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Alan Kaplan (Canada):

Are there any special problems in diagnosing asthma in children? Do they vary by age?

You can't do objective measurements, which is how you make a diagnosis of asthma, until kids are closer to 6, so you are just taking your best guess at the situation and then applying therapy. Also with infants, the younger the child, the larger the differential diagnosis, and the more frequently viral infections occur, especially in day care situations, so all those are going to be factors in making the diagnosis. For children 6 to 12, at that point you can do objective measurements, although spirometry is underperformed in Canada. Probably less than 30% of the time is there an objective measurement of lung function, so most kids are treated with a trial of therapy rather than an objective measurement. In that situation, we can make the diagnosis but it's not being done on a regular basis. This is also true for adolescents and teenagers, and this is made more difficult by the fact that they're terrifically non-compliant, and our Canadian asthma guidelines say there aren't any data for how to manage their asthma, but the principles of course are the same.

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

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.

What questions do parents/carers and patients ask of you?

Will my child outgrow it? Are steroids bad for me? Is my child going to die from this? What do the medicines do to them? Are they going to get shorter? Are they going to grow? Are you sure it's asthma? Could it be something else? Should they take herbal medications instead because they're natural and they won't hurt my child? Can I stop the medicines when Johnny's well?

Which educational strategies work?

The strategies they can understand. In the best world, the teacher would be someone with a good knowledge base who is able to impart that education to a family or family member. That would be the right person. Sometimes that's going to be the family physician, sometimes it's going to be an educator, someone working in an asthma centre. Sometimes no matter what you tell people, they're not going to listen. The classic example is the teenager; having someone who can relate to him or her is going to be the important thing.

Which in your opinion are the top three problems children and parents/carers face in managing asthma in daily life?

For very young children, 1) it is difficult to make a clear diagnosis, 2) there is the question whether they will grow out of it; and 3) frequent undertreatment by parents because of fear of the medication.

For older children: 1) cost of medication, 2) compliance with medication, and 3) environmental triggers, such as smoking by family members.