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April 9, 2008 > Changing Attitudes About Asthma

Changing Attitudes About Asthma

Pediatric Hospitalist Talks About Effective Management

Treatment for many chronic childhood conditions and diseases is limited simply because medical science has not yet uncovered a viable solution. But when it comes to pediatric asthma, the biggest hurdle to attaining effective treatment often has more to do with parents' attitudes toward the disease.
"The biggest barrier to the overall population having good control over asthma is that people view it as something that is really terrible to have, and therefore they don't want to admit that their child has it," according to Dr. David P. Hoffman, a pediatric hospitalist at Washington Hospital. "There are a lot of myths associated with asthma, so typically parents will - at least at first - think of it as 'My kid doesn't have asthma, he just has trouble breathing when he has a cold. We'll just treat him when he has a cold.'"
One reason for this, Dr. Hoffman says, is that many times asthma runs in families, and parents may have frightening or uncomfortable memories of the disease from their own childhood.
Improving a child's quality of life
Fortunately, treatment for asthma has improved vastly over the last several decades with the advent of safe and effective medicines.
Although approximately a third of children with asthma will stop having difficulty breathing as they age, leaving asthma untreated can cause "lung remodeling" that can leave a child with impaired lung function for the rest of their lives. Treating the underlying inflammation in asthma with daily controller medications like inhaled corticosteroids can prevent this permanent damage in addition to making a child's quality of life better in the short run, Dr. Hoffman states.
Getting parents to feel comfortable giving their child with asthma a medication on a daily basis is the real hurdle to overcome. Dr. Hoffman says he tells parents up front: "I know having asthma is the last thing you want for your child, but denying it will only make things worse. If you just look in your child's classroom, two or three of those children have asthma - and the one that doesn't know it is the worst off."
He adds that, "Today, one of every six Olympic athletes has asthma. By understanding asthma and taking controller medications regularly and reliever medications appropriately, an individual with asthma should be able to accomplish anything - even excelling in sports."
As a general guideline, Dr. Hoffman says that if a child has been sick enough to come to the emergency room for an asthma attack, falls into the appropriate age category and has a history of breathing problems and responds to medications, then he or she should probably be treated with inhaled corticosteroids.
Despite drastic advances in medications, when they hear the word "steroid," parents may become fearful of seeking treatment for their child, Dr. Hoffman finds.
He explains that many people instantly associate "steroid" with the anabolic steroids that make the news in relation to professional athletes - when, in fact, the type of steroids used for asthma is completely different and is used to decrease the immune response that triggers an asthma attack.
Asthma treatment has come a long way
Twenty years ago the only way to administer the steroid medication that effectively treated asthma was orally or intravenously, which over the long run could cause weight gain, growth retardation, and other unpleasant side effects.
With the advent of inhaled steroids, patients get a much smaller dose of medicine that is delivered directly to the lungs, rather than having to be absorbed by the body first. Other than improving quality of life and the ability to breathe, Dr. Hoffman says the inhaled form of steroids have been clinically shown to have virtually no side effects even when taken daily for many years.
"I try to make the point that inhaled steroids are not an enemy at all," he says. "When you take an inhaled steroid, you won't notice side effects. More than any other medicine that I prescribe, I can say inhaled steroids are not going to cause any noticeable effect, except that your child will stop coughing as much and will probably never have to be brought to the emergency room."
According to Dr. Hoffman, kids with undiagnosed or untreated asthma will often seem as though they spend more time ill than healthy.
"Kids get 10 colds a year on average," he explains. "With kids that have asthma, they end up coughing for two weeks afterward."
When you do the math, these children could suffer from symptoms 20 to 30 weeks out of the year when there's really no need, according to Dr. Hoffman.
Performing a "lung tune-up"
In many cases, asthma is triggered by a viral pathogen like the cold or flu virus. Dr. Hoffman says that if a child begins to experience increased asthma symptoms in October, he will often prescribe an aggressive treatment regimen in the beginning to quell the problem. He then begins to ratchet down the dose to the lowest effective level.
"Once they're down to a tiny dose, if they notice things aren't going quite as well, then we bump back up, but in many cases, we're able to maintain them on a very low dose, and sometimes wean them off of it completely by May," he says. "Once the patient has been on an effective dose of inhaled steroids for about a month, the lungs are looking like a normal healthy person's lungs."
Dr. Hoffman points out that, unless the child is chronically exposed to some other trigger such as cigarette smoke, acid reflux, or an allergen, he or she will often be fine without inhaled steroids until the next cold and flu season. The parents and the child's pediatrician can then re-evaluate the need for reinitiating inhaled steroids in October, he says.
"I feel that these medicines are so safe and effective that it is usually best to keep kids on these medicines year round or automatically start kids back on the inhaled steroids at a modest dose at the start of the cold and flu season," he notes. "Once a child's asthma is controlled, the dose of inhaled steroid can be gradually lowered while the parents and pediatrician observe for the resurgence of asthma symptoms."
Dr. Hoffman refers to this process of finding the lowest effective dose of inhaled steroid as a "lung tune-up" and says patients typically respond very well without any ill effects at all.
"If parents and patients are compliant with treatment, there are very few cases of pediatric asthma that can't be well-controlled," he says. "In those few cases that are resistant to inhaled corticosteroids, allergy testing, evaluation for gastroesophageal reflux, or the addition of another asthma controller medication may be necessary."
The Pediatric Hospitalist program at Washington Hospital serves to ensure that young patients entering the hospital for treatment or evaluation receive the highest level of care. Dr. Hoffman and his colleagues, under the medical direction of Dr. Lyn Dos Santos, provide expert consultation in the Emergency Department, perform Well Baby visits within 24 hours to all the newborns in the hospital and work with local pediatricians to offer continuity of care when patients enter the hospital.

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