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Björn Ställberg (Sweden):

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

There are a lot of problems! For really small children, the problem is you can't do any lung function test. In the teenage years, children may complain of having a lot of problems playing sports; however, testing, including lung function testing, allergy testing, it's all normal. Then you try medication and nothing helps. Is it real asthma or not? It's easier to have a correct diagnosis when you're having a lot of problems. When you're wheezing a lot, it's easy to say, "Okay, this is asthma." But if the child comes to the doctor and says, "Yesterday I had problems playing soccer, also 2 weeks ago I had problems." But when I see them everything is okay, that's a problem. We don't use exhaled nitric oxide, that's in the future. We're talking about it a lot in Sweden, because the machines are cheaper now, but it's still too expensive. And we need more studies.

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

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.

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

I think one of the most important questions is about pets. In Sweden it's very popular to have cats, so they ask can I have the cat? Can I keep the cat? Can I keep the dog? There's a lot of discussion around pets. Of course there's also a lot of discussion around the prognosis of their asthma. Also about medication, practical things. And also discussion about what will happen in 1 year, 2 years, 3 years. What happens if we still have problems in 2 months? Can you add any medication? I think it's important for the parents to know that if the child still has problems in 1 or 2 months you can add medication. And that it's important to come back.

Which educational strategies work?

With asthma patients it's important to individualize education. It depends on what the problems are. Perhaps the patient is a 16-year-old boy who wants to play a sport or a 16-year-old girl who loves her cat. It's important to give a simple and short written treatment plan; I usually write a small note. I suspect that adult patients seldom read my notes, but parents of small children will post the paper in the kitchen somewhere. When you have small children you do everything for them. In fact, sometimes the problem for small children is that parents give them too much medication; they're too afraid about asthma. And of course we use small brochures and booklets. Many young people today go to the computer, the Internet. Finally, I think it's very important to talk about the treatment goals: 1. symptom free, 2. no need of rescue medication, and 3. no exercise-induced problems. So they know that if they don't reach the treatment goals they have to come back and we have to change medication. Also it's important to keep the messages consistent from doctor, nurses, pharmacists.

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

Problems for parents: Parents may be divorced, and one parent may have a cat, for example.
Allergic asthma is especially a problem: children may not be able to go to a friend's house or a relative's house. Also cat dander follows the clothes, and children who do well at home on the weekend may gradually do worse over the week at school. Many have eczema and are itching a lot; many have food allergies, and the parents are afraid of children getting a severe food allergy reaction.
Taking medications regularly.
When children are small, parents are afraid of the disease, of what may happen. They have medications but cannot travel without them. They are small problems, but together many small problems add up to a big problem.