Asthma in adolescence

doi:10.1016/S1526-0542(02)00309-3

Paediatric Respiratory Reviews

Volume 4, Issue 1, March 2003, Pages 47-54

https://doi.org/10.1016/S1526-0542(02)00309-3 Get rights and content

Abstract

The care of adolescents with asthma has been largely neglected, yet adolescents have particular needs that differ from those of children or adults with asthma. There are over 800 000 teenagers in the UK who suffer from asthma and underdiagnosis and poor treatment are common. The prevalence and level of morbidity from asthma in adolescents are as high as or higher than the rates in younger schoolchildren. Poor symptom control frequently reflects poor compliance with treatment. The beliefs and fears of teenagers about their asthma and its treatment are often not recognised or addressed in clinical consultations. Improved communication on the part of health professionals, which results in negotiating simple management plans that are tailored to the individual patient’s concerns and goals, is more likely to improve compliance and asthma control than are complex plans made unilaterally by the doctor. The transition of care from the paediatric to the adult clinic remains a challenge for paediatricians and there is a lack of consensus over the best method of achieving this.

Section snippets

INTRODUCTION

Adolescence is a time of intense physical, emotional, psychological and social change (Table 1).¹ It should be a time of excitement when teenagers strive to reduce their dependency on their parents and gain the freedom to make their own decisions. Asthma, and the way in which it is treated, can impede these changes and increase the stress that is a part of normal adolescence.1., 2.

Between 4 and 4.5 million teenagers live in the UK; based on recent prevalence figures,3., 4. it is estimated that

THE PREVALENCE OF ASTHMA IN ADOLESCENCE

We know that the prevalence of asthma and wheeze in children has increased steadily over the past 30 years8., 9., 10. but it is less well recognised that the prevalence of asthma has also risen among adolescents in that time.11., 12. The prevalence of wheezing among British teenagers, for example, increased by 70% between 1974 and 1986.¹¹ In 12-year-old boys, the prevalence of wheeze in the previous year rose from 9.8% in 1973 to 15.2% in 1988.¹²

In the 1990s, the world-wide prevalence of

UNDERDIAGNOSIS, UNDERTREATMENT AND MORBIDITY

Diagnosing asthma is more straightforward in teenagers than in younger children and infants as a narrower range of conditions needs to be considered in the differential diagnosis of the adolescent who presents with recurrent cough, breathlessness or wheeze. Hyperventilation, vocal cord dysfunction, habit or psychogenic cough, bronchiectasis and a variety of rarer conditions can all masquerade as asthma, but a careful history and examination will usually identify the characteristic features of

COMPLIANCE AND CONCORDANCE

Although underdiagnosis is an important cause of morbidity in teenagers, it is clear that there is an unacceptably high rate of symptoms even when asthma has been diagnosed and treatment prescribed. In a minority of patients, poor control reflects particularly severe or refractory asthma. In others, the problem is that they have been given inadequate or inappropriate treatment. In many teenagers, however, poor compliance is an important factor.

Compliance, when used in a medical context, means

ATTITUDES OF SECONDARY SCHOOLCHILDREN TO ASTHMA

Our understanding of these issues was increased by a large national survey that was performed by the National Asthma Campaign in 1997.36., 37. The aim was to examine the views towards asthma of a representative sample of British secondary schoolchildren. Identifying the key issues led to the development of a range of National Asthma Campaign information sheets and other resources for teenagers with asthma, their parents, teachers and health professionals.

A PRACTICAL APPROACH TO IMPROVING COMPLIANCE

These surveys are helpful in identifying the issues that are of importance to adolescents with asthma. We need to move way from the traditional model of care in which the doctor decides what the important issues are and tells the patient what to do. Such an approach is unlikely to be successful, particularly with a teenager who is trying to establish autonomy. We need a much more patient-centred approach, in which the clinician listens to, identifies and addresses the patient’s concerns rather

ORGANISING AND TRANSFERRING CARE

Although it is accepted that the emotional and psychosocial needs of adolescents with asthma differ from those of younger children or of adults, it is not clear what the best model of care should be.1., 41., 42., 43. It is often inappropriate for teenagers to be seen in a paediatric clinic or admitted to a children’s ward but it may also be premature for them to be seen in an adult setting. In North America, Australia and some parts of Europe, specialist clinicians provide adolescent care in

PRACTICE POINTS

•
The special needs of adolescents with asthma have been largely ignored or neglected.
•
Up to one in five adolescents suffers from asthma.
•
Asthma is both underdiagnosed and undertreated in this age group.
•
Mortality and morbidity from asthma are higher in adolescents than children.
•
Poor compliance or concordance with treatment is common in adolescents, as it is in younger children and adults.
•
The concerns that adolescents with asthma have about their illness and its treatment are often not recognised or

References (43)

E.C. Wright
Non-compliance – or how many aunts has Matilda
Lancet
(1993)
H. Milgrom et al.
Non-compliance and treatment failure in children with asthma
J. Allergy Clin. Immunol.
(1996)
A. Charlton
Changing pattern of cigarette smoking among teenagers and young adults
Paediatr. Respir. Rev.
(2001)
J.F. Price
Issues in adolescent asthma: what are the needs?
Thorax
(1996)
C. Spargo et al.
Asthma in teenagers: exploding the myths
Asthma J.
(1997)
International Study of Asthma and Allergies in Childhood Steering Committee. Worldwide variation in prevalence of...
A. Venn et al.
Questionnaire study of effect of sex and age on prevalence of wheeze and asthma in adolescence
BMJ
(1998)
National Asthma Campaign. Asthma Audit 1997–1998. London: National Asthma...
British Thoracic Society et al. Guidelines on the management of asthma. Thorax 1993; 48:...
British Thoracic Society et al. Guidelines on the management of asthma. Thorax 1997; 52:...

M. Omran et al.

Continuing increase in respiratory symptoms and atopy in Aberdeen schoolchildren

BMJ

(1996)

G. Ng-Man-Kwong et al.

Increasing prevalence of asthma diagnosis and symptoms in children is confined to mild symptoms

Thorax

(2001)

A. Venn et al.

Increasing prevalence of wheeze and asthma in Nottingham schoolchildren 1988–1995

Eur. Respir. J.

(1998)

S. Lewis et al.

Study of the aetiology of wheezing illness at age 16 in 2 national British birth cohorts

Thorax

(1996)

M.L. Burr et al.

Changes in asthma prevalence: two surveys 15 years apart

Arch. Dis. Child

(1989)

B. Kaur et al.

Prevalence of asthma symptoms, diagnosis and treatment in 12–14 children (International Study of Asthma and Allergies in Childhood, ISAAC UK)

BMJ

(1998)

M.R. Becklake et al.

Gender differences in airway behaviour over the human life span

Thorax

(1999)

M. Hibbert et al.

Changes in lung, airway and chest wall function in boys and girls between 8 and 12 years

J. Appl. Physiol.

(1984)

T. Douglas et al.

Differential diagnosis of asthma in children

Asthma J.

(2001)

H.C. Siersted et al.

Population based study of risk factors for underdiagnosis of asthma in adolescence: Odense schoolchild project

BMJ

(1998)

Gallup. The Impact of Asthma Survey 1996. London: National Asthma Campaigns Allen and Hanburys,...

Cited by (57)

Transitioning Asthma Care From Adolescents to Adults: Severe Asthma Series
2021, Chest
Citation Excerpt :
Transition care of long-term health conditions needs to be planned, age-appropriate, and effective. A rushed, haphazard transfer of care may place at high risk a young person’s physical and emotional development during a critical time of change; a time during which maladaptive behavior can lead to long-term health consequences.7 A 16-year-old student in secondary school had been attending the pediatric asthma clinic since the age of 11.
Children with asthma grow to become adults with asthma. Adolescents are not simply older children and do not automatically transform into independent adults, nor do they become proficient in self-management of their condition overnight. Adolescence is a high-risk time for many people with asthma, with increased risk of asthma-related morbidity and mortality. Children with high-risk asthma attend hospital-based asthma clinics with their parents until they reach young adulthood, and parents usually take on the significant burden of disease management on behalf of their children. Once patients are transferred to adult medical teams, many will continue to have limited knowledge about their asthma, limited understanding of how to manage their symptoms and comorbidities, and limited comprehension of how and why to take their regular medication. Adolescence is a critical time of change during which young people yearn for autonomy. Effective transition gives young people the skills and knowledge necessary to manage their health independently and provides the substrate for autonomous care, the bed rock of long-term conditions. This review focuses on the challenges of adolescent health care and provides guidance on how to take a planned, patient-centered approach to ensure each transition is effective and safe.
Severe Asthma in Children and Young People
2021, Encyclopedia of Respiratory Medicine, Second Edition
Asthma is the commonest chronic disease in children. Children and young people (CYP) with severe asthma represent only about 5% of this cohort but have a high burden of disease due to persistent asthma symptoms and/or regular asthma attacks that often require hospitalization.
CYP with severe asthma are at increased risk of life threatening attacks, medication side effects and an accelerated decline in lung function, as each additional asthma attack can result in a persistent reduction in lung function. The most common reason for poor asthma control is a failure to optimize the basics of asthma care, including poor medication adherence, inappropriate inhaler device, or poor inhaler technique. All CYP with severe asthma should receive a multidisciplinary systematic assessment at a dedicated severe asthma center. This can ensure appropriate asthma diagnosis, phenotyping, and effective management with appropriate treatment. Multidisciplinary teams are also skilled to identify and treat comorbidities, treatable factors and environmental exposures, and have greater awareness and ability to resolve treatment-related issues, including safeguarding and psychosocial factors. Frequent treatment with oral corticosteroids is often unavoidable in severe asthma, but these drugs carry a significant burden of side effects that are best avoided where possible. Newly available monoclonal antibody therapeutics (‘biologics’) have the capacity to transform the landscape of severe asthma management – offering personalized therapy that targets the immunological origins of certain asthma endotypes, improving quality of life, reducing short term and long-term morbidities and simultaneously helping to reduce systemic corticosteroid use. Multidisciplinary assessment at a dedicated severe asthma center is essential before initiating biological treatment.
46 - Severe Asthma
2019, Kendig's Disorders of the Respiratory Tract in Children
Most pediatric asthma is easily treated with low-dose inhaled corticosteroids, occasionally combined with a long-acting bronchodilator, provided the medications are administered regularly and correctly. If the child does not respond to treatment, rather than escalating treatment uncritically, a detailed, protocolized assessment is mandatory. This should include a review of the diagnosis and assessment of the presence or otherwise of any extrapulmonary comorbidities, such as obesity, exercise-induced laryngeal obstruction and lifestyle and social factors, such as adherence, perhaps the most important cause of “treatment resistant asthma,” and allergen and tobacco exposure; this enables successful management of 90% of referrals with apparent severe asthma. For the rest, bronchoscopic assessment of airway pathology is advisable, combined with a parenteral steroid trial, to deconstruct airway pathology by determining the presence and nature of any inflammation and whether there is fixed airflow obstruction. If inflammation is present, it is eosinophilic not neutrophilic but signature T-helper cell cytokines are difficult to detect, suggesting alternative pathways are important. There is no agreed upon pediatric definition of steroid responsiveness, and we advocate a multidomain approach. Other than for omalizumab, treatments for steroid-resistant asthma have no evidence base in children. The child with recurrent asthma attacks is particularly difficult to manage and is at high risk of further attacks and death from asthma. In summary, therapy-resistant asthma is rare but a really difficult problem when present. Most apparent therapy-resistant asthma can be successfully treated by optimizing basic management, especially ensuring adherence to standard therapy.
Approaching Current and New Drug Therapies for Pediatric Asthma
2017, Pediatric Clinics of North America
Citation Excerpt :
According to a telephone survey, based on parental report, adolescents assume 75% of their daily controller medication responsibility by age 15% and 100% of the responsibility by age 19,32 underscoring the potential substantial impact of nonadherence in adolescents. The etiologies of this nonadherence in adolescents are multifactorial, including changes in cognitive development, desire for peer approval, anxiety and depression, and risk-taking behavior.29–31,33–36 Before a clinician prescribes escalating therapies in adolescents, these conditions should be explored for potential reasons for poor control or medication nonadherence.
Low-Income Children, Adolescents, and Caregivers Facing Respiratory Problems: Support Needs and Preferences
2016, Journal of Pediatric Nursing
Burdens of poverty are often compounded by respiratory problems. This study aimed to identify the support needs and intervention preferences for low-income families facing this challenge.
Interviews were conducted in two Canadian provinces with low-income children/adolescents (n = 32) diagnosed with respiratory health problems and their parents or family caregiver (n = 37).
These vulnerable children and parents described non-supportive interactions with some health service providers and inadequate information. They reported isolation and support deficits, exacerbated by limited resources and health restrictions. Children/adolescents felt isolated and excluded and wanted to connect with peers. Group or dyadic level support, delivered by peers and health professionals, was desired. The importance of logistics to enhance accessibility and appeal of group or dyadic support interventions was clearly identified.
The findings of this study reveal that low-income children and their families encounter challenges to accessing support and to utilizing support resources.
Partnerships with low-income children/adolescents and family caregivers in provision of education and social support can combat isolation and ignorance. Reducing inequities for this high risk population could be achieved by providing support from experienced peers, in combination with health professional guidance, and knowledge about pulmonary health.
Life-threatening anaphylaxis to egg and milk oral immunotherapy in asthmatic teenagers
2014, Annals of Allergy, Asthma and Immunology

View all citing articles on Scopus

View full text

SERIES: DIFFICULT ASTHMAAsthma in adolescence

Abstract

Section snippets

INTRODUCTION

THE PREVALENCE OF ASTHMA IN ADOLESCENCE

UNDERDIAGNOSIS, UNDERTREATMENT AND MORBIDITY

COMPLIANCE AND CONCORDANCE

ATTITUDES OF SECONDARY SCHOOLCHILDREN TO ASTHMA

A PRACTICAL APPROACH TO IMPROVING COMPLIANCE

ORGANISING AND TRANSFERRING CARE

PRACTICE POINTS

Lancet

J. Allergy Clin. Immunol.

Paediatr. Respir. Rev.

Issues in adolescent asthma: what are the needs?

Thorax

Asthma in teenagers: exploding the myths

Asthma J.

Questionnaire study of effect of sex and age on prevalence of wheeze and asthma in adolescence

BMJ

Continuing increase in respiratory symptoms and atopy in Aberdeen schoolchildren

BMJ

Increasing prevalence of asthma diagnosis and symptoms in children is confined to mild symptoms

Thorax

Increasing prevalence of wheeze and asthma in Nottingham schoolchildren 1988–1995

Eur. Respir. J.

Study of the aetiology of wheezing illness at age 16 in 2 national British birth cohorts

Thorax

Changes in asthma prevalence: two surveys 15 years apart

Arch. Dis. Child

Prevalence of asthma symptoms, diagnosis and treatment in 12–14 children (International Study of Asthma and Allergies in Childhood, ISAAC UK)

BMJ

Gender differences in airway behaviour over the human life span

Thorax

Changes in lung, airway and chest wall function in boys and girls between 8 and 12 years

J. Appl. Physiol.

Differential diagnosis of asthma in children

Asthma J.

Population based study of risk factors for underdiagnosis of asthma in adolescence: Odense schoolchild project

BMJ

SERIES: DIFFICULT ASTHMA
Asthma in adolescence