Asthma is the most common reason for childhood hospitalization in this country. It also accounts for a significant proportion of emergency department visits, urgent visits to physicians, and missed school days. It causes disruption in sleep, play, and family functioning. Many caregivers must rearrange their schedules in order to care for their child's asthma. This situation has persisted despite our improved understanding of asthma pathophysiology and the availability of better controller therapies.
Because they are on the front lines, pediatricians play an important role in the recognition and management of childhood asthma. Of course, not all children present with classic signs of asthma, such as wheezing, chest tightness, or nocturnal cough. The differential diagnosis of cough is extensive, but cough may be the sole manifestation of asthma. Asthma symptoms may be episodic, rather than continuous. When symptoms occur for the first time in a young child, it is often unclear whether asthma truly is the appropriate diagnosis.
This issue of Pediatric Annals is aimed to help pediatricians in the diagnosis and comprehensive management of asthma. The 1997 Expert Panel Report nom the National Asthma Education and Prevention Program1 and the 1999 Pediatric Asthma Promoting Best Practice2 emphasize the need toi) diagnose correctly, 2) prescribe pharmacologic therapy, 3) institute appropriate environmental control measures, and 4) educate individuals and families dealing with asthma. The busy pediatrician needs to identify those children at risk to develop asthma, counsel families, and make decisions about treatment while weighing the risks and benefits. Dr. Kumar's article focuses on these issues in very young children, who are often the ones for whom such decisions are difficult, particularly when considering the chronic use of agents with potential side effects, such as inhaled corticosteroids. His discussion about risk factors helps to provide a framework for considering the diagnosis, weighing the treatment options and presenting this information to parents.
As children grow, the diagnosis of asthma is more likely to be established. Trigger factors tend to increase and vary, with allergen triggers becoming more prominent. The breadth and number of therapeutic alternatives is also much greater for older children. These factors complicate the appropriate selection of controller therapy. Drs. Hogan and Wilson address these concerns in their review of step-wise management of asthma in school-aged children. Special attention is given to factors that may contribute to poor asthma control, such as gastroesophageal reflux, sinusitis, and poorly controlled allergic rhinitis. Given the wide range of choices, I have included a discussion of inhaler devices and special considerations when treating children with aerosolized therapy. A rational approach for the selection of age and developmentally-appropriate therapy is presented as well.
Since allergy is a significant driving factor in childhood asthma, a separate discussion of environmental allergens is warranted. Dr. Phipatanakul discusses the role of indoor environmental allergens in the inception of asthma and the effect of allergen exposure and sensitization on asthma morbidity. She also provides guidelines for instituting effective allergen control measures.
I thank the authors for their thoughtful contributions. Together, we must focus upon establishing the diagnosis and instituting appropriate therapy, while ensuring that our young patients lead rich, active lives. As new therapeutic developments become available, we will achieve more successes in asthma. Until then, I hope that you will find this issue of Pediatric Annals a valuable reference that you will re-visit over the years.
1. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: US Department of Health and Human Services, National Institutes of Health; 1997. NIH publication 97-4051.
2. Pediatric Asthma Promoting Best Practice. Milwaukee, Wis: The American Academy of Allergy, Asthma and Immunology; 1999.