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Responses by subject

What do you think are the special issues and challenges in treating children with asthma? Do they vary by age?

Angela Boque (Spain):

I think the inhalation techniques and inhalation devices, like the spacers, are all quite difficult for children. This is a great challenge. Even if you spend a lot of time teaching technique, you never know exactly how much medicine gets into a baby or a child. You don't know how much the family understands. And how well they do the technique at home. I think this is a big challenge for health professionals in paediatric clinics.

Len Fromer (USA):

Getting to the point of recognizing asthma as an atopic disease, by and large. And then beyond that, that inflammation is the root of the problem. That we're dealing with one airway from the tip of the nose to the alveoli, so that if there is inflammation in the nose it will trigger a problem in the lung. So getting the families to link that and then getting people to focus on trigger avoidance and prevention in addition to regular planned care--not episodic rescue care. By using appropriate avoidance of triggers and controller medication. That's clearly the biggest challenge. People feel well in between attacks, so they say, "Why should I bother to take the medicine?!"

Svein Høegh Henrichsen (Norway):

The problem with smaller children very often would be the parents. The older they get, the more they are aware, the more you can communicate with the child about their asthma. I think that the greatest challenge actually is to motivate them to take their asthma medication every day, especially the inhaled corticosteroid because they don't feel the direct release from it, and parents are often afraid of corticosteroids. And most people don't like taking medication every day anyway; it's not different for children. That's the purpose of my asthma nurse as well: to take quite a bit of time to inform them of the disease and treatment.

Chris Hogan (Australia):

I happened to chair the Victoria State Government Asthma Expert Advisory Board, and we did a study on the public health interventions in asthma. And across a range of criteria, the most common and severe issue we found was cigarette smoking. Australian smoking rates are probably amongst the lowest in the world, but they're still a major issue. The incidence of smoking in adults has dropped from about 45-55% 30 years ago to 10-15% now. But what's happened is that the incidence of smoking among people under the age of 25 is steadily climbing. So it's a matter of fighting that battle all over again. What's happened is that a lot of people now are well aware of the health messages and well aware of the reasons that they shouldn't smoke, but they just don't care.

Alexandre Holanda (Brazil):

I think that education is a big issue in terms of how to understand the disease and to use the devices correctly. I think that's the major thing for the youngest children, and probably for everybody really. Illiteracy in the public sector is a problem; it's hard to explain the disease and also how to use the devices-if they are able to have the devices as well-and to explain that the disease is recurrent, that there's no cure. The understanding of the disease probably is the biggest problem. Because then from understanding the disease comes understanding how to treat the disease of course.

Alan Kaplan (Canada):

The youngest ones have the hardest differential diagnosis. They can have upper airway disorders that mimic asthma, they can have congenital abnormalities, vascular bands that can make kids wheeze. And they just get a lot of wheezing with respiratory infections, they don't necessarily have to have asthma. And there is no objective measure of lung function at that age to make a clear diagnosis of asthma. Over all the ages of children there's the concern about inhaled corticosteroids and growth. I think there are some good studies that show that using the lowest dose possible in kids who need the steroids for their asthma is not going to cause a growth suppression. And that uncontrolled asthma itself will cause a growth suppression, so it's better to treat the asthma. For the older kids, there's a paucity of people doing spirometry to get a full objective measure. In the teenage group, the biggest difficulty is compliance because kids don't want to be different from their peers. Younger kids are not too bad actually; they want to be able to keep up in hockey and soccer-they'll actually take their medicine. But once they become teenagers, if they're not athletically minded, then it just makes them different, and they don't want to be different and, therefore, taking their medication makes them different so they stop it. And of course smoking attempts start getting more common in the adolescent teenage group, so that's another issue for managing their asthma. Of course cost of medication is another issue, as well as cost of devices. In Canada even though the medications may be covered, frequently the spacer devices are not. Peak flow meters are frequently not covered, so the control of asthma has to be done by symptoms or, less commonly, but what should be happening more frequently, by spirometry.

Sarath Paranavitane (Sri Lanka):

What happens commonly is that no sooner than the cough and wheeze settle down, then the parents stop the medication, even though I had counselled them not to do so. They come back and say, "They were doing fine with the inhaler, so I stopped it." So I have to restart them on the inhaler again. That's our biggest challenge. The second issue is the cost factor.

Dermot Ryan (UK):

Getting parents to accept a diagnosis of asthma; the administration of the medication; convincing them that kids really do need to take their medication virtually all the time; getting the parents to stop smoking.

Björn Ställberg (Sweden):

I think one problem is underdiagnosis, especially in school children: for example, a 10-year-old girl or boy with recurrent cough, they have infections, perhaps are not doing so well in sports; the child is sitting in front of the computer because they get asthma when they play sports. The problem in the smallest children, I think, is that the medication is more effective in allergic asthma. For viral-induced wheezing, the medications we have today are not so effective. A special issue when they are small is you can't do objective lung function tests. The problem when they are older, from about 12 to 13 and up to 18, they never do as I say. I think that is a worldwide problem! I think that today, if I have as a GP good knowledge of asthma and experience, we have very good medications, but not for the youngest wheezers. But for allergic asthma we have good medications. Another issue of course is when you go to your GP, your family doctor, it's important that he or she has the knowledge of the disease. It will differ a lot of course between the doctors.

Hakan Yaman (Turkey):

One challenge is to keep children adherent to the medication. Another challenge is to see the patient regularly. Of course, lack of time for education and lack of community resources are other problems.

Osman Yusuf (Pakistan):

Primary care physicians are not adequately or properly trained or qualified in managing asthma, with the result that you have underdiagnosis, overtreatment, and maltreatment of asthma. Number two, easy accessibility of medications in Pakistan at all levels actually reduces the number of visits of patients to qualified practitioners for asthma. The third issue is the patient factor: patients are not very happy going to qualified medical practitioners, because of the long-term treatment, the supposed side effects of treatment, the cost of medication; and by this I'm talking about the western system of medication. I'm not referring to the local healers or traditional medicine. A major issue is the economics of it: the cost of medicine, therefore the ability of patients to pay, the accessibility to health-care facilities, all these come into play.

The next common issue in several developing countries is that of gender. If it is a son who's unwell, the family would like to spend lots of money getting the son treated because he's going to carry the name of the family forward. While if it's a daughter, in the more illiterate and less educated parts of Pakistan, they wouldn't worry about her so much. Another big issue is the actual stigma associated with the word 'asthma,' so 'allergy' is conveniently used as a cover-up for that. The biggest need is government commitment to asthma care and education-we need that a lot, and we're working on it.

Ramadan, the Muslim month of fasting, entails the abstinence from food, drink, and all worldly desires from before sunrise till sunset, for one lunar month. Muslim children may feel uncomfortable taking even inhaled medications while fasting in Ramadan. However, in fact, if taken properly through a spacer, inhaled medication can be taken even while fasting.