Asthma is recognized as the most common chronic disease in children. Childhood asthma symptoms include frequent coughing, a whistling or wheezing sound when breathing out, shortness of breath and chest congestion or tightness.

Global initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2021. Available from: www.ginasthma.org

According to the Global Initiative for Asthma (GINA) guidelines, Pressurized Metered Dose Inhaler (pMDI) is the preferred device for asthma patients. To use an inhaler properly for the medication to be delivered effectively, continuous training is required. Poor inhaler technique leads to poor asthma control, increased risk of exacerbation and increased adverse effects. However, nebulizers are the only viable alternative delivery system in children that is reserved for children who cannot be taught effective use of a spacer device.

Asthma: Steps in testing and diagnosis - Children (Mayo clinic)⁹

It can be very difficult to diagnose asthma in very young children, because there are quite many conditions that could cause asthma-like symptoms within this age group. Doctors seldom do lung tests in children under age 5. Therefore, diagnosis is generally based on a child’s signs and symptoms, medical history, and physical examination.

International expert opinion on the use of nebulization for pediatric asthma therapy during the COVID-19 pandemic¹⁰

With the current coronavirus disease (COVID-19) pandemic, guidelines are continuously being updated. Even though these updated guidelines broadly agree in their recommendations for asthma medications, guidance on the use of nebulizers for delivery of medication is contradictory. Concerns have been raised that nebulizer-use by COVID-patients could transmit potentially viable infection to bystander hosts. However, existing data are limited and poor. A clear guidance on the safe use of nebulization, both in hospital and at home, especially in pediatric asthma is needed. Therefore, this study provides evidence-based, clinically relevant, and practical recommendations in the use of nebulization during the COVID-19 pandemic. Their overall recommendation suggests that nebulization should remain the choice of treatment for children who require this mode of treatment. The mentioned safety measures in this article will guide physicians on best practice in pediatric asthma during this pandemic.

Childhood asthma outcomes during the COVID-19 pandemic: Finding from the PeARL multi-national cohort¹¹

This multinational cohort study included 1,054 children with asthma and 505 non-asthmatic children aged between 4 and 18 years from 25 pediatric departments, in 15 countries globally. Their findings evaluated the impact of COVID-19 pandemic on childhood asthma outcomes. They found, among others, that 66% of asthmatic children had improved asthma control and in 33% the improvement exceeded the minimal clinically important difference. Compared to non-asthmatic controls, children with asthma were not at increased risk of LRTIs, emergency visits, episodes of pyrexia and hospitalization during the pandemic.

Provider demonstration and assessment of child device technique during pediatric asthma visits¹²

The purpose of this study was to find out the extent to which children use metered dose inhalers, turbohalers, diskuses and peak flow meters correctly during pediatric asthma visits. Results show that only 8.1% of children perform all the metered dose inhaler steps correctly, 22% performed all of the diskus steps correctly, 15.6% performed all of the turbohaler steps correctly and 24% performed all of the peak flow meter steps correctly. This study shows shocking results regarding current child device technique and highlights the importance of training children and parents well to manage asthma symptoms successfully.

Inhaler counselling, the real deal or just fresh air?¹³

The aim of this study was to find out whether healthcare professionals within the local community were able to counsel pediatric patients on the right steps with multi-dose inhalers (MDI), MDIs with a spacer and turbohalers. Within this audit 92 healthcare professionals, 43 nurses, 9 doctors, 13 hospital pharmacy staff and 27 community pharmacies team members were included. Overall, 13% of all participants counselled on all the necessary criteria for an MDI inhaler. The pharmacy teams in the hospital and community had the highest competency levels with 31% and 30%. No doctors or nurses were able to identify all steps. Regarding the essential steps needed for MDI with a spacer device, only 10% of all participants were able to competently counsel, again with no doctors or nurses achieving all steps. Concluding that more needs to be done to improve inhaler literacy within the local healthcare community.

Nebulized Inhaler Corticosteroids in Asthma Treatment in Children 5 Years or Younger:
A Systematic Review and Global Expert Analysis¹⁴

Nebulized corticosteroids (NebCSs) are a key treatment option for young children with asthma or viral-induced wheezing (VIW), however there are no constant recommendations on their best use. This systematic review aimed to create a consistent clarification of the role of NebCSs in children 5 years or younger, for the management of asthma maintenance therapy, acute asthma exacerbations, and the treatment of viral-induced wheeze. Results showed that NebCSs are at least as successful as oral corticosteroids in the emergency room when it comes to the management of mild to moderate asthma exacerbations. Furthermore, intermittent NebCS treatment of viral-induced wheeze was as effective as continuous daily treatment. Concluding that NebCSs are effective and well-tolerated in patients 5 years or younger, for their management of acute or chronic asthma.

Are wheezing, asthma and eczema in children associated with mother’s health during pregnancy? Evidence from an Australian birth cohort¹⁶

This study investigated the prevalence of wheezing, asthma and eczema among Australian children using longitudinal data from birth to 15 years of age. Furthermore, this study examined the association between maternal health factors (such as asthma, smoking, medical use, and pre-pregnancy obesity) during pregnancy, and respiratory and allergic morbidities on their offspring. Asthma prevalence among 0-1 year aged children was 11.7%, with an increase to 15.4% when the children were 10-11 years old. Wheezing and eczema were more common when the children were 2-3 years old. Furthermore, maternal asthma, smoking during pregnancy, and pre-pregnancy obesity significantly increased risk of wheezing and asthma in children.

Asthma

Global Initiative for Asthma (GINA) Strategy 2021 provides healthcare professionals with updated evidence-based strategy for asthma management and prevention.¹

Trials have shown that as-needed combination of ICS-formoterol reduces severe exacerbations by >60% in mild asthma compared with SABA alone.¹

Asthma prevalence is higher in high income countries, but asthma-related mortality occurs in low-middle income countries.³

Early in life, asthma is more common in boys while after adolescence asthma is more frequent in females.⁴

Despite the evidence and current guidelines, SABA over-reliance and ICS under-reliance still occurs, resulting in increased exacerbations and hospitalization.⁶

Asthma and allergic rhinitis were associated with worse clinical outcomes of COVID-19.⁸

Only 8.1% of children perform all metered dose inhaler steps correctly.¹²

Only around 10% of healthcare professionals are capable of teaching patients how to use inhaler devices correctly, including spacer.¹³

Maternal asthma, smoking during pregnancy, and pre-pregnancy obesity significantly increases risk of wheezing and asthma in children.¹⁶

Hay fever (allergic rhinitis)

Hay fever is caused by an allergic response to outdoor and indoor allergens, such as pollen, dust mites, and animals with fur or feathers. It is a type of inflammation that occurs when the immune system overreacts to these allergens in the air, causing symptoms such as runny nose, sneezing, swelling around the eyes and itchiness.

Allergic rhinitis: the “Ghost Diagnosis” in patients with asthma¹⁷

A common comorbidity of asthma is allergic rhinitis (AR), which contributes to asthma severity. Over 80% of asthmatics have AR, while AR itself also affects 10-30% of adults and up to 40% of children. AR has been associated with an increased risk of asthma severity and development. Even though the exact mechanisms underlying these relationships still need to be determined, evidence does support the role of allergen sensitization. Immunotherapy for AR has shown to improve both asthma and rhinitis symptoms, in addition to preventing future allergen sensitizations and asthma development. Therefore, recognizing, diagnosing, and treating AR can significantly improve quality of life and reduce asthma morbidity.

Meta-analysis of the comorbidity rate of allergic rhinitis and asthma in Chinese children¹⁸

Allergic rhinitis (AR) and asthma often occur simultaneously. They are both the two most common inflammatory conditions of the airway in children. The comorbidity of AR and asthma in Chinese children is high. Statistically, the prevalence of AR was higher in children with asthma, as opposed to the prevalence of asthma in children with AR. Therefore, these study results signify the importance of improving the recognition and treatment under both conditions.

Allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is a fungal infection of the lung due to a hypersensitivity reaction to antigens of Aspergillus Fumigatus after colonization into the airways. Aspergillus species are molds. There are over 100 specifies worldwide, but most illnesses are caused by Aspergillus fumigatus, Aspergillus Niger, Aspergillus Flavus and Aspergillus Clavatus.¹⁹

Allergic bronchopulmonary aspergillosis in asthma and cystic fibrosis²⁰

ABPA, a Th2 hypersensitivity lung disease, affects asthmatic and cystic fibrosis patients. Sensitization to Aspergillus Fumigatus is common in atopic asthmatic patients (about 25% are sensitized), yet only 1-2% of asthmatic patients develop ABPA. This infection is characterized by wheezing and pulmonary infiltrates, which may lead to pulmonary fibrosis and/or bronchiectasis.

Obesity

According to the World Health Organisation (2016), there are around 2 billion adults overweight, of which 650 million are affected by obesity (BMI≥30 kg/m²). Obesity increases the risk for asthma. Epidemiological data indicate that asthma is more common in obese than lean patients.²¹

Obesity and Asthma: Physiological Perspective²²

Obesity causes physiological changes which are conducive to either development of asthma or cause of poorly controlled asthma state. Abdominal and thoracic fat generate stiffening of the lungs and diaphragmatic movements, which leads to reduction of resting lung volumes such as functional residual capacity. This causes decreased expiratory reserve volume, which results in expiratory flow limitation during normal breathing in obesity. Obesity has effects on lung function that can cause respiratory distress similar to asthma and may also stimulate the effects of pre-existing asthma even more.

Overweight/Obesity and Risk of Seasonal Asthma Exacerbations²³

Obesity is associated with an increased risk for asthma exacerbations. Whether this risk is also related to the season is not known. This study is done to determine the relationship of increased body mass index (BMI) to the season of asthma exacerbation. Higher BMI values show an increase of risk for asthma exacerbations in adults and children with persistent asthma, particularly for adults during fall-winter. Possible mechanisms for above results include vitamin D status, viral infections, and corticosteroid responsiveness.

Comorbidities of Asthma

A common comorbidity of asthma is allergic rhinitis (80%> of asthmatics have AR).¹⁷

Allergic rhinitis affects 10-30% of adults and up to 40% of children.¹⁷

Allergic rhinitis has been associated with an increased risk of asthma severity and development.¹⁷

Allergic bronchopulmonary aspergillosis affects asthmatic patients. About 25% of patients are sensitized to Aspergillus Fumigatus, yet only 1-2% develop ABPA.²⁰

Obesity causes physiological changes which are conducive to the development of asthma or cause of poorly controlled asthma state.²²

Obesity is associated with an increased risk of asthma exacerbations (particularly for adults during fall-winter).²³