Asthma Management Handbook

Assessing symptoms and control in children 6 years and over

Recommendations

For children with a new asthma diagnosis or those not taking regular treatment, assess frequency and occurrence of symptoms to determine the pattern and severity of asthma.

Note: This assessment should be based on overall pattern of symptoms between flare-ups, not on symptoms seen during short-term (e.g. during a flare-up).

Table. Definitions of asthma patterns in children aged 6 years and over not taking regular preventer

Category

Pattern and intensity of symptoms (when not taking regular treatment)

Infrequent intermittent asthma †

Symptom-free for at least 6 weeks at a time (flare-ups up to once every 6 weeks on average but no symptoms between flare-ups)

Frequent intermittent asthma

Flare-ups more than once every 6 weeks on average but no symptoms between flare-ups

Persistent asthma

Mild

FEV1 ≥80% predicted and at least one of:

  • Daytime symptoms more than once per week but not every day
  • Night-time symptoms more than twice per month but not every week

Moderate

Any of:

  • FEV1 <80% predicted
  • Daytime symptoms daily
  • Night-time symptoms more than once per week
  • Symptoms sometimes restrict activity or sleep

Severe

Any of:

  • FEV1 ≤60% predicted
  • Daytime symptoms‡ continual
  • Night-time symptoms frequent
  • Flare-ups frequent
  • Symptoms frequently restrict activity or sleep

† It may not be appropriate to make the diagnosis of asthma in children aged 6 or older who wheeze only during upper respiratory tract infections. These children can be considered to have episodic (viral) wheeze.

‡ Symptoms between flare-ups. A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g. symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g. events that require urgent action by parents and health professionals to prevent a serious outcome such as hospitalisation or death from asthma).

Asset ID: 15

Close
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Assess level of asthma control based on:

  • symptoms
  • spirometry (for children able to perform spirometry reliably).

Notes

If reliable equipment and appropriately trained staff are available, spirometry can be performed in primary care. If not, refer to an appropriate provider such as an accredited respiratory function laboratory.

Most children aged 6 and older can perform spirometry reliably.

Table. Definition of levels of recent asthma symptom control in children (regardless of current treatment regimen)

Good control Partial control Poor control

All of:

  • Daytime symptoms ≤2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • No limitation of activities
  • No symptoms§ during night or when wakes up
  • Need for reliever# ≤2 days per week

Any of:

  • Daytime symptoms >2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • Any limitation of activities*
  • Any symptoms during night or when wakes up††
  • Need for reliever# >2 days per week

Either of:

  • Daytime symptoms >2 days per week (lasting from minutes to hours or recurring, and partially or fully relieved by rapid-acting bronchodilator)
  • ≥3 features of partial control within the same week

† e.g. wheezing or breathing problems

‡ child is fully active; runs and plays without symptoms

§ including no coughing during sleep

# not including short-acting beta2 agonist taken prophylactically before exercise. (Record this separately and take into account when assessing management.)

* e.g. wheeze or breathlessness during exercise, vigorous play or laughing

†† e.g. waking with symptoms of wheezing or breathing problems

Note: Recent asthma control is based on symptoms over the previous 4 weeks. Each child’s risk factors for future asthma outcomes should also be assessed and taken into account in management.

Adapted from

Global Initiative for Asthma (GINA). Global strategy for the diagnosis and management of asthma in children 5 years and younger. GINA, 2009. Available from: http://www.ginasthma.org/

Asset ID: 23

Close
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

If the diagnosis of asthma was made in the past or elsewhere, confirm the diagnosis, if possible.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

If parents or carers are present, arrange to see adolescents alone for part of the consultation so that you can confidentially discuss sensitive issues like adherence to asthma medicines and exposure to smoke from tobacco or other drugs.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • The Royal Australasian College of Physicians, 20081

More information

Classification of symptom patterns in children

The pattern and severity of symptoms in a child with asthma or wheezing disorder is a guide to initial treatment.

Table. Definitions of asthma patterns in children aged 0–5 years not taking regular preventer

Category

Pattern and intensity of symptoms (when not taking regular treatment)

Infrequent intermittent asthma

Symptom-free for at least 6 weeks at a time (flare-ups up to once every 6 weeks on average but no symptoms between flare-ups)

Frequent intermittent asthma

Flare-ups more than once every 6 weeks on average but no symptoms between flare-ups

Persistent asthma

Mild

At least one of:

  • Daytime symptoms more than once per week but not every day
  • Night-time symptoms more than twice per month but not every week

Moderate

Any of:

  • Daytime symptoms daily
  • Night-time symptoms more than once per week
  • Symptoms sometimes restrict activity or sleep

Severe

Any of:

  • Daytime symptoms continual
  • Night-time symptoms frequent
  • Flare-ups frequent
  • Symptoms frequently restrict activity or sleep

† Symptoms between flare-ups. A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g. symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g. events that require urgent action by parents and health professionals to prevent a serious outcome such as hospitalisation or death from asthma).

Note: Use this table when the diagnosis of asthma can be made with reasonable confidence (e.g. a child with wheezing accompanied by persistent cough or breathing difficulty, no signs or symptoms that suggest a potentially serious alternative diagnosis, and the presence of other factors that increase the probability of asthma such as family history of allergies or asthma).

Asset ID: 14

Close

Table. Definitions of asthma patterns in children aged 6 years and over not taking regular preventer

Category

Pattern and intensity of symptoms (when not taking regular treatment)

Infrequent intermittent asthma †

Symptom-free for at least 6 weeks at a time (flare-ups up to once every 6 weeks on average but no symptoms between flare-ups)

Frequent intermittent asthma

Flare-ups more than once every 6 weeks on average but no symptoms between flare-ups

Persistent asthma

Mild

FEV1 ≥80% predicted and at least one of:

  • Daytime symptoms more than once per week but not every day
  • Night-time symptoms more than twice per month but not every week

Moderate

Any of:

  • FEV1 <80% predicted
  • Daytime symptoms daily
  • Night-time symptoms more than once per week
  • Symptoms sometimes restrict activity or sleep

Severe

Any of:

  • FEV1 ≤60% predicted
  • Daytime symptoms‡ continual
  • Night-time symptoms frequent
  • Flare-ups frequent
  • Symptoms frequently restrict activity or sleep

† It may not be appropriate to make the diagnosis of asthma in children aged 6 or older who wheeze only during upper respiratory tract infections. These children can be considered to have episodic (viral) wheeze.

‡ Symptoms between flare-ups. A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g. symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g. events that require urgent action by parents and health professionals to prevent a serious outcome such as hospitalisation or death from asthma).

Asset ID: 15

Close
For children already taking regular preventer treatment, adjustments to the treatment regimen are based on finding the lowest dose of medicines that will maintain good control of symptoms.
Close
Classification of recent asthma symptom control in children

Ongoing review of asthma involves both assessing recent asthma symptom control and assessing risks for poor asthma outcomes (e.g. flare-ups, adverse effects of medicines).

Recent asthma symptom control is assessed according to the frequency of asthma symptoms over the previous 4 weeks.

Table. Definition of levels of recent asthma symptom control in children (regardless of current treatment regimen)

Good control Partial control Poor control

All of:

  • Daytime symptoms ≤2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • No limitation of activities
  • No symptoms§ during night or when wakes up
  • Need for reliever# ≤2 days per week

Any of:

  • Daytime symptoms >2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • Any limitation of activities*
  • Any symptoms during night or when wakes up††
  • Need for reliever# >2 days per week

Either of:

  • Daytime symptoms >2 days per week (lasting from minutes to hours or recurring, and partially or fully relieved by rapid-acting bronchodilator)
  • ≥3 features of partial control within the same week

† e.g. wheezing or breathing problems

‡ child is fully active; runs and plays without symptoms

§ including no coughing during sleep

# not including short-acting beta2 agonist taken prophylactically before exercise. (Record this separately and take into account when assessing management.)

* e.g. wheeze or breathlessness during exercise, vigorous play or laughing

†† e.g. waking with symptoms of wheezing or breathing problems

Note: Recent asthma control is based on symptoms over the previous 4 weeks. Each child’s risk factors for future asthma outcomes should also be assessed and taken into account in management.

Adapted from

Global Initiative for Asthma (GINA). Global strategy for the diagnosis and management of asthma in children 5 years and younger. GINA, 2009. Available from: http://www.ginasthma.org/

Asset ID: 23

Close
Close
Approaches to assessment and monitoring of asthma control in children

Assessment of asthma control in children is based mainly on recent asthma symptom control (assessed by the frequency and severity of symptoms between flare-ups and the degree to which asthma symptoms affect daily activities such as interference with physical activity or missed school days), the frequency of flare-ups, and spirometry in children who are able to perform the test reliably.

Parents commonly underestimate the severity of their child's asthma and overestimate asthma control.2

Standardised questionnaires

Questionnaire-based instruments have been validated for assessing asthma control in children:

Measures of airway inflammation

Measures of airway inflammation (e.g. sputum test, exhaled nitric oxide) are not used in clinical practice to guide treatment decisions. Tailoring the dose of inhaled corticosteroids based on exhaled nitric oxide appears to achieve only a small benefit in children, and may lead to higher doses.8 

Close
Confidentiality issues for adolescents

Adolescents’ concerns about confidentiality prevent them using health care services, especially if substance use is likely to be raised. Adolescents are more likely to disclose information about health risk behaviours, and are more likely to return for review, if they know that confidential information will not be revealed to their parents or others.9

When adolescents are accompanied by parents or carers, health care providers should consider seeing the adolescent alone for part of each consultation.9

Health professionals should discuss confidentiality and its limits with adolescents.9, 10 Adolescents are more willing to communicate honestly with healthcare professionals who discuss confidentiality with them.1

Health professionals need to clearly explain which personal health information can be confidential and which must be shared with parents, and keep parents informed.

Health care providers should advise adolescents that they can obtain their own Medicare card once they turn 15.9

Close
Psychosocial factors affecting adolescent health

Adolescence is a time of rapid growth and physical, cognitive, emotional and social development. An adolescent’s age is not a reliable indicator of maturity in each of these areas.1

Mental health disorders (e.g. depression, anxiety, eating disorders) are common and clinically important among young people.1 A significant proportion of adult mental health problems emerge during adolescence.1

Adolescence is also a time when people can begin risky behaviours (e.g. smoking, poor eating habits, physical inactivity, and drug and alcohol use), which can continue into adulthood.1, 11 Although smoking rates among adolescents and young people are declining,12 approximately 6% of adolescents aged 15–17 years smoke, and 4% smoke at least daily.13 Smoking rates are higher among Aboriginal and Torres Strait Islander young people, young people living in rural and remote communities, and young people of lower socioeconomic status.1412

Adolescents with chronic disease show higher rates of health risk behaviours than healthy adolescents.115 Some risk behaviours are based on incorrect health beliefs (e.g. the myth that smoking cannabis is good for asthma).

Risk-taking behaviour – as well as poor understanding of their health condition – may contribute to the higher rate of food-induced fatal anaphylaxis among adolescents and young adults, compared with other age groups.16

Depression, risk behaviours and poor adherence to medicines are interrelated.17 Adolescents with asthma who adhere poorly to asthma treatment and hide their asthma are more likely to start smoking than other adolescents with asthma.18 Among adolescent boys, those with lower quality of life are most likely to start smoking.18

Adolescents often wish to discuss their health concerns with health professionals but are reluctant to discuss sensitive issues unless asked directly and confidentially.1

Close

References

  1. The Royal Australasian College of Physicians. Routine adolescent psychosocial health assessment. Position statement. The Royal Australasian College of Physicians, Sydney, 2008. Available from: http://www.racp.edu.au/fellows/resources/paediatric-resources
  2. Carroll WD, Wildhaber J, Brand PL. Parent misperception of control in childhood/adolescent asthma: The room to breathe survey. Eur Respir J. 2011; 39: 90-96. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21700607
  3. Juniper EF, Gruffydd-Jones K, Ward S, Svensson K. Asthma Control Questionnaire in children: validation, measurement properties, interpretation. Eur Respir J. 2010; 36: 1410-6. Available from: http://erj.ersjournals.com/content/36/6/1410.long
  4. Murphy KR, Zeiger RS, Kosinski M, et al. Test for respiratory and asthma control in kids (TRACK): a caregiver-completed questionnaire for preschool-aged children. J Allergy Clin Immunol. 2009; 123: 833-9. Available from: http://www.jacionline.org/article/S0091-6749(09)00212-7/fulltext
  5. Zeiger RS, Mellon M, Chipps B, et al. Test for Respiratory and Asthma Control in Kids (TRACK): clinically meaningful changes in score. J Allergy Clin Immunol. 2011; 128: 983-8. Available from: http://www.jacionline.org/article/S0091-6749(11)01287-5/fulltext
  6. Liu AH, Zeiger R, Sorkness C, et al. Development and cross-sectional validation of the Childhood Asthma Control Test. J Allergy Clin Immunol. 2007; 119: 817-25. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17353040
  7. Liu AH, Zeiger RS, Sorkness CA, et al. The Childhood Asthma Control Test: retrospective determination and clinical validation of a cut point to identify children with very poorly controlled asthma. J Allergy Clin Immunol. 2010; 126: 267-73, 273.e1. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20624640
  8. Petsky HL, Cates CJ, Li A, et al. Tailored interventions based on exhaled nitric oxide versus clinical symptoms for asthma in children and adults. Cochrane Database Syst Rev. 2009; Issue 4: CD006340. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006340.pub3/full
  9. The Royal Australasian College of Physicians Joint Adolescent Health Committee. Confidential Health Care for Adolescents and Young People (12–24 years). The Royal Australasian College of Physicians, 2010. Available from: http://www.racp.edu.au/
  10. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
  11. Sawyer SM, Afifi RA, Bearinger LH, et al. Adolescence: a foundation for future health. Lancet. 2012; 379: 1630-1640. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22538178
  12. Australian Institute of Health and Welfare. Australia’s health 2010. no. 12 Cat. no. AUS 122. Australian Institute of Health and Welfare, Canberra, 2010. Available from: http://www.aihw.gov.au/publication-detail/?id=6442468376
  13. Australian Bureau of Statistics. 4364.0.55.003 - Australian Health Survey: Updated Results, 2011-2012. Australian Bureau of Statistics, Canberra, 2013. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/E3E02505DCAF230CCA257B82001794EB?opendocument
  14. Australian Bureau of Statistics. The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples, Oct 2010. Cat. no. 4704.0. Australian Bureau of Statistics, Canberra, 2011. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/lookup/4704.0Chapter755Oct+2010#currentdailysmokers
  15. Suris JC, Michaud PA, Akre C, Sawyer SM. Health risk behaviors in adolescents with chronic conditions. Pediatrics. 2008; 122: e1113-8. Available from: http://pediatrics.aappublications.org/content/122/5/e1113.long
  16. Australasian Society of Clinical Immunology and Allergy (ASCIA). ASCIA health professional information paper. Nutritional management of food allergy. ASCIA, Sydney, 2013. Available from: http://www.allergy.org.au/health-professionals/hp-information/asthma-and-allergy/nutritional-management-of-food-allergy
  17. Bender BG. Risk taking, depression, adherence, and symptom control in adolescents and young adults with asthma. Am J Respir Crit Care Med. 2006; 173: 953-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16424441
  18. Van De Ven MO, Engels RC, Sawyer SM. Asthma-specific predictors of smoking onset in adolescents with asthma: a longitudinal study. J Pediatr Psychol. 2009; 34: 118-28. Available from: http://jpepsy.oxfordjournals.org/content/34/2/118.long