In the United States, 8.4% of children have asthma. Among this cohort, 5% have asthma that is classified as severe and poorly controlled despite adherence to standard treatments. However, a much larger proportion of children with asthma report frequent symptoms that are difficult to control. The highest rates of uncontrolled asthma occur in black children (63%), young children aged 0 to 4 years (59%), and girls (53%). A number of factors can affect asthma control in these children and make it difficult to control.
To help pediatricians and front-line healthcare providers recognize and diagnose difficult-to-control asthma in children, Susan S. Laubach, MD, FAAP, associate clinical professor of Pediatrics, University of California San Diego, and director, Allergy Clinic, Rady Children’s Hospital, San Diego, California, provided an overview of factors that make asthma difficult to control and key questions that should be asked to identify these factors to make the diagnosis during a session at the American Academy of Pediatrics (AAP) 2019 National Conference and Exhibition in New Orleans, Louisiana, titled “Breathe easy: Diagnosis and management of difficult-to-control asthma” on Sunday, October 27, 2019.
These key questions include: 1) Is this really asthma?; 2) Are the treatments working?; 3) Are there unrecognized triggers?; and 4) Are there comorbidities? For each question, Laubach used a case study to illustrate how clinicians should approach a child with difficult-to-control asthma to ensure optimal management.
Laubach discussed a personalized asthma management approach taken from the 2019 Global Strategy for Asthma Management and Prevention (GINA) Report that is based on a strategy of assessing, adjusting, and reviewing symptoms and risks of severe asthma to confirm the diagnosis and implement interventions. As the first step, assessing requires confirming a diagnosis if necessary; identifying symptom control and modifiable risk factors as well as comorbidities; inhaler technique and adherence; and understanding patient goals. Adjusting includes treatment of modifiable risk factors and comorbidities; managing with nonpharmaceutical strategies; educating the patients; and use of asthma medications. Reviewing focuses on reviewing the response to treatments including symptoms, exacerbations, adverse effects, lung function, and patient satisfaction.
In addition to a review of the recommended step-up treatments used to control asthma symptoms, Laubach listed other factors that contribute to making asthma difficult to control. Many of these factors, she emphasized, are modifiable. She urged clinicians to consider “other diagnoses in the differential diagnosis of a child who coughs and wheezes; adhering to the treatment guidelines to make sure the correct medications and doses are being used for a child’s level of severity; checking inhaler technique; addressing parental concerns about adverse effects of medications; assessing for environmental triggers (such as allergies, tobacco, smoke exposure, and pollution); comorbidities (such as obesity, reflux, and sinus disease); and age-specific concerns (especially in adolescence).”
Laubach ended her talk with a brief description of new biologic therapies available for older children and adults.
Overall, Laubach emphasized the need for pediatricians to look for factors underlying difficult-to-control asthma and getting help as needed. “When asthma is difficult to control, consider the underlying factors and consider consulting allergy or pulmonary specialists,” she said.