Tackling paediatric asthma – The time has come

Asthma is the most common chronic condition in childhood and the leading cause for paediatric hospitalizations (1). Children with asthma pose a much higher cost to our health care system than children without asthma (2). Asthma also poses an increased burden to families of children with asthma (3). Asthma hospitalizations have dramatically decreased in all age groups except young children (4). Recent Canadian data show that the overall state of asthma control is poor, with more than one-half of Canadian children classified as ‘uncontrolled’ according to Canadian asthma guideline control parameters (5). Canadian data also show that both parental and physician perception of asthma control in children is poor (6). It is now generally accepted that asthma is an ambulatory-care-sensitive condition and appropriate outpatient management results in decreased urgent health care use (7). National evidence-based guidelines recognize that medication and avoidance of asthma triggers are the ways to achieve better asthma control (8). The single most effective therapy we have to decrease asthma hospitalizations is inhaled corticosteroids. Most researchers and clinicians agree that it is probably the widespread use of inhaled corticosteroid therapy that has resulted in the lower hospitalization and mortality rates for asthma over the past decade (7). Despite widespread availability, asthma medications are still underutilized in children with asthma. Some of this under-treatment may be attributed to physicians underestimating disease severity and another portion may be explained by patient noncompliance. The only effective way known to increase compliance with therapy is asthma education. Hence, asthma education is also considered a cornerstone to disease management in national guidelines (8). The aim of asthma education is to increase asthma knowledge and self-management skills, which in turn changes behaviour (often with medication compliance and avoidance of triggers) and results in improved asthma outcomes. Asthma education has been shown to improve a wide range of asthma outcomes, including symptoms, health care use and pulmonary function (9). A question that often arises is, what is effective asthma education? Education that can be expected to change behaviour and outcomes in chronic disease is not a simple 5 min encounter with a physician. It is widely accepted that successful education for chronic diseases requires skills in education, as well as a current and appropriate knowledge of the disease and its management (10). Important determinants of success include individual face-to-face interactions between the patient and educator, and follow-up sessions for reinforcement. Essential elements of asthma education include ensuring patients understand the modes of presentation for asthma, the role of their medication, the criteria for disease control and how to change their medications when their asthma worsens. They also need repeated training on inhalation device techniques to ensure effective drug delivery and the provision of a written action plan. It is important that the educator helps the child and family identify actions necessary to control the disease and barriers to self-management, and helps the patient develop strategies to overcome these barriers. All of this takes a minimum of one-half hour of initial counselling. Although most paediatricians agree in principle that asthma education is important, many barriers exist to implementing an asthma education program. The first barrier, developing a standardized program for asthma education, has recently been successfully overcome. Canada has been an international leader in this arena, being one of the first countries to develop a national certification process (11) with professional designation (ie, Certified Asthma Educator). National standards have been developed on ‘what to teach’ and ‘how to teach’, and a process has been implemented for continuing competency issues. Other countries are now following suit. Several other barriers exist, not the least of which is finding the time and funding to set up an asthma education clinic and pay an asthma educator. Currently, most provinces do not have designated funding for asthma educators with asthma clinics being set up on an ad hoc basis. Paediatric patients also have unique needs, in that a family-centred and developmentally appropriate approach needs to be taken with asthma education. A recent article in Paediatrics & Child Health by Smith et al (12) demonstrated how a regional paediatric asthma education clinic can be set up successfully in a community hospital setting. This is no small task, and the authors should be congratulated for their hard work. The state of asthma education in Canada has recently been reviewed by Cowie et al (13). There are not enough asthma education clinics in Canada to refer even the highest risk asthmatics to. There is also wide regional variation in the availability of such programs. The province of Quebec has taken a lead in developing a much more wide-reaching approach with an organized network of asthma education clinics that are staffed by certified asthma educators and funded by the provincial government under the umbrella of the Quebec Asthma and COPD Network (www.rqam.ca). Health services research suggests that to decrease avoidable hospitalizations, childhood asthma is the leading condition that paediatricians could target for more intensive education, monitoring and follow-up (14). Canadian data suggest that we have an unmet need for asthma education programs (12). Families with children with asthma have unique needs that make them different from adults with asthma. Paediatricians must rise to the task to meet these needs with unique models of care as exemplified by Smith et al (12).

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