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[Editorial] Controlling asthma

Tags: General

In today's Lancet, ahead of World Asthma Day on May 6 and the American Thoracic Society's international conference (ATS 2014) in San Diego (May 16—21), we publish several papers on asthma and other areas of respiratory medicine. A two-part Series on asthma draws attention to challenges in the diagnosis and management of preschool wheeze and the effects of outdoor air pollution on the disease. Asthma is the most common chronic disorder in children. The health and economic burden of wheeze and asthma is particularly high in young children. Almost half of all children have at least one episode of wheeze before 6 years of age, and 48% of preschool children (younger than 5 years) with asthma report an asthma attack in the preceding year—a rate higher than any other age group. Emergency department visits and hospital admissions are also greater for this group compared with children and adults with asthma.
Despite this burden, management of childhood asthma is often substandard, even in high-income countries. Research in European countries has shown that two-thirds of hospital admissions for asthma in children could be avoided with better preventive care. Mortality also varies between countries in Europe for this highly treatable disorder. The UK has the highest mortality rates from asthma both among children aged 6—7 years and children aged 13—14 years when compared with Sweden, Portugal, Finland, Italy, Austria, Germany, and Spain.
Daily low-dose inhaled corticosteroids can prevent exacerbations in children with repeated wheezing episodes and effectively control asthma. However, as Francine Ducharme and colleagues note in their Series paper, most preschool children with recurrent and persistent asthma symptoms do not receive daily anti-inflammatory drugs. Suboptimum treatment occurs for several reasons, including perceived unclear benefit, physician discomfort in prescribing long-term controller therapy, and low parental compliance. Physician and parental reluctance to give these drugs to young children might stem from concern about adverse effects. Daily inhaled corticosteroids are associated with a small but statistically significant effect on growth compared with placebo, according to the few data available. Evidence in prepubertal school-age children suggests that the magnitude of growth suppression is molecule dependent. In the absence of solid data for preschool children, the authors recommend selection of the safest molecules and careful monitoring of growth.
For school-age children, asthma control could soon be taking a step forward in the UK. The Medicines and Healthcare Products Regulatory Agency is due to launch a public consultation on the provision of emergency inhalers and spacers in schools for children having an acute attack. The development of guidelines for schools will also be crucial to the safe and effective administration of these drugs.

Worldwide, public health interventions could also improve asthma outcomes for children. In an Article in today's issue, Jasper Been and colleagues report the first systematic review and meta-analysis on the effect of smoke-free legislation on child health. As well as decreasing rates of preterm birth, smoke-free legislation reduced paediatric hospital admission for asthma by 10% after introduction. Children are likely to have benefited from reductions in maternal smoking and increases in the proportion of smoke-free homes. These results call for the urgent scale-up of smoke-free environments in countries that have not yet legislated.

Outdoor air pollution is another important contributor to asthma. In their Series paper, Michael Guarnieri and John Balmes show that short-term exposure to ozone, nitrogen dioxide, sulphur dioxide, particulate matter (less than 2·5 μm [PM2·5]), and traffic-related air pollution can increase the risk of exacerbations of asthma. Evidence also suggests that long-term exposure to air pollution, especially from traffic, can lead to new cases of asthma in adults and children. Motor vehicle emissions and power plants are key sources of pollution. Although tough regulation to reduce levels of these harmful emitters is vital, ultimately countries will need to move away from fossil fuel combustion to achieve truly clean air.

The theme of this year's World Asthma Day, 2014, is you can control your asthma. Individuals are hampered from successful control if gaps in implementation of treatment exist. And people with asthma living in countries that do not curb second-hand smoke exposure and pollution are not helped by these unhealthy environments. Physicians, parents, and policy makers all have a part to play in making asthma the controllable disease it should be for children and adults.

See ReviewRespir Med 2014; 2: 405—15

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