Abbreviations:
Despite advances in knowledge about asthma and its management, we could be doing better. We believe that all children in New Zealand have the right to achieve the highest standard of asthma outcomes equally. In New Zealand, a large number of children are not faring well with their asthma, especially due to disadvantages that arise from inadequate income for the basics needed for wellbeing, and unhealthy indoor environments (homes which are crowded, cold, damp, mouldy,1 smoke-exposed or with unflued gas heating2). Children aged 13–17 years usually do not have free primary healthcare visits or prescriptions. Māori and Pacific children with asthma are more likely to have severe asthma symptoms and be hospitalised, but are less likely to be prescribed inhaled corticosteroid (ICS), have an action plan or receive adequate education (see “Māori—getting it right for Māori children with asthma” and “Pacific peoples—getting it right for Pacific children with asthma”). Other groups who experience inequities include refugees, people living in remote rural areas and people with low English language proficiency. All health professionals have a role in improving outcomes and reducing inequities, and these guidelines specify the actions required regarding asthma.
Three important reports were released by the Asthma and Respiratory Foundation of New Zealand in 2015:The Impact of Respiratory Disease in New Zealand: 2014 Update,3 He Māramatanga Huangō: Asthma Health Literacy for Māori Children in New Zealand4 and Te Hā Ora: The National Respiratory Strategy.5 In 2017 The Impact of Respiratory Disease in New Zealand report was updated.These reports describe the context of the growing impact of asthma in New Zealand, especially among children, the inequities suffered by Māori, Pacific peoples and low-income families, and the intersectorial and holistic approaches needed to tackle the issues.
This guide is a complete update of the outdated Paediatric Society of New Zealand 2005 Management of Asthma in Children aged 1–15 years. The following guidelines were reviewed in the preparation of this document: the National Asthma Council of Australia 2015 Australian Asthma Handbook version 1.1, including the companion Quick Reference Guide,6 the Global Initiative for Asthma 2016 Asthma Management and Prevention, including the companion Pocket Guide,7 the SIGN 2016 British Guidelines on the Management of Asthma, including the Quick Reference Guide,8 and the Asthma and Respiratory Foundation NZ Adult Asthma Guidelines: A Quick Reference Guide.9
A systematic review was not performed, although relevant references were reviewed as required to formulate this guideline, and to clarify differences in recommendations made between guidelines. Readers are referred to the above published guidelines and handbooks for the more comprehensive detail and references that they provide. Additional analyses and reviews on the assessment and management of preschool wheezing were consulted.10–12
No levels of evidence grades are provided here due to the format of this quick reference guide. Readers are referred to the above published guidelines and handbooks for the level of evidence for the recommendations on which the Child and Adolescent Asthma Guidelines: A Quick Reference Guide are based.
These guidelines apply to children 15 years and below. However, adolescents mature at different rates, and for many who are still maturing and require adult support with their asthma care, these guidelines will usually apply. Once adolescents are largely responsible for their own management, application of the recently published Adult Asthma Guidelines: A Quick Reference Guide, intended for those 16 years and over, becomes more appropriate. Special care is needed to ensure that the adolescent transitions in a developmentally appropriate way as they become more independent, make their own decisions and emerge as adults. Adolescents transitioning from family to self-management may have differing priorities.
There are special considerations in young children (1–4 years) who wheeze, as many of them do not go on to develop asthma (see Diagnosis).
The Guideline Development Group included representatives from a range of professions, disciplines and backgrounds relevant to the scope of the guidelines. A Draft for Consultation of this report was peer-reviewed by a wide range of respiratory health experts and key professional organisations (see Appendix C).
The guidelines are primarily presented through lists, tables and figures in an electronic format, which can be used in clinical practice. Key references are provided where necessary to support recommendations that may differ from previous or other guidelines, or standard clinical practice.
The guidelines will be translated into tools for practical use by health professionals, and used to update existing consumer resources. They will be published on the Asthma and Respiratory Foundation NZ website, and disseminated widely via a range of publications, training opportunities and other communication channels to health professionals, nursing and medical schools, primary health organisations and district health boards.
The implementation of the Child and Adolescent Guidelines: A Quick Reference Guide by organisations will require communication, education and training strategies.
The expiry date of the guide is 2022.
These are the top 10 ways health professionals can help (apart from prescribing medicines)
Encourage the continuity of care with doctors and nurses in your practice and secondary care, and make follow-up appointments—relationships help. Easy access to a trusted nurse and telephone follow-up is recommended.
Work with families to attain and maintain wellness, and not accept sickness as the norm.
Ask about smoke exposure, encourage reducing tobacco smoke exposure in the child’s environment (home and car) and recommend smoking cessation. If appropriate, give advice and refer to a local smoking cessation service or Quitline (0800 778 778). Provide Health Sponsorship Council’s pamphlet A Guide to Making Your Home and Car Smokefree (www.healthed.govt.nz/).
A lot of New Zealanders live in unhealthy housing, and conditions are worse in private rental housing. Some families are homeless. Therefore ask about housing and unhealthy features (crowding, cold, damp, mouldy, unflued gas heater). (http://www.asthmafoundation.org.nz/about-us/advocacy/national-respiratory-strategy; http://www.energywise.govt.nz/). Provide the family with information about having a healthy home (“Tips for healthy living” http://www.asthmafoundation.org.nz/your-health/healthy-living) and if relevant, refer for healthy housing assessment if available in your region.
Assume that most families struggle with income and ask about it. Inquire about the ability to access the doctor, the pharmacy and paying for prescriptions. Does the child have partly or uncontrolled persistent asthma and meet criteria for Child Disability Allowance?13 (http://www.workandincome.govt.nz/). It is important for all family members to use the same pharmacy because once patients and their families have collected 20 new prescription items in a year, they won’t have to pay any more prescription charges until 1 February the following year (http://www.health.govt.nz/your-health/conditions-and-treatments/treatments-and-surgery/medications/prescription-charges).
Assume little health literacy, and use steps described in He Māramatanga Huangō: Asthma Health Literacy for Māori Children in New Zealand. Specifically ask the child and whānau what they understand, what they want to know, and use simple language to explain about asthma. For example, use the term ‘asthma flare-up’ rather than ‘asthma exacerbation’.
Firstly, assume inhaler device technique is poor and check it. Secondly, assume adherence is imperfect and don’t judge. Ask questions in an open way, such as “Many people take less preventer than the doctor prescribes—about how many times a week do you take your asthma preventer?”14–16
Develop an appropriate asthma action plan with the child and family and check on each visit. Plans should be made available to schools and child care facilities where appropriate. (http://www.asthmafoundation.org.nz/resources).
Help the family to understand how to access care appropriate to asthma severity, and identify any barriers they have. Consider referral to asthma educator, Māori providers or paediatrician where available and appropriate.
Ensure the family know when and how to call an ambulance. In some regions this service may incur a charge.
Goal: All children who have asthma are promptly and correctly diagnosed
Table 1: Clinical features that increase or decrease the probability of asthma in children and adolescents.
Figure 1A: Diagnostic pathway for asthma and wheeze in children 1–4 years.6,8
Figure 1B: Diagnostic pathway for asthma and wheeze in children 5–15 years.18,19
For those with infrequent symptoms, or who wheeze only with viral illnesses, ICS are not indicated. An alternative term sometimes used is ‘infrequent episodic (viral) wheeze’.
For those with frequent episodes of wheeze (more than every 6–8 weeks), only with viral illnesses, but no symptoms in the interval between—give a trial of ICS for a minimum of eight weeks. If there is a positive response, these children should then be labelled as ‘preschool asthma’, if not, the treatment should be stopped and the child should remain labelled as ‘frequent preschool wheeze’. An alternative term sometimes used is ‘frequent episodic (viral) wheeze’.
Those with frequent symptoms typical for asthma during and in the interval between viral illnesses. Treat as for asthma and give a trial of ICS (preferred) or montelukast, and the same treatment is indicated if there are severe attacks (see Figure 6). An alternative term sometimes used for this pattern is ‘multi-trigger wheeze’. This label does NOT mean the child will go on to have asthma at school age or as an adult, which may be reassuring for many families.
In children under one year, bronchiolitis is the most common cause of wheezing, and the PREDICT Australasian Bronchiolitis Clinical Practice Guideline17 should be followed. If the illness does not seem to be bronchiolitis, then refer to Table 1 and Figure 1A for guidance.
Goal: All children with asthma are assessed for their severity, control and future risk
1. Asthma Control Test for children 4–11 years (below; Adult guideline for ≥12 years9).
Table 2: GINA assessment of asthma symptom control in people six years and over (1) (See Table 3).
2. The GINA yes/no questions about the four criteria in Table 2 above, regardless of current treatment regimen.7
Table 3: Features associated with increased risk of severe asthma exacerbations and/or death from asthma.20
Goal: The child and family participate in goal-setting
Figure 2: Asthma management as a continuous cycle of monitoring and reassessment, adapted from GINA (1).
*(patient or parent).
Goal: Personal, whānau or environmental factors which may be unsettling asthma are identified and addressed (see Health professional to 10 actions section)
Goal: Effective self/family education and management is achieved
Goal: All children with asthma are provided with an asthma action plan
Goal: Adolescents with asthma transition smoothly towards emerging adulthood, with good asthma control
a) Many adolescents have poor knowledge about asthma and treatments.
b) Non-adherence is frequently caused by forgetting to take medication.
c) Adolescents with established routines are better able to self-manage.
d) Some adolescents do not use treatments or use them incorrectly due to erroneous beliefs about their asthma and medication.
e) Asthma self-management is difficult for those with a lack of support at school.
f) Parents play a key role in reminding adolescents to take medication.
g) Many adolescents are embarrassed about having asthma and using medication, particularly around their friends and peers.
h) Many adolescents report difficulties in communicating with their healthcare professional.
Goal: Māori children have asthma outcomes equal to non-Māori and non-Pasifika children
Māori rights in regards to health, recognised in Te Tiriti O Waitangi and other national and international declarations, promote both Māori participation in health-related decision making, as well as equity of health outcomes for all New Zealanders. Currently, Māori with asthma are more likely to be hospitalised or die due to asthma. Despite this, Māori with asthma are less likely to be prescribed ICS, have an asthma action plan or receive adequate education. Major barriers to good asthma management for Māori may include access to care, discontinuity and poor quality care, and poor health literacy. Māori whānau have greater exposure to environmental triggers for asthma, such as smoking and poor housing.9,30
It is recommended that for Māori with asthma:
Goal: Pacific children have asthma outcomes equal to non-Pacific & non-Māori children
The Pacific population is diverse and growing fast, with Pacific children numbering one in four babies born in Auckland. Pacific children have great disparities and unequal access to healthcare compared with other New Zealand children, which is well documented.32–37 Changes will come from health workers understanding the drivers for poor health in minority groups, and action at multiple levels of the health and social systems. Central action to improve the health of Pacific children will be a commitment to work with the strengths of the Pacific communities.
The following recommendations for health services and practitioners are based on theory and lessons from good practice:
Goal: All aspects of the health system will support better asthma care, aiming to decrease inequities and improve outcomes
Good asthma management requires a system approach incorporating information systems to improve quality and service delivery. The following are recommended:
Goal: The correct inhaler device is considered and age appropriate
Table 4: Inhaler devices recommended by age group.
Figure 3: Stepwise approach to treatment of children with wheeze 1–4 years.
Figure 4: Stepwise approach to treatment of children with asthma 5–15 years.
Goal: The right step of medicine in the right device is used for the age and symptoms of the child
Table 5: The recommended low and standard daily dose of ICS in children with asthma. “High” doses are double the standard doses (see Tables 4 and 5).
Goal: For all children with asthma it should be clear if ICS should be prescribed, and if so, a prescription given and the medicine taken
Goal: LABAs should never be prescribed without ICS
Goal: All children should be managed to avoid life-threatening asthma or death
Table 6: Criteria for acute referral to hospital and/or hospital admission in children and adolescents.
Figure 5: Algorithm for community management of moderate, severe and life-threatening acute asthma in children and adolescents. (Mild asthma is asthma symptoms not usually requiring medical attention and should be managed according to the asthma action plan.)
Table 7: Pre-discharge considerations in children and adolescents.
List of organisations and individuals consulted for feedback:
All DHBs
All PHOs
Asthma NZ
Australasian College of Emergency Medicine
Authors of adult guidelines
Breathing works
Canterbury Health
Conference delegates
Departments of General Practice for Medical Schools
General Practice NZ
Health Informatics NZ
Health Information Standards Organisation
Ian Town
Internal Medicine Society of Australia and NZ
Julian Crane
Kidz First
Maternal and Child Health Mid-Central District Health
Medtech
Ministry of Education
Ministry of Health NGO
National Health IT Board
Ngā Kaitiakio Te Punao Rongoāo Aotearoa, Māori Pharmacists’ Association
NZ Medical Association
NZ Resuscitation Council
NZ Speech Therapists Association
NZNO & NZNO Respiratory Nurses Section
Paediatric Society
Paediatrics’ Otago Medical School
Pasifika GP Network
Pasifika Medical Association
PHARMAC Pharmaceutical Management Agency
Pharmaceutical Society of NZ
Pharmacy Guild of NZ
Philippa Howden-Chapman
POI Team Public Health South
ProCare Clinical Advisory Committee
Respiratory and Sleep Medicine Auckland University
Royal Australasian College of Physicians
Royal NZ College of GPs
Special Education
St Johns Ambulance
Starship Children’s Health
Te Ora: Māori Medical Practitioners
Te Rūngangao Aotearoa (NZNO Māori)
Thoracic Society of Australia and NZ—NZ Branch
TSANZ Nurses special interest group
Wellington Free Ambulance
The purpose of the New Zealand Child and adolescent asthma guidelines: a quick reference guide is to provide simple, practical, evidence-based recommendations for the diagnosis, assessment and management of asthma in children and adolescents in New Zealand, with the aim of improving outcomes and reducing inequities. The intended users are health professionals responsible for delivering asthma care in the community and hospital emergency department settings, and those responsible for the training of such health professionals.
Abbreviations:
Despite advances in knowledge about asthma and its management, we could be doing better. We believe that all children in New Zealand have the right to achieve the highest standard of asthma outcomes equally. In New Zealand, a large number of children are not faring well with their asthma, especially due to disadvantages that arise from inadequate income for the basics needed for wellbeing, and unhealthy indoor environments (homes which are crowded, cold, damp, mouldy,1 smoke-exposed or with unflued gas heating2). Children aged 13–17 years usually do not have free primary healthcare visits or prescriptions. Māori and Pacific children with asthma are more likely to have severe asthma symptoms and be hospitalised, but are less likely to be prescribed inhaled corticosteroid (ICS), have an action plan or receive adequate education (see “Māori—getting it right for Māori children with asthma” and “Pacific peoples—getting it right for Pacific children with asthma”). Other groups who experience inequities include refugees, people living in remote rural areas and people with low English language proficiency. All health professionals have a role in improving outcomes and reducing inequities, and these guidelines specify the actions required regarding asthma.
Three important reports were released by the Asthma and Respiratory Foundation of New Zealand in 2015:The Impact of Respiratory Disease in New Zealand: 2014 Update,3 He Māramatanga Huangō: Asthma Health Literacy for Māori Children in New Zealand4 and Te Hā Ora: The National Respiratory Strategy.5 In 2017 The Impact of Respiratory Disease in New Zealand report was updated.These reports describe the context of the growing impact of asthma in New Zealand, especially among children, the inequities suffered by Māori, Pacific peoples and low-income families, and the intersectorial and holistic approaches needed to tackle the issues.
This guide is a complete update of the outdated Paediatric Society of New Zealand 2005 Management of Asthma in Children aged 1–15 years. The following guidelines were reviewed in the preparation of this document: the National Asthma Council of Australia 2015 Australian Asthma Handbook version 1.1, including the companion Quick Reference Guide,6 the Global Initiative for Asthma 2016 Asthma Management and Prevention, including the companion Pocket Guide,7 the SIGN 2016 British Guidelines on the Management of Asthma, including the Quick Reference Guide,8 and the Asthma and Respiratory Foundation NZ Adult Asthma Guidelines: A Quick Reference Guide.9
A systematic review was not performed, although relevant references were reviewed as required to formulate this guideline, and to clarify differences in recommendations made between guidelines. Readers are referred to the above published guidelines and handbooks for the more comprehensive detail and references that they provide. Additional analyses and reviews on the assessment and management of preschool wheezing were consulted.10–12
No levels of evidence grades are provided here due to the format of this quick reference guide. Readers are referred to the above published guidelines and handbooks for the level of evidence for the recommendations on which the Child and Adolescent Asthma Guidelines: A Quick Reference Guide are based.
These guidelines apply to children 15 years and below. However, adolescents mature at different rates, and for many who are still maturing and require adult support with their asthma care, these guidelines will usually apply. Once adolescents are largely responsible for their own management, application of the recently published Adult Asthma Guidelines: A Quick Reference Guide, intended for those 16 years and over, becomes more appropriate. Special care is needed to ensure that the adolescent transitions in a developmentally appropriate way as they become more independent, make their own decisions and emerge as adults. Adolescents transitioning from family to self-management may have differing priorities.
There are special considerations in young children (1–4 years) who wheeze, as many of them do not go on to develop asthma (see Diagnosis).
The Guideline Development Group included representatives from a range of professions, disciplines and backgrounds relevant to the scope of the guidelines. A Draft for Consultation of this report was peer-reviewed by a wide range of respiratory health experts and key professional organisations (see Appendix C).
The guidelines are primarily presented through lists, tables and figures in an electronic format, which can be used in clinical practice. Key references are provided where necessary to support recommendations that may differ from previous or other guidelines, or standard clinical practice.
The guidelines will be translated into tools for practical use by health professionals, and used to update existing consumer resources. They will be published on the Asthma and Respiratory Foundation NZ website, and disseminated widely via a range of publications, training opportunities and other communication channels to health professionals, nursing and medical schools, primary health organisations and district health boards.
The implementation of the Child and Adolescent Guidelines: A Quick Reference Guide by organisations will require communication, education and training strategies.
The expiry date of the guide is 2022.
These are the top 10 ways health professionals can help (apart from prescribing medicines)
Encourage the continuity of care with doctors and nurses in your practice and secondary care, and make follow-up appointments—relationships help. Easy access to a trusted nurse and telephone follow-up is recommended.
Work with families to attain and maintain wellness, and not accept sickness as the norm.
Ask about smoke exposure, encourage reducing tobacco smoke exposure in the child’s environment (home and car) and recommend smoking cessation. If appropriate, give advice and refer to a local smoking cessation service or Quitline (0800 778 778). Provide Health Sponsorship Council’s pamphlet A Guide to Making Your Home and Car Smokefree (www.healthed.govt.nz/).
A lot of New Zealanders live in unhealthy housing, and conditions are worse in private rental housing. Some families are homeless. Therefore ask about housing and unhealthy features (crowding, cold, damp, mouldy, unflued gas heater). (http://www.asthmafoundation.org.nz/about-us/advocacy/national-respiratory-strategy; http://www.energywise.govt.nz/). Provide the family with information about having a healthy home (“Tips for healthy living” http://www.asthmafoundation.org.nz/your-health/healthy-living) and if relevant, refer for healthy housing assessment if available in your region.
Assume that most families struggle with income and ask about it. Inquire about the ability to access the doctor, the pharmacy and paying for prescriptions. Does the child have partly or uncontrolled persistent asthma and meet criteria for Child Disability Allowance?13 (http://www.workandincome.govt.nz/). It is important for all family members to use the same pharmacy because once patients and their families have collected 20 new prescription items in a year, they won’t have to pay any more prescription charges until 1 February the following year (http://www.health.govt.nz/your-health/conditions-and-treatments/treatments-and-surgery/medications/prescription-charges).
Assume little health literacy, and use steps described in He Māramatanga Huangō: Asthma Health Literacy for Māori Children in New Zealand. Specifically ask the child and whānau what they understand, what they want to know, and use simple language to explain about asthma. For example, use the term ‘asthma flare-up’ rather than ‘asthma exacerbation’.
Firstly, assume inhaler device technique is poor and check it. Secondly, assume adherence is imperfect and don’t judge. Ask questions in an open way, such as “Many people take less preventer than the doctor prescribes—about how many times a week do you take your asthma preventer?”14–16
Develop an appropriate asthma action plan with the child and family and check on each visit. Plans should be made available to schools and child care facilities where appropriate. (http://www.asthmafoundation.org.nz/resources).
Help the family to understand how to access care appropriate to asthma severity, and identify any barriers they have. Consider referral to asthma educator, Māori providers or paediatrician where available and appropriate.
Ensure the family know when and how to call an ambulance. In some regions this service may incur a charge.
Goal: All children who have asthma are promptly and correctly diagnosed
Table 1: Clinical features that increase or decrease the probability of asthma in children and adolescents.
Figure 1A: Diagnostic pathway for asthma and wheeze in children 1–4 years.6,8
Figure 1B: Diagnostic pathway for asthma and wheeze in children 5–15 years.18,19
For those with infrequent symptoms, or who wheeze only with viral illnesses, ICS are not indicated. An alternative term sometimes used is ‘infrequent episodic (viral) wheeze’.
For those with frequent episodes of wheeze (more than every 6–8 weeks), only with viral illnesses, but no symptoms in the interval between—give a trial of ICS for a minimum of eight weeks. If there is a positive response, these children should then be labelled as ‘preschool asthma’, if not, the treatment should be stopped and the child should remain labelled as ‘frequent preschool wheeze’. An alternative term sometimes used is ‘frequent episodic (viral) wheeze’.
Those with frequent symptoms typical for asthma during and in the interval between viral illnesses. Treat as for asthma and give a trial of ICS (preferred) or montelukast, and the same treatment is indicated if there are severe attacks (see Figure 6). An alternative term sometimes used for this pattern is ‘multi-trigger wheeze’. This label does NOT mean the child will go on to have asthma at school age or as an adult, which may be reassuring for many families.
In children under one year, bronchiolitis is the most common cause of wheezing, and the PREDICT Australasian Bronchiolitis Clinical Practice Guideline17 should be followed. If the illness does not seem to be bronchiolitis, then refer to Table 1 and Figure 1A for guidance.
Goal: All children with asthma are assessed for their severity, control and future risk
1. Asthma Control Test for children 4–11 years (below; Adult guideline for ≥12 years9).
Table 2: GINA assessment of asthma symptom control in people six years and over (1) (See Table 3).
2. The GINA yes/no questions about the four criteria in Table 2 above, regardless of current treatment regimen.7
Table 3: Features associated with increased risk of severe asthma exacerbations and/or death from asthma.20
Goal: The child and family participate in goal-setting
Figure 2: Asthma management as a continuous cycle of monitoring and reassessment, adapted from GINA (1).
*(patient or parent).
Goal: Personal, whānau or environmental factors which may be unsettling asthma are identified and addressed (see Health professional to 10 actions section)
Goal: Effective self/family education and management is achieved
Goal: All children with asthma are provided with an asthma action plan
Goal: Adolescents with asthma transition smoothly towards emerging adulthood, with good asthma control
a) Many adolescents have poor knowledge about asthma and treatments.
b) Non-adherence is frequently caused by forgetting to take medication.
c) Adolescents with established routines are better able to self-manage.
d) Some adolescents do not use treatments or use them incorrectly due to erroneous beliefs about their asthma and medication.
e) Asthma self-management is difficult for those with a lack of support at school.
f) Parents play a key role in reminding adolescents to take medication.
g) Many adolescents are embarrassed about having asthma and using medication, particularly around their friends and peers.
h) Many adolescents report difficulties in communicating with their healthcare professional.
Goal: Māori children have asthma outcomes equal to non-Māori and non-Pasifika children
Māori rights in regards to health, recognised in Te Tiriti O Waitangi and other national and international declarations, promote both Māori participation in health-related decision making, as well as equity of health outcomes for all New Zealanders. Currently, Māori with asthma are more likely to be hospitalised or die due to asthma. Despite this, Māori with asthma are less likely to be prescribed ICS, have an asthma action plan or receive adequate education. Major barriers to good asthma management for Māori may include access to care, discontinuity and poor quality care, and poor health literacy. Māori whānau have greater exposure to environmental triggers for asthma, such as smoking and poor housing.9,30
It is recommended that for Māori with asthma:
Goal: Pacific children have asthma outcomes equal to non-Pacific & non-Māori children
The Pacific population is diverse and growing fast, with Pacific children numbering one in four babies born in Auckland. Pacific children have great disparities and unequal access to healthcare compared with other New Zealand children, which is well documented.32–37 Changes will come from health workers understanding the drivers for poor health in minority groups, and action at multiple levels of the health and social systems. Central action to improve the health of Pacific children will be a commitment to work with the strengths of the Pacific communities.
The following recommendations for health services and practitioners are based on theory and lessons from good practice:
Goal: All aspects of the health system will support better asthma care, aiming to decrease inequities and improve outcomes
Good asthma management requires a system approach incorporating information systems to improve quality and service delivery. The following are recommended:
Goal: The correct inhaler device is considered and age appropriate
Table 4: Inhaler devices recommended by age group.
Figure 3: Stepwise approach to treatment of children with wheeze 1–4 years.
Figure 4: Stepwise approach to treatment of children with asthma 5–15 years.
Goal: The right step of medicine in the right device is used for the age and symptoms of the child
Table 5: The recommended low and standard daily dose of ICS in children with asthma. “High” doses are double the standard doses (see Tables 4 and 5).
Goal: For all children with asthma it should be clear if ICS should be prescribed, and if so, a prescription given and the medicine taken
Goal: LABAs should never be prescribed without ICS
Goal: All children should be managed to avoid life-threatening asthma or death
Table 6: Criteria for acute referral to hospital and/or hospital admission in children and adolescents.
Figure 5: Algorithm for community management of moderate, severe and life-threatening acute asthma in children and adolescents. (Mild asthma is asthma symptoms not usually requiring medical attention and should be managed according to the asthma action plan.)
Table 7: Pre-discharge considerations in children and adolescents.
List of organisations and individuals consulted for feedback:
All DHBs
All PHOs
Asthma NZ
Australasian College of Emergency Medicine
Authors of adult guidelines
Breathing works
Canterbury Health
Conference delegates
Departments of General Practice for Medical Schools
General Practice NZ
Health Informatics NZ
Health Information Standards Organisation
Ian Town
Internal Medicine Society of Australia and NZ
Julian Crane
Kidz First
Maternal and Child Health Mid-Central District Health
Medtech
Ministry of Education
Ministry of Health NGO
National Health IT Board
Ngā Kaitiakio Te Punao Rongoāo Aotearoa, Māori Pharmacists’ Association
NZ Medical Association
NZ Resuscitation Council
NZ Speech Therapists Association
NZNO & NZNO Respiratory Nurses Section
Paediatric Society
Paediatrics’ Otago Medical School
Pasifika GP Network
Pasifika Medical Association
PHARMAC Pharmaceutical Management Agency
Pharmaceutical Society of NZ
Pharmacy Guild of NZ
Philippa Howden-Chapman
POI Team Public Health South
ProCare Clinical Advisory Committee
Respiratory and Sleep Medicine Auckland University
Royal Australasian College of Physicians
Royal NZ College of GPs
Special Education
St Johns Ambulance
Starship Children’s Health
Te Ora: Māori Medical Practitioners
Te Rūngangao Aotearoa (NZNO Māori)
Thoracic Society of Australia and NZ—NZ Branch
TSANZ Nurses special interest group
Wellington Free Ambulance
The purpose of the New Zealand Child and adolescent asthma guidelines: a quick reference guide is to provide simple, practical, evidence-based recommendations for the diagnosis, assessment and management of asthma in children and adolescents in New Zealand, with the aim of improving outcomes and reducing inequities. The intended users are health professionals responsible for delivering asthma care in the community and hospital emergency department settings, and those responsible for the training of such health professionals.
Abbreviations:
Despite advances in knowledge about asthma and its management, we could be doing better. We believe that all children in New Zealand have the right to achieve the highest standard of asthma outcomes equally. In New Zealand, a large number of children are not faring well with their asthma, especially due to disadvantages that arise from inadequate income for the basics needed for wellbeing, and unhealthy indoor environments (homes which are crowded, cold, damp, mouldy,1 smoke-exposed or with unflued gas heating2). Children aged 13–17 years usually do not have free primary healthcare visits or prescriptions. Māori and Pacific children with asthma are more likely to have severe asthma symptoms and be hospitalised, but are less likely to be prescribed inhaled corticosteroid (ICS), have an action plan or receive adequate education (see “Māori—getting it right for Māori children with asthma” and “Pacific peoples—getting it right for Pacific children with asthma”). Other groups who experience inequities include refugees, people living in remote rural areas and people with low English language proficiency. All health professionals have a role in improving outcomes and reducing inequities, and these guidelines specify the actions required regarding asthma.
Three important reports were released by the Asthma and Respiratory Foundation of New Zealand in 2015:The Impact of Respiratory Disease in New Zealand: 2014 Update,3 He Māramatanga Huangō: Asthma Health Literacy for Māori Children in New Zealand4 and Te Hā Ora: The National Respiratory Strategy.5 In 2017 The Impact of Respiratory Disease in New Zealand report was updated.These reports describe the context of the growing impact of asthma in New Zealand, especially among children, the inequities suffered by Māori, Pacific peoples and low-income families, and the intersectorial and holistic approaches needed to tackle the issues.
This guide is a complete update of the outdated Paediatric Society of New Zealand 2005 Management of Asthma in Children aged 1–15 years. The following guidelines were reviewed in the preparation of this document: the National Asthma Council of Australia 2015 Australian Asthma Handbook version 1.1, including the companion Quick Reference Guide,6 the Global Initiative for Asthma 2016 Asthma Management and Prevention, including the companion Pocket Guide,7 the SIGN 2016 British Guidelines on the Management of Asthma, including the Quick Reference Guide,8 and the Asthma and Respiratory Foundation NZ Adult Asthma Guidelines: A Quick Reference Guide.9
A systematic review was not performed, although relevant references were reviewed as required to formulate this guideline, and to clarify differences in recommendations made between guidelines. Readers are referred to the above published guidelines and handbooks for the more comprehensive detail and references that they provide. Additional analyses and reviews on the assessment and management of preschool wheezing were consulted.10–12
No levels of evidence grades are provided here due to the format of this quick reference guide. Readers are referred to the above published guidelines and handbooks for the level of evidence for the recommendations on which the Child and Adolescent Asthma Guidelines: A Quick Reference Guide are based.
These guidelines apply to children 15 years and below. However, adolescents mature at different rates, and for many who are still maturing and require adult support with their asthma care, these guidelines will usually apply. Once adolescents are largely responsible for their own management, application of the recently published Adult Asthma Guidelines: A Quick Reference Guide, intended for those 16 years and over, becomes more appropriate. Special care is needed to ensure that the adolescent transitions in a developmentally appropriate way as they become more independent, make their own decisions and emerge as adults. Adolescents transitioning from family to self-management may have differing priorities.
There are special considerations in young children (1–4 years) who wheeze, as many of them do not go on to develop asthma (see Diagnosis).
The Guideline Development Group included representatives from a range of professions, disciplines and backgrounds relevant to the scope of the guidelines. A Draft for Consultation of this report was peer-reviewed by a wide range of respiratory health experts and key professional organisations (see Appendix C).
The guidelines are primarily presented through lists, tables and figures in an electronic format, which can be used in clinical practice. Key references are provided where necessary to support recommendations that may differ from previous or other guidelines, or standard clinical practice.
The guidelines will be translated into tools for practical use by health professionals, and used to update existing consumer resources. They will be published on the Asthma and Respiratory Foundation NZ website, and disseminated widely via a range of publications, training opportunities and other communication channels to health professionals, nursing and medical schools, primary health organisations and district health boards.
The implementation of the Child and Adolescent Guidelines: A Quick Reference Guide by organisations will require communication, education and training strategies.
The expiry date of the guide is 2022.
These are the top 10 ways health professionals can help (apart from prescribing medicines)
Encourage the continuity of care with doctors and nurses in your practice and secondary care, and make follow-up appointments—relationships help. Easy access to a trusted nurse and telephone follow-up is recommended.
Work with families to attain and maintain wellness, and not accept sickness as the norm.
Ask about smoke exposure, encourage reducing tobacco smoke exposure in the child’s environment (home and car) and recommend smoking cessation. If appropriate, give advice and refer to a local smoking cessation service or Quitline (0800 778 778). Provide Health Sponsorship Council’s pamphlet A Guide to Making Your Home and Car Smokefree (www.healthed.govt.nz/).
A lot of New Zealanders live in unhealthy housing, and conditions are worse in private rental housing. Some families are homeless. Therefore ask about housing and unhealthy features (crowding, cold, damp, mouldy, unflued gas heater). (http://www.asthmafoundation.org.nz/about-us/advocacy/national-respiratory-strategy; http://www.energywise.govt.nz/). Provide the family with information about having a healthy home (“Tips for healthy living” http://www.asthmafoundation.org.nz/your-health/healthy-living) and if relevant, refer for healthy housing assessment if available in your region.
Assume that most families struggle with income and ask about it. Inquire about the ability to access the doctor, the pharmacy and paying for prescriptions. Does the child have partly or uncontrolled persistent asthma and meet criteria for Child Disability Allowance?13 (http://www.workandincome.govt.nz/). It is important for all family members to use the same pharmacy because once patients and their families have collected 20 new prescription items in a year, they won’t have to pay any more prescription charges until 1 February the following year (http://www.health.govt.nz/your-health/conditions-and-treatments/treatments-and-surgery/medications/prescription-charges).
Assume little health literacy, and use steps described in He Māramatanga Huangō: Asthma Health Literacy for Māori Children in New Zealand. Specifically ask the child and whānau what they understand, what they want to know, and use simple language to explain about asthma. For example, use the term ‘asthma flare-up’ rather than ‘asthma exacerbation’.
Firstly, assume inhaler device technique is poor and check it. Secondly, assume adherence is imperfect and don’t judge. Ask questions in an open way, such as “Many people take less preventer than the doctor prescribes—about how many times a week do you take your asthma preventer?”14–16
Develop an appropriate asthma action plan with the child and family and check on each visit. Plans should be made available to schools and child care facilities where appropriate. (http://www.asthmafoundation.org.nz/resources).
Help the family to understand how to access care appropriate to asthma severity, and identify any barriers they have. Consider referral to asthma educator, Māori providers or paediatrician where available and appropriate.
Ensure the family know when and how to call an ambulance. In some regions this service may incur a charge.
Goal: All children who have asthma are promptly and correctly diagnosed
Table 1: Clinical features that increase or decrease the probability of asthma in children and adolescents.
Figure 1A: Diagnostic pathway for asthma and wheeze in children 1–4 years.6,8
Figure 1B: Diagnostic pathway for asthma and wheeze in children 5–15 years.18,19
For those with infrequent symptoms, or who wheeze only with viral illnesses, ICS are not indicated. An alternative term sometimes used is ‘infrequent episodic (viral) wheeze’.
For those with frequent episodes of wheeze (more than every 6–8 weeks), only with viral illnesses, but no symptoms in the interval between—give a trial of ICS for a minimum of eight weeks. If there is a positive response, these children should then be labelled as ‘preschool asthma’, if not, the treatment should be stopped and the child should remain labelled as ‘frequent preschool wheeze’. An alternative term sometimes used is ‘frequent episodic (viral) wheeze’.
Those with frequent symptoms typical for asthma during and in the interval between viral illnesses. Treat as for asthma and give a trial of ICS (preferred) or montelukast, and the same treatment is indicated if there are severe attacks (see Figure 6). An alternative term sometimes used for this pattern is ‘multi-trigger wheeze’. This label does NOT mean the child will go on to have asthma at school age or as an adult, which may be reassuring for many families.
In children under one year, bronchiolitis is the most common cause of wheezing, and the PREDICT Australasian Bronchiolitis Clinical Practice Guideline17 should be followed. If the illness does not seem to be bronchiolitis, then refer to Table 1 and Figure 1A for guidance.
Goal: All children with asthma are assessed for their severity, control and future risk
1. Asthma Control Test for children 4–11 years (below; Adult guideline for ≥12 years9).
Table 2: GINA assessment of asthma symptom control in people six years and over (1) (See Table 3).
2. The GINA yes/no questions about the four criteria in Table 2 above, regardless of current treatment regimen.7
Table 3: Features associated with increased risk of severe asthma exacerbations and/or death from asthma.20
Goal: The child and family participate in goal-setting
Figure 2: Asthma management as a continuous cycle of monitoring and reassessment, adapted from GINA (1).
*(patient or parent).
Goal: Personal, whānau or environmental factors which may be unsettling asthma are identified and addressed (see Health professional to 10 actions section)
Goal: Effective self/family education and management is achieved
Goal: All children with asthma are provided with an asthma action plan
Goal: Adolescents with asthma transition smoothly towards emerging adulthood, with good asthma control
a) Many adolescents have poor knowledge about asthma and treatments.
b) Non-adherence is frequently caused by forgetting to take medication.
c) Adolescents with established routines are better able to self-manage.
d) Some adolescents do not use treatments or use them incorrectly due to erroneous beliefs about their asthma and medication.
e) Asthma self-management is difficult for those with a lack of support at school.
f) Parents play a key role in reminding adolescents to take medication.
g) Many adolescents are embarrassed about having asthma and using medication, particularly around their friends and peers.
h) Many adolescents report difficulties in communicating with their healthcare professional.
Goal: Māori children have asthma outcomes equal to non-Māori and non-Pasifika children
Māori rights in regards to health, recognised in Te Tiriti O Waitangi and other national and international declarations, promote both Māori participation in health-related decision making, as well as equity of health outcomes for all New Zealanders. Currently, Māori with asthma are more likely to be hospitalised or die due to asthma. Despite this, Māori with asthma are less likely to be prescribed ICS, have an asthma action plan or receive adequate education. Major barriers to good asthma management for Māori may include access to care, discontinuity and poor quality care, and poor health literacy. Māori whānau have greater exposure to environmental triggers for asthma, such as smoking and poor housing.9,30
It is recommended that for Māori with asthma:
Goal: Pacific children have asthma outcomes equal to non-Pacific & non-Māori children
The Pacific population is diverse and growing fast, with Pacific children numbering one in four babies born in Auckland. Pacific children have great disparities and unequal access to healthcare compared with other New Zealand children, which is well documented.32–37 Changes will come from health workers understanding the drivers for poor health in minority groups, and action at multiple levels of the health and social systems. Central action to improve the health of Pacific children will be a commitment to work with the strengths of the Pacific communities.
The following recommendations for health services and practitioners are based on theory and lessons from good practice:
Goal: All aspects of the health system will support better asthma care, aiming to decrease inequities and improve outcomes
Good asthma management requires a system approach incorporating information systems to improve quality and service delivery. The following are recommended:
Goal: The correct inhaler device is considered and age appropriate
Table 4: Inhaler devices recommended by age group.
Figure 3: Stepwise approach to treatment of children with wheeze 1–4 years.
Figure 4: Stepwise approach to treatment of children with asthma 5–15 years.
Goal: The right step of medicine in the right device is used for the age and symptoms of the child
Table 5: The recommended low and standard daily dose of ICS in children with asthma. “High” doses are double the standard doses (see Tables 4 and 5).
Goal: For all children with asthma it should be clear if ICS should be prescribed, and if so, a prescription given and the medicine taken
Goal: LABAs should never be prescribed without ICS
Goal: All children should be managed to avoid life-threatening asthma or death
Table 6: Criteria for acute referral to hospital and/or hospital admission in children and adolescents.
Figure 5: Algorithm for community management of moderate, severe and life-threatening acute asthma in children and adolescents. (Mild asthma is asthma symptoms not usually requiring medical attention and should be managed according to the asthma action plan.)
Table 7: Pre-discharge considerations in children and adolescents.
List of organisations and individuals consulted for feedback:
All DHBs
All PHOs
Asthma NZ
Australasian College of Emergency Medicine
Authors of adult guidelines
Breathing works
Canterbury Health
Conference delegates
Departments of General Practice for Medical Schools
General Practice NZ
Health Informatics NZ
Health Information Standards Organisation
Ian Town
Internal Medicine Society of Australia and NZ
Julian Crane
Kidz First
Maternal and Child Health Mid-Central District Health
Medtech
Ministry of Education
Ministry of Health NGO
National Health IT Board
Ngā Kaitiakio Te Punao Rongoāo Aotearoa, Māori Pharmacists’ Association
NZ Medical Association
NZ Resuscitation Council
NZ Speech Therapists Association
NZNO & NZNO Respiratory Nurses Section
Paediatric Society
Paediatrics’ Otago Medical School
Pasifika GP Network
Pasifika Medical Association
PHARMAC Pharmaceutical Management Agency
Pharmaceutical Society of NZ
Pharmacy Guild of NZ
Philippa Howden-Chapman
POI Team Public Health South
ProCare Clinical Advisory Committee
Respiratory and Sleep Medicine Auckland University
Royal Australasian College of Physicians
Royal NZ College of GPs
Special Education
St Johns Ambulance
Starship Children’s Health
Te Ora: Māori Medical Practitioners
Te Rūngangao Aotearoa (NZNO Māori)
Thoracic Society of Australia and NZ—NZ Branch
TSANZ Nurses special interest group
Wellington Free Ambulance
The purpose of the New Zealand Child and adolescent asthma guidelines: a quick reference guide is to provide simple, practical, evidence-based recommendations for the diagnosis, assessment and management of asthma in children and adolescents in New Zealand, with the aim of improving outcomes and reducing inequities. The intended users are health professionals responsible for delivering asthma care in the community and hospital emergency department settings, and those responsible for the training of such health professionals.
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