Pediatric Asthma GINA Guidelines

What is Asthma in Children?

Asthma refers to a heterogeneous disease, which is usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheezing, SOB, chest tightness, and cough, which vary over time and in intensity, together with variable expiratory airflow obstruction. For diagnosing asthma (underlying chronic inflammation), there should be two things: Variable respiratory symptoms, Expiratory airflow obstruction.

What is Allergic Asthma in children?

The most common variant. In the history of allergic rhinitis, food allergy, or atopic dermatitis. Symptoms triggered by external and internal allergens. Immunoglobulin E levels are raised.

Eosinophiles are present in Sputum and nasal secretion. Responds very well to inhaled corticosteroids.

What is Non-Allergic Asthma in children?

The Ig E levels- normal. Eosinophilia is NOT seen in sputum and nasal smear. Eosinophils may be present but may be neutrophilic or lymphocytic predominant. Response to inhaled corticosteroids is relatively less compared to allergic asthma.

Adult-Onset / Late-Onset Asthma

It is more commonly seen in females >> than males. It should be differentiated from occupational asthma, which is more of the adult's onset occupational interstitial lung disease with the spectrum extending to asthma. Occurs in middle-aged females. Very variable response to therapy. The vast majority of them are poor respondents to inhaled corticosteroids.

Asthma with persistent airflow obstruction

These are the patients who began asthma. Occurs due to airway remodeling.

Asthma with Obesity

Obesity, with a BMI above 31-35, has a higher likelihood of developing asthma.

Diagnostic Criteria - GINA 2021

Children over 6 to 11 years, adolescents, and adults. History of variable respiratory symptoms. Wheeze or SOB or chest tightness or cough. Variability in intensity with time/triggers / viral infection is often seen. Confirmed variable expiratory airflow obstruction. Documented expiratory airflow limitation. When FEV1 is reduced, confirm that FEV1 / FVC is also reduced (normal: > 0.75-0.80 adults and > 0.90 children). Documented excessive variability in lung function. Any 1 or more of the following 6 spirometric measurements should be present. 

1. Positive bronchodilator Reversibility test. Firstly, check the baseline measurement of spirometry. Then, give one dose of bronchodilator (inhaled bronchodilator), and 15-30 min later, again check the same value. Positive- If the FEV1 is increased by >12% of the predicted in children, In adults, more than 12% or more than 200 ml.
2. Excessive variability in twice-daily PEFR over 2 weeks: Average daily diurnal variability in PEF >13% in children. In adults, the variability should be >10%.
3. Significant increase in lung function after 4 weeks of anti-inflammatory treatment. Applicable only to adults. Increase in FEV1 occurs by >12% or >200ml. in adults after 4 weeks of anti-inflammatory therapy.
4. Positive exercise challenge test: Fall in FEV1 by >12% of predicted or in PEFR by >15%.
5. The positive bronchial challenge test (usually adults only): Fall in FEV1 by >20% after giving methacholine or Fall in FEV1 occurs by >15% with standardized hyperventilation, hypertonic saline, or mannitol challenge.
6. Excessive variation in lung function between visits: Variation in FEV1 by >12% or in PEFR by >15% between visits in children.

What is the Bronchodilator Test?

In the Bronchodilator test, First, do baseline FEV1 or PEF. → Give bronchodilator (SABA, i.e., salbutamol (albuterol)- 400 micrograms) → Then, 15 to 30 min later, FEV1 or PEF repeated → the improvement in FEV1 or PEF will be noticed. If the patient is already taking a bronchodilator test for any reason, there should be a minimum gap from the last dose before the test is performed. If on SABA (salbutamol) - the gap should be > 4 hours

If on LABA BD dose - The gap should be ≥ 24 hours.

If on LABA OD dose -The gap should be ≥ 36 hours.

Diagnosis in Children <5 years of Age for pediatric asthma 

It is challenging to make a diagnosis in this age group: -

The symptoms can be variable even in non-asthmatic children, and the variability of clinical symptoms will not be a very accurate clue in this age group. Spirometry is not possible. 

According to the GINA guidelines, diagnosis in this age group is based on the following:

• Respiratory symptoms can be intermittent or episodic. 
• Risk factors - Family history of asthma and allergy. Child - Some degree of ectopic dermatitis like eczema or allergic rhinitis or food allergy, etc. 
• The therapeutic response to controller medication. Give a trial basis of salbutamol or inhaled agents. See whether the patient has improved on symptoms or not. 
• Exclusion of alternate diagnoses: A foreign body or any obstruction. Viral infections can produce wheezing without the patient being asthmatic.

Features of Examination

• Cough: Recurrent or persistent non-productive cough that may be worse at night or accompanied by wheezing and breathing difficulties. Cough occurs with exercise, laughing, crying, or exposure to tobacco smoke, particularly in the absence of an apparent respiratory infection.
• Wheezing: Recurrent wheezing, including during sleep or with triggers such as activity, laughing, crying, or exposure to tobacco smoke or air pollution.
• Difficult or heavy breathing or shortness of breath: Occurring with exercise, laughing, or crying
• Reduced activity: Not running or laughing at the same intensity as other children; tires earlier during walks (want to be carried).
• Past or family history: Other allergic diseases (atopic dermatitis or allergic rhinitis, food allergy), asthma in a first-degree relative(s)
• Therapeutic trial: Clinical improvement during 2-3 months of controller treatment and worsening when treatment is stopped.

Management of asthma in children 

Second Line / Reserve therapies in childhood asthma

Inhaled LAMA: Tiotropium- ≥ 6 years (LAMA stands for the long-acting muscarinic antagonist).

Biologicals:

• Most commonly used: Omalizumab (Anti IgE) - ≥ 6 years,
• S. C. Mepolizumab (anti-IL5) - ≥ 6 years,
• S.C. Benralizumab (anti-IL5R) - ≥ 12 years
• Dupilumab (anti-IL4R) - ≥ 12 years.

Management - Children aged 5 years and Younger

Management-Children aged 6-11 years

Important points to remember about Pediatric Asthma

• The symptoms should be variable and intermittent.
• According to the guidelines, if the person has persistent chronic sputum production, it is less likely to have asthma.
• If the patient has only a cough with no other symptoms, it is less likely to have asthma.
• If there is acute or chronic chest pain but no tightness, it is less likely to be asthma.
• No diurnal variation (not essential), but less likely to be asthma.
• There is no role of oral SABA in children. Therapies like oral azithromycin therapy and bronchial thermoplasty, add-on therapies in refractory or resistant asthma - are approved for adults but prohibited in children.

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