GINA Guidelines : particularités pédiatriques Dr G de Bilderling Pneumologie pédiatrique CHR Namur

Prevalence increasing in many countries, especially in children Prevalence increasing in many countries, especially in children Factors that Exacerbate Asthma : Factors that Exacerbate Asthma : Viral infections +++ Viral infections +++ Asthma Diagnosis Asthma Diagnosis Spirometry > 6y Spirometry > 6y Measurements of allergic status Measurements of allergic status

Asthmatic phenotypes MartinezJ Allergy Clin Immunol 2003;111: Pronostic 1

Modified Asthma Predictive Index < 3 years and recurrent wheezing episodes 2 criteria : allergic rhinitis Wheezing episodes not associated with URTI Eosinophilia 75% of these children will have active asthma 1 criteria : Parental asthma Atopic dermatitis or and Castro-Rodriguez AJRCCM 2000;162: Pronostic 7 Aeroallergern sensitization

SUMMARY OF STEPWISE MANAGEMENT IN CHILDREN LESS THAN 5 YEARS British guidelines on the management of asthma. Thorax 2003, 58

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age Drug Low Daily Dose (  g) Medium Daily Dose (  g) High Daily Dose (  g) > 5 y Age 5 y Age 5 y Age < 5 y Drug Low Daily Dose (  g) Medium Daily Dose (  g) High Daily Dose (  g) > 5 y Age 5 y Age 5 y Age < 5 yBeclomethasone > > > > >1000 >400 >1000 >400Budesonide > > >1000 >400 Budesonide-Neb Inhalation Suspension > > >1000 >1000 Ciclesonide 80 – – > > > > > >320 Flunisolide > > >2000 >1250 >2000 >1250 Fluticasone > > > > >500 >500 >500 >500 Mometasone furoate > > > > > >400 Triamcinolone acetonide > > >2000 >1200

Survey of adrenal crisis associated with inhaled corticosteroids in the United Kingdom Todd GRG, Acerini CL, Ross-Russel R, Zahra S, Warber JT, McCance D. Arch Dis Child 2002; 87: ChildrenAdults Males/females (n)17/113/2 Males/females (n)17/113/2 Mean age (yrs) :6.4 (3.3-10)41 (18-80) Mean age (yrs) :6.4 (3.3-10)41 (18-80) Presentation (n) : Presentation (n) : Acute hypoglycaemia231 Acute hypoglycaemia231 Decreased consiousness/coma130 Decreased consiousness/coma130 Coma and convulsions101 Coma and convulsions101 ( Death: pneumococcal septicaemia)1 pneumococcal septicaemia)1 Insidious54 Insidious54 Duration of ICS R/ (yrs)1.7 (n = 22)3.3 (n = 4) Duration of ICS R/ (yrs)1.7 (n = 22)3.3 (n = 4) Mean dose of FP in µg/day (range)( )( Mean dose of FP in µg/day (range)( )(

Age-related devices AgeFirst choiceSecond choise 0-2MDI+spacer, facemask Nebulisations 3-6MDI+spacerNebulisations 6-12 (SABA)MDI+spacer, Breath actuated, DPI (chronic) MDI+spacerDPI 12+ (SABA)Breath actuated, DPI (chronic) MDI+spacerDPI, breath actuated ExacerbationMDI+spacerNebulisations

Aérosols doseurs : UTILISATION INCORRECTE Deux asthmatiques sur trois utilisent mal les aérosols* 1 - secouer préalablement avant l’usage 2 - débuter l ’inspiration avant d’activer l’inhalateur 3 - inhaler doucement et profondément 4 - activer l’inhalateur en une seule fois 5 - retenir sa respiration 5 sec ou + après inhalation technique optimale fréquence d’usage correct des inhalateurs (%) adultes enfants * résultats d’une enquête INSERM sur 768 patients adultes et enfants

Young children are more difficult to diagnose. Young children are more difficult to diagnose. Treatment (inhalation device) must be adapted to age. Treatment (inhalation device) must be adapted to age. Partnership is even more important in this age-group. Partnership is even more important in this age-group. Young children are more difficult to diagnose. Young children are more difficult to diagnose. Treatment (inhalation device) must be adapted to age. Treatment (inhalation device) must be adapted to age. Partnership is even more important in this age-group. Partnership is even more important in this age-group. Asthma Management and Prevention Program: Summary