “getting the basics right.” This means that long before considering the newest and most aggressive class of drugs, it is necessary to ensure that young people are taking their medication correctly.
“Medication adherence is probably the biggest problem,” Gavin says. Again, many children with severe asthma feel well between flares, which can cause them to neglect inhalers or other medications. “But even children with severe asthma [have]“Symptoms have difficulty taking their medication as prescribed on a regular basis,” Gavin says. “Do they hold their breath after inhaling the corticosteroids for 10 seconds to make sure the drug reaches deep into the lungs?” These are the types of lapses he sees in both children and adults with severe asthma. In some cases, fixing these problems can bring your asthma under control.
Once the treatment period and all other modifiable factors have passed, children with severe asthma may be eligible for a “biological” medication, so named because it is derived from an organism. For severe asthma, all biological treatments are monoclonal antibodies — specialized proteins that affect the function of the immune system in ways that relieve the type of inflammation that causes asthma symptoms. The U.S. Food and Drug Administration has approved three of these medications for use in children with severe asthma, and all three are given by injection into the skin, usually in a doctor’s office. Sometimes doctors watch children for up to two hours after the injection is given. “They’re usually given every two, four, or eight weeks, and they tend to be very effective,” Gaffin says. In most cases, children who take these medications have severe flares and daily symptoms.
But there are potential drawbacks to these drugs, including injection pain, headache, sore throat, fatigue, and risk of allergies. The potential long-term effects of the drugs are also unknown. “One problem is that although these drugs have been tested, there are usually not a large number of children participating in clinical trials, so a lot of the data is extrapolated from adults,” Gaffin says.
And Bush describes it more frankly. “It’s a scandal that almost all of the data is in kids 12 or older and adults,” he says. “Younger children are a forgotten people.” He agrees that biology often works well, and prescribes it where appropriate. “But it is very expensive, and no one knows the optimal duration of treatment,” he adds.
Severe asthma, unlike milder and more manageable asthma, tends not to cure or improve as the child reaches adulthood. However, Bush says the disease is already changing, and it is difficult to know based on the evidence currently available whether biopharmaceuticals will be needed indefinitely, or whether temporary courses can be effective.
Pijnenburg reiterates many of these concerns, but also emphasizes that biology can be “life-changing agents” for some children. “We don’t know if we need to keep it on forever, if we can wean the kids off them, or how we should wean them,” she says. “But we often get excellent control with biopharmaceuticals, so kids go into adulthood and don’t have many symptoms.”
While severe asthma is a complex and difficult condition to manage in children, newer medications — along with a more rigorous approach to identifying environmental and lifestyle factors that may be contributing to a child’s symptoms — are helping more children out of asthma. This kind of progress is worth celebrating.
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