In India many oral preparations of both these are available. Maximum bronchodilatory effect is reached in five to ten minutes with inhaled salbutamol. Oral salbutamol takes 30 minutes. There is no place for oral medication in acute asthma unless the child is totally unable to take inhaled steroids by any means available.

 

The role of montelukast in the management of childhood asthma would evolve over the next few years. Montelukast is recommended in school children of five years and above in whom low doses of inhaled steroids combined with long-acting beta agonists have failed to control asthma. So it is a second choice add-on therapy. In pre-school children with persistent symptoms not controlled with low dose inhaled steroids, montelukast is the first line add-on therapy, as long-acting beta agonists do not have a licensed number of trials. In the USA, montelukast is used as a first line anti-inflammatory therapy. In the UK, the drug is not recommended, as there is no evidence to justify it and also, the drug has not been around long enough. For short-term use (say two years) it is an extremely safe drug.

 

There is no evidence that breast-feeding reduces the prevalence of asthma or affects its long-term outcome. There are many other very good reasons for breast-feeding but unfortunately no claims can be made in terms of asthma.

 

Exercise is vitally important for children with asthma. It won't affect the long-term outcome but it will certainly improve their capacity for coping with asthma and also improve their quality of life. Swimming is particularly a good exercise for children with asthma. Do encourage all children with asthma to exercise regularly.

 

In a study conducted in London 10 years ago, doctors Michael and Nicholas Wilson noted that children who had cold and fizzy drinks were more prone to asthma attacks. The study involved English children and Indian children living in London. They all were given a cold or fizzy drink and the responsiveness of the airways was tested with histamine challenge before and after. It was found that in 20 percent of the English children and 70 percent of the Indian children, the lung airways became more reactive after a cold or fizzy drink. The results of that study prompted doctors to advise parents (particularly Indian parents living in England) that cold and fizzy drinks might increase the risk of their children having asthma attacks.

As regards omega 3-fatty acids there is not much to say. There are few studies being published. It is very interesting work a both the work on fatty acids and work on antioxidants. These studies have just begun to suggest that they may affect development of asthma.

 

Pollution does not increase incidence. This has been clearly shown by the German study that compared the incidence of asthma in highly polluted and dirty East Germany and the very clean West Germany. It was found that asthma was more common in middle class West Germany compared to East Germany. So prevalence is not affected by outdoor pollution but the severity is. If a child is already an asthmatic, living in a polluted area it increases the risks of asthma attacks. In other words, polluted atmosphere makes asthma worse.

 

There is no evidence of any relation between duration of therapy and growth. Growth is exclusively related to dose. And at low doses, considered to be appropriate doses, there is no danger of growth suppression in the long-term.

 

There are no reports of side effect other than local atrophic effect on the epithelium. Bruising inside has not been reported in children treated with appropriate dose of inhaled steroid. Only when large doses are used for long period of time suppression of the adrenal gland might be seen.

 

The one word answer is NO. There are no drugs to prevent mild recurrent asthma. If a child has mild intermittent asthma and has only occasional symptoms we just have to treat symptoms when they occur. What should be done is to treat them with bronchodilators. If the attacks are severe but intermittent then treat with short courses of oral steroids. One class of drugs that might prove to be useful in this situation is the leukotriene receptor antagonists. Potentially, they may prevent intermittent mild asthma. However, studies have not been done yet, so we don't know for sure.

 

The highest recommended dose is 400 mcg a day in severe asthma. One rarely needs to go to that dose. In general, patients are very effectively treated with 100 to 200 mcg a day, some of them even with only 50 mcg a day. There may be a very small number of children who do not respond to a standard dose of inhaled steroid combined with any other add-on therapy. Only in these children will we need higher doses. It is important to balance the possible risks of high dose inhaled steroids against the absolutely certain adverse effects of uncontrolled severe asthma. The highest dose of fluticasone that has ever been given is 1000 mcg a day.

 

As much as 75 percent of the children whose asthma is not controlled by low doses of inhaled steroids benefit by adding a long-acting beta agonist. We can give a leukotriene receptor antagonist to the remaining 25 percent. In the pre-school child where long-acting beta agonists are not licensed for use, prescribe a leukotriene receptor antagonist as first line add-on therapy. One other place where leukotriene receptor antagonists are used is where parents absolutely refuse to allow their child to have inhaled steroids.

 

The treatment of a child who is receiving that sort of a combination therapy should be reviewed every two months. If the child becomes asymptomatic during that period, reduce treatment. Now the next question is which one should be reduced first? Always reduce the inhaled steroid first. After reducing the inhaled steroid, if the child remains asymptomatic then stop the add-on therapy. Take these decisions at an interval of two months.

 

As fluticasone has been available in the UK for the past 10 years, we have 10 years of clinical experience of fluticasone in children. The longest published well-designed clinical trials have been for over two years. And the data is that there is suspicion of a small degree of growth suppression at 200 mcg a day in school age children. However, at less than half centimetre a year, the suppression is half of that seen with 400 mcg a day beclomethasone or budesonide. There are no studies of children treated with fluticasone throughout their childhood to look at their final height.

 

There is little evidence that anti-allergics, even those with anti-anaphylactic properties like ketotifen, are directly useful in the treatment of asthma. However, these drugs are effective in the treatment of rhinitis. It is important to treat allergic rhinitis if it co-occurs with asthma. It may indeed indirectly affect asthma. It is good to use these drugs if the child is already on inhaled steroids to stop what is described as cumulative effect of topical steroids.

 

A child with recurrent or persistent wheeze is a very common problem in paediatric practise and parents normally ask these questions:

1. Is my child having asthma?
2. Should I avoid certain foods?
3. Should the child be put on inhaled long-term steroids?
4. What is the prognosis? What should be our response to these questions?

It depends on what other information one has. The child has at least an 80 percent chance of going on to have persistent wheezing througout childhood, if he or she fulfils the following:

• Under the age of three
• Has an asthmatic mother
• Father smokes
• Child has eczema
• Child has had frequent episodes of wheezing not associated with viral infections.

In this case, the child should be treated with an inhaled steroid.

There is no evidence that dietary measures influence the short-term or long-term outcome.

 

One should regard acute asthma in a child as failure of health professional management. If that happens, then the treatment should be with high dose 2 agonist bronchodilator, which can be given either by nebuliser or by spacer. A dose of 2.5 mg of nebulised salbutamol is equivalent to 600 mcg or six puffs of salbutamol by spacer. This can be given frequently and continuously in the beginning of the attack.

It is not necessary to administer systemic steroids by injection unless the child is vomiting or unable to take them orally, because inhaled treatment works just as well and just as fast. The best established dose of oral steroid is prednisolone 2 mg/kg/day given for three to seven days. Some people advocate a once-a-day dose. But the half-life of prednisolone is about 12 hours and therefore it should be given 12-hourly to treat an acute attack. Oral prednisolone, nebulised salbutamol or salbutamol by spacer can be used. In severe asthma, the addition of nebulised ipratropium bromide has been shown to help but not in relatively mild asthma attack. Intravenous aminophylline is undoubtedly effective. It must be done under careful supervision. Oxygen must be given to the child as it is an essential part of asthma management.

 

There is lot of work going on in Perth, Australia and Southampton, UK looking precisely at whether a vaccine can be produced. If it is possible to identify a compound arising from bacteria that would drive our immature immunological response towards the TH-1 type response and if that is done safely then there is every prospect of a vaccine. But safety is likely to be the biggest issue as is the case with any vaccine. One can often get the immune system to do what one wants but it does many other things that one does not want it to do. Still a vaccine is a possibility.

 

What is appropriate in the UK may not be so in India. Yet, the broad principles ought to be the same.

First is the motivation, which means making the diagnosis and stating the diagnosis. If asthma centres are set up widely then asthma ceases to be a worrying disease. It becomes a very common disease readily treatable in centres that do it well. So there is a philosophy that needs to come first.

What one needs in the asthma centre is a doctor (or doctors) skilled in the management of asthma. In the UK, training nurses to help doctors in their job, made a great difference to the management of asthma in children. Doctors often don't have the time to show patients how to use inhalers and to answer questions. The nurses neither diagnose nor prescribe but advise on the use of inhalers. They answer patients' queries whenever possible and check with the doctor in case of doubts. So an asthma nurse is an essential component of the asthma centre.

Further, there is also a need for some sort of lung function testing facilities. Peak flow meters are not sufficient. Now there are good hand-held spirometers that are very reliable and are economical. One should record the spirometer readings i.e. FEV 1 and forced vital capacity when children come to the clinic and if they are old enough to do it. Children are able to use the spirometers after the age of six. Under the age of six, only clinical checks may help.

These are some of the fundamental requirements for an asthma centre. But the first and foremost is the philosophy regarding asthma that it is a common, easily treatable disease and when treated in time allows children to lead a normal life.