Pediatric asthma: a clinical management update.

ASTHMA IS THE MOST common pediatric chronic illness, affecting over 5 million children in this country. This estimate includes approximately 1.3 million children under the age of 5 years (American Academy of Allergy, Asthma, and Immunology [AAAAI], 1999). Despite major therapeutic advances made in the last decade, pediatric morbidity has not changed, and mortality has increased (National Asthma Education and Prevention Program [NAEPP], 1997a). The prevalence of asthma among urban African-American children is twice that among suburban white children (Gergen, Mullally, & Evans, 1998; Josephs, Peterson, & Ownby, unpublished). Each year, asthma is the cause of 10 million school absences, which are usually accompanied by job absences for parents or other caregivers. In addition, this disease is responsible for 3,028,000 doctor visits, 570,000 emergency room visits, and 164,000 hospitalizations per year for children under the age of 15 years (AAAAI, 1999). The physical, emotional, social, and financial costs associated with this disease are high. Asthma management has changed in the last several years. These changes are primarily caused by the acknowledgment of the role of the inflammatory aspect in the pathogenesis and treatment of asthma (NAEPP, 1997b). A number of recent reports have documented these changes and describe new clinical guidelines for the diagnosis and management of asthma (AAAAI, 1999; NAEPP, 1995, 1997a, 1997b). Asthma is often misdiagnosed and, therefore, undertreated in infants and children. The majority of children with asthma (50% to 80%) develop symptoms before their 5th birthdays. The diagnosis of asthma includes a good medical history, physical examination, and the use of objective measures. Although spirometry is recommended to confirm the diagnosis of asthma, it is not physically possible for children under the age of 4 years to complete this test. The most reliable way to diagnose asthma in the very young child includes clinical judgement and the child’s response to treatment (AAAAI, 1999). The most recent published report, ‘‘Pediatric Asthma: Promoting Best Practice,’’ (AAAAI, 1999) suggests that the goal of asthma therapy is to ‘‘maintain control of asthma with the least amount of medication and, hence, minimal risk for adverse effects’’ (p 36). Successful asthma management is described as including the following 4 components: (1) regular assessment and monitoring; (2) controlling factors that contribute to symptoms and disease severity; (3) pharmacological therapy; and (4) educating the child, family, and other caregivers to adhere to a written asthma management plan that includes daily management and information on how to handle asthma episodes. Regular assessment and monitoring includes regularly scheduled visits with a health professional, periodic pulmonary function tests, home peak flow monitoring, symptom monitoring, and the development of a written action plan that includes long-term and quick-relief medications. Referral to an asthma specialist may be recommended if the child is under the age of 3 years and also if the child does not respond to therapy after 3 to 6 months of treatment (AAAAI, 1999). Controlling factors that contribute to symptoms and disease severity includes the identification and the control of offending allergens. Allergy testing may be recommend to identify the offending allergen(s). Home and school environments should be as ‘‘allergy free’’ as possible. Certain health disor-