State of the art review

Improving the global diagnosis and management of

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asthma in children
Warren Lenney,1,2,3 Andrew Bush,4,5,6 Dominic A Fitzgerald,7,8 Monica Fletcher,3,9
Anders Ostrem,10 Soren Pedersen,11 Stanley J Szefler,12,13 Heather J Zar,14,15 on behalf
of the GSK Paediatric Project Advisory Board and Committee

For numbered affiliations see Abstract a separate clinical entity.2 The pathophysiology
end of article. Asthma is the most common chronic condition in of asthma in all ages of patients was thought to
children worldwide. It affects daytime activities, primarily involve bronchial smooth muscle hyper-
Correspondence to trophy with intermittent smooth muscle spasm.3 4
sleep and school attendance and causes anxiety
Professor Warren Lenney,
GlaxoSmithKline, 980 Great to parents, families and other carers. The quality of With greater knowledge of the underlying immune
West Road, London TW8 9GS, asthma diagnosis and management globally still needs mechanisms,5 6 ‘asthma’ gradually became used as
UK; w
​ .​lenney46@​hotmail.​co.u​ k substantial improvement. From infancy to the teenage a term for an inflammatory condition with ICS
years, there are age-specific challenges, including recommended as the first-line controller7; but
Received 2 February 2018
Revised 28 March 2018 both underdiagnosis and overdiagnosis with stigma- ‘asthma’ is now no more a diagnosis than ‘anaemia’
Accepted 9 April 2018 related barriers to treatment in some cultures and in or ‘arthritis’ and should only be used as an umbrella
Published Online First adolescents. Guidelines are increasingly evidence based, term to describe a clinical spectrum that includes
14 May 2018 but their impact on improving outcomes has been symptoms of wheeze, breathlessness, chest tight-
negligible in many parts of the world, often due to lack ness and cough.6 Some have questioned whether
of implementation. New thinking is needed to enable the term ‘asthma’ should be abandoned altogether
substantial improvements in outcomes. The disease due to the increasing recognition of many different
varies globally and plans will need to differ for individual phenotypes in all age groups.8 9 However, prob-
countries or places where region-specific barriers prevent ably better than abandoning this term is to ask the
optimal care. A wide selection of educational activities question: ‘Which of the asthmas does this patient
is needed, including community-targeted initiatives, have?’6
to engage with families. The Paediatric Asthma Project There have been successful attempts to improve
Plan has been initiated to strengthen diagnosis and the education of healthcare professionals, children
management of asthma. This encompasses a vision for and their families.10 However, childhood ‘asthmas’
the next 10–15 years, building on the knowledge and remain poorly diagnosed, with control falling
experience from previous educational projects. It will take short of expected standards. The 2015 National
into account the educational needs of patients, carers Review of Asthma Deaths in England & Wales
and healthcare professionals as well as the accessibility demonstrated that paediatric case record-keeping
and affordability of medication, particularly in low and was worse than that in adults, the overall stan-
middle-income countries where the prevalence of asthma dard of care for children and young people being
is rising more rapidly. This overview presents a first step inadequate.11 The most recent asthma guidelines
for those involved in the diagnosis and management from the UK National Institute for Health and
of childhood asthma to strengthen care for children Care Excellence focus on recommendations for
globally. diagnosis and management of patients with mild-
to-moderate asthma and are targeted at primary
‘Each generation is equidistant from care physicians.12 Many issues contribute to the
barbarism.’ inability to accurately diagnose asthma in children,
Alfred North Whitehead, mathematician including failure to perform any objective tests,
and philosopher (1861–1947) issues surrounding age appropriateness of tests,
misunderstanding of the significance of symptoms
and—especially in some areas of the world—stigma.
Introduction Patients, parents and carers have misconceptions
Why is the quality of asthma diagnosis in children about asthma control in children13 that differ
so universally poor? Why, despite our increased across the world.14 It is vital to recognise these
knowledge, a profusion of evidence-based guide- differences, train local healthcare professionals
lines and the development of effective medica- and develop a comprehensive global plan that will
tions, do we remain incapable of improving asthma benefit children wherever they live—an objective
control, and preventing asthma attacks and death, of the Lancet Asthma Commission.6 This overview
in many parts of the world? Surely, we can do better. aims to highlight the global burden of childhood
The word ‘asthma’ has been used in children and asthma, recognising regional differences around
in adults for centuries.1 Nearly 50 years ago, just the world and determine a road map to develop a
before inhaled corticosteroids (ICS) were devel- training and education programme to improve the
To cite: Lenney W, Bush A, oped, we were told that all recurrent wheezing in diagnosis and management of these very common
Fitzgerald DA, et al. Thorax children fitted into ‘asthma’ and that ‘wheezy bron- conditions. While every effort has been made to
2018;73:662–669. chitis’ in the preschool age group did not exist as provide source references for the information
662   Lenney W, et al. Thorax 2018;73:662–669. doi:10.1136/thoraxjnl-2018-211626
 State of the art review
presented, some statements are necessarily opinion based as a not be feasible in some below 3 years of age, and in resource-

Thorax: first published as 10.1136/thoraxjnl-2018-211626 on 14 May 2018. Downloaded from http://thorax.bmj.com/ on 10 December 2018 by guest. Protected by copyright.
definitive citation is not available. poor regions.33 Airway inflammation and airflow limitation are
difficult to measure in young children, but all too often are not
even attempted.34 This may result in undertreatment of chil-
The ‘Asthmas’
dren with eosinophilic airway inflammation and overtreatment
Asthma should be considered a disease with a broad clinical spec-
trum, making no assumptions about the underlying pathology. of children with transient, non-eosinophilic wheezing.32 Under-
Airway disease should be deconstructed into components of treatment may have consequences for the child with asthma, in
fixed and variable obstructions, inflammation (presence and terms of chronic symptoms and repeated attacks of wheeze,35 36
type) and infection.6 The context should be considered, including although early intervention with ICS does not prevent progres-
comorbidities such as obesity, and social and environmental sion to eosinophilic airway inflammation.37–40 Overtreatment
issues. The latter include adherence and exposure to allergens of transient wheezing risks treatment side effects without any
and pollutants, with emphasis on identifying what is treatable.15 benefit.
This approach highlights that asthma in high-income countries Most asthma symptoms in children are intermittent and vari-
may not be the same as that in the high-infection, high-pollution able,7 but children may adapt their lifestyle to minimise symp-
settings that are common in low and middle-income countries toms by reducing physical activity; so it is vital that we really
(LMICs). The childhood asthmas are a spectrum of disease with understand their true level of asthma control.41 Control by ICS
similar clinical features but with wide variations in presentation, is the present cornerstone of treatment in eosinophilic airway
aetiology and pathophysiology.16 17 The pattern of inflamma- inflammation-driven asthma, yet poor adherence is common and
tory phenotypes is different from that in adults, with eosino- remains under-recognised.42 Even with the use of short courses
philic phenotypes predominating.18 Symptoms and markers of of oral corticosteroids (OCS) to relieve asthma attacks, there is
inflammation in children do not always correlate,19 and there are variation in the dosage used and the length of the OCS course
no reliable, evidence-based biomarkers for accurate diagnosis, within the UK alone.43 There are concerns from the USA about
monitoring response to therapy or risk assessment. the overuse of short courses of OCS,44 and global standardisa-
Prenatal factors associated with subsequent asthma inception tion in future would be helpful. Intentional barriers to adherence
include a family history of atopic disease, maternal smoking and within the family setting are common. These may have unsci-
asthma, environmental pollution (especially tobacco smoke and entific bases driven by culture-specific perceptions and medica-
indoor biomass exposure), diet, nutrition, maternal stress, use of tion beliefs.45 Effective education can reduce these concerns and
antibiotics and birth by caesarean section.17 In childhood, factors increase willingness to accept ongoing preventative treatment. A
associated with more severe asthma symptoms and worse asthma clear strategy for early review of treatment and the management
control include allergic sensitisation (particularly multiple early plan is essential, but rarely takes place.46
aeroallergen sensitisation20–22) and exposure to high environ- Lower airway deposition of medication can be improved
mental levels of the allergen. Allergic conditions such as atopic by the use of a spacer,40 although poor technique occurs with
dermatitis or allergic rhinitis, early severe viral respiratory infec- most inhaler systems47 and recommendations in guidelines are
tions (especially rhinovirus C or respiratory syncytial virus), not always followed.48 The high cost and lack of availability
decreased lung function in infancy, small family size, low socio- of commercially produced spacers limit their use in LMICs,
economic status, antibiotic usage, infections and gender may all although spacers made with plastic bottles can be equally effec-
influence asthma severity21 23 Secondhand tobacco smoke, use of tive.49 In some LMICs, access to any form of care can be lacking
biomass fuels and air pollution are associated with an increased or care may be unaffordable.49
likelihood of attacks in those who already have asthma.24 The Teenagers often wish to take charge of their own health;
influence of these factors varies globally.23 24 Fortunately, smoke- some may stop medication due to stigma or embarrass-
free legislation has achieved substantial benefits for child respi- ment.50 Barriers to asthma management are more common in
ratory health, including lower hospital admission rates and teenage boys,50 but teenage girls fare worse in overall asthma
hospital attendances for asthma attacks.25 26 However, these control.51 In adolescence, a lack of self-management skills and
gains are being jeopardised by the increasing promotion of e-cig- insufficient health literacy knowledge contribute to poorer
arettes and the often weak responses by the legislature. outcomes and worse adherence.52 Teenagers with asthma are
at risk of being neglected due to the gap in available services,
Age-specific challenges to asthma diagnosis and and the fact that this is an age when patients do not regularly
management attend appointments.53 Neither paediatric nor adult clinics
Diagnosis is particularly challenging in the first 3 years of life, seem adept with the transition of care.53 Cooperation between
both in identifying whether the child has an airway disease at all paediatric asthma specialists and primary care physicians is
and in recognising the underlying pathophysiology.27–31 Recur- essential to strengthen this transition and optimise long-term
rent wheezing is common but most will lose their symptoms by care.54–58
the age of 6 years.27 Diagnosis is made almost entirely on a clin- Identification of children whose symptoms will persist needs
ical history of recurrent wheeze, recurrent cough for days, chest to be improved.9 59 The Melbourne longitudinal cohort study
tightness, breathlessness and sometimes includes response to a has followed children from 7 to more than 50 years of age.60
trial of ICS treatment.28 These symptoms, however, do not tell Those with initial severe asthma were more likely to have symp-
us which child has which specific phenotype.28 There is no stan- toms persisting throughout, with lung function remaining low
dard definition for the type, severity or frequency of symptoms from study enrolment.60 The Asthma Predictive Index may
in this young age group, and evidence-based recommendations provide improved predictions but lacks sensitivity or specificity
are lacking.32 Should we routinely measure blood eosinophil and has not been validated in LMIC settings.61 Among children
and/or IgE levels, perform skin prick tests and attempt lung with mild-to-moderate asthma, 75% have been shown to have
function and bronchodilator responsiveness assessments? abnormal lung growth in childhood, often with a further decline
Many of these are possible in young children, although may in early adulthood.62
Lenney W, et al. Thorax 2018;73:662–669. doi:10.1136/thoraxjnl-2018-211626 663
 State of the art review
Where are we now? major challenge, with regular treatment unaffordable for most

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A plethora of asthma management guidelines have been families.
published but healthcare providers rarely follow them, with little In China, parents do not seem to recognise or understand the
change in use observed over time.63 64 It is unlikely that any one concept of difficult-to-treat (refractory) asthma. In Japan, there
guideline can be applied globally and new ideas, rather than new may be less concern about treatment adherence as regular doctor
guidelines, are needed to improve diagnosis and management.65 visits occur where repeat prescriptions are offered. Childhood
asthma deaths have steadily fallen in Japan; although the death
Global overview rate in China is low, the disease prevalence has increased, partic-
Similar challenges exist worldwide, but there are region-specific ularly in large cities.
differences. There is a general lack of effective primary care,
poor coordination between primary and secondary care, inac- Australasia and Europe
curate diagnosis and poor adherence to treatment and failure Here, the overall prevalence is high.71–73 Access to healthcare is
to effectively tackle those factors that can make asthma worse. less problematic due to well-established healthcare systems and
There is a tendency to progress with the use of expensive medi- subsidised medication costs. There are some remote sparsely
cines without first ensuring basic management approaches have populated areas where access, and accuracy of diagnosis, may be
been optimised, that there has been a lack of recognition of less reliable. Even where access is good, diagnosis can be wanting
asthma attacks and a failure of regional applicability together and the overuse of reliever treatment, underuse of ICS and lack
with implementation of simplified treatment guidelines. Only of planned follow-up are all evident.11 74
a few countries have been successful in the widespread imple- Lung function assessment remains patchy, with little
mentation of national treatment guidelines. Shining examples of agreement on its value despite information from long-term
these are the Finland Asthma Project,10 the 12-year to 15-year studies.9 60 62 Even basic attention to patient inhaler technique
study in Costa Rica66 and the Belo Horizonte Project in Brazil.67 by UK prescribers, a number of years following clear recommen-
Lessons from these and other regional innovative incentives still dations within national treatment guidelines, has been shown
need to be shared across the globe and we will incorporate these to be lacking.48 Similarly, the use of markers of severity or
into our educational plan. In addition, the availability and cost disease progression is poorly developed. Mortality is higher and
of medications and spacers in LMICs remain a huge barrier that more could be done for those most vulnerable in society, who
could be overcome with directed resources, much in the way are over-represented.75 Better coordination is needed among
vaccination rates have improved in this setting.68 primary healthcare, hospitals, schools and child protection agen-
cies.76 Greater patient engagement is needed, particularly during
Asthma by geographical region the teenage years.
Asthma has been considered a disease of higher income countries, There is a drive in the UK12 and Australia77 towards a better
but this view is now obsolete, with the prevalence rising faster focus on phenotyping patients to improve the accuracy of diag-
in LMICs.14 To better understand the global context, a group nosis and provide tailored treatment strategies. This is particu-
of respiratory paediatricians and healthcare professionals met in larly pertinent in the non-atopic, obese adolescent.78
March 2017. Each was chosen for their in-depth knowledge of
childhood asthma within their world region. Information was South America
shared on the similarities and differences between world regions Asthma care here has many similarities with Asia and Africa.
and proposals developed as a basis for discussion. There is often poor access to care resulting in lack of control and
increased asthma attacks, low accessibility to effective medica-
Africa tions, weak clinical infrastructures, poor patient compliance, lack
In Africa, like many LMICs, the burden of disease is high and of effective education and difficult social and cultural factors.
outcomes are disproportionately worse among the poorest Prescriptive international guidelines do not always fit into local
populations.14 69 Underdiagnosis and undertreatment with social and cultural backgrounds in some countries. Albarran et
appropriate inhaled therapies prevail.14 69 There is a major lack al suggested this could apply to the Global Initiative for Asthma
of resources, poor health system infrastructure, lack of inhaled guideline recommendations in countries such as Venezuela.79
bronchodilators and corticosteroids and lack of knowledge of The authors warned about too rigid an application of such
childhood asthma.14 69 This results in the widespread use of oral recommendations.38 In contrast, the Wheezy Child Programme
bronchodilator therapy alone. The high incidence of tubercu- in Belo Horizonte, Brazil, showed that expensive medications
losis, HIV and respiratory infections hinders the accurate diag- are not necessary to achieve a good outcome, with the simple use
nosis of asthma.69 Poor access to care and the unavailability and of regular ICS and intermittent short-acting β2-agonists (SABAs)
unaffordability of inhaled medications and spacers are chal- highly effective in reducing hospital admissions and emergency
lenges.68 Outdoor pollution, exposure to secondary tobacco room visits in young children with asthma from 1994 onwards.67
smoke, indoor air pollution or viral infections are highly preva- Overdiagnosis in very young and underdiagnosis in older chil-
lent and all precipitate asthma attacks.70 dren are continuing themes. There is no consistent intercountry
agreement about step-down treatment. The disease burden is
Asia high, multifactorial and mimics the financial and political vari-
In Asia, wide disparities in care are seen, reflecting the diver- abilities seen in South American countries.80
sity of healthcare systems. Access to care differs widely between
China, Japan, the Indian subcontinent, Singapore and other North America
Southeast Asian countries. Where access is more limited, early Children up to 3 years old tend to be underdiagnosed, while
diagnosis is problematic and can result in years of inappropriate patients aged 4–11 years are more likely to be overdiagnosed.
treatment or more likely no treatment at all. The cost of care Access to therapy is strongly related to patient demographics.
in countries with less established healthcare systems remains a Rural, low-income and Latino groups have limited access to
664 Lenney W, et al. Thorax 2018;73:662–669. doi:10.1136/thoraxjnl-2018-211626
 State of the art review
Any asthma education plan in children needs to be age appro-
Box 1 Main global challenges in paediatric asthma

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priate. Several initiatives have been developed to improve
knowledge and self-management. One of the first was the
►► Accurate diagnosis of asthma and its type (eg, eosinophilic vs American AIR WISE Education Program, which consisted
non-eosinophilic) of four weekly self-management sessions.85 It reduced the need
►► Accessing appropriate treatment for emergency asthma treatments through better knowledge and
►► Improving adherence to treatment changes in behaviour. Similarly, the USA-based Open Airways
►► Determining the key local environmental factors responsible for Schools programme aims to educate and empower children
for triggering symptoms by taking a fun and interactive approach to asthma self-manage-
►► Stopping the escalation of treatment along guideline steps ment.86 In Bermuda, the island-wide Open Airways programme
without considering why the simple basics are not working is a model of excellence using a range of techniques, including
►► Adapting global guidelines to local needs and implementing annual assemblies and small group sessions.47 Improved adher-
these in clinical practice ence and control was also seen in those with persistent asthma
►► Culturally appropriate training and education in childhood who participated in an internet-based monitoring and educa-
asthma for all tion programme.87 Such new technology could provide addi-
tional means of addressing treatment adherence using connected
inhalers, which record patient usage.88 Several other educational
initiatives hope to provide families with information needed
asthma specialists and conventional therapy. US drug prices to manage their asthma effectively. These include the Asthma
are very high, making it problematic for those with no medical Initiative of Michigan89; the Centres for Disease Control and
insurance. High prices affect the willingness of health insurance Prevention90; the American Academy of Allergy Asthma and
providers to reimburse for or allow the prescribing of high-cost Immunology 91 and the School-based Asthma Management
medications. Individual healthcare systems play a major role in
Program.92 The National Asthma Education and Prevention
the philosophy of treatment, but medications may be frequently
Program (2003)93 provides schools with a guide to managing
switched based on formulary recommendations and costs,
asthma among pupils.
confusing patients and probably affecting treatment adherence.
What is lacking is a better coordinated approach. Lack of
Tracking of asthma hospitalisations is poor and lung function
coordination with few well-funded initiatives in LMICs has high-
testing is limited. There is a need to improve identification of
lighted the disparities in asthma education and resource alloca-
those at risk of attacks and to follow them up. Clinicians are
tion. The Asthma Drug Facility provided a great step forward in
aware of guidelines but only relating to the treatment steps.37
enabling access to affordable, good-quality, essential asthma drugs
Key global challenges are summarised in box 1.
in LMICs; however, this initiative is no longer operational, and
there is a need to establish a similar global means of ensuring equi-
Where would we like to be? table access to high-quality, low-cost inhaled medication. A range
Improving the knowledge and understanding of asthma is of educational activities could be employed, including communi-
important and beneficial.81 82 The child and family should be at ty-targeted activities. This could take the form of active learning
the centre of such plans, managed by well-informed local health- modules, social media or community groups (asthma clubs and
care professionals and supported by regional services, including church/school groups). Technology-based solutions, designed in
schools and town councils. The package we propose will be collaboration with children, could also prove successful. A toolbox
sensitive to local cultural attitudes as well as to the age of the of best practice examples on how to improve asthma treatment is
child. The needs of young children and their families, and those needed whereby local respiratory experts could provide region-
of teenagers, are clearly very different.83 ally targeted input and examples before local rollout. An approach
The word ‘asthma’ carries a stigma in many countries around using role models or ‘Asthma Champions’ to destigmatise asthma
the world, such as some South American countries, resulting in could be particularly useful in many regions such as Africa, with
unwillingness to accept the diagnosis. In Nigeria, it is not only delivery targeted via channels such as social media, short media
a stigma: parents believe it is an infectious disease, so take their service (SMS) messages, radio, television or newspapers. We
child out of school when a diagnosis is made (personal commu- could identify, for example, high-profile sports personalities with
nications, GF and CC). Such misconceptions can also lead to asthma who would be very strong leaders of this programme.
misdiagnosis and treatment with antibiotics.69 Teachers there- Opinion-based publications proposing adaptation of international
fore need support and training in asthma within any educational treatment guidelines to meet the local challenges could assist in
package. tailoring treatment to meet the needs of the local population.
Policy-makers must be provided with compelling evidence
to demonstrate the burden of the disease in both familial and
financial terms, to ensure that improvements reach beyond The Paediatric Asthma Project Plan
locally committed clinics.84 In LMICs, increased governmental It can take 17 years for new medical practices to be adopted.94
understanding of the long-term socioeconomic burden caused The transfer of scientific knowledge into day-to-day clinical
by failure to diagnose asthma and lack of effective treatment practice is complex and relies on a systems approach, knowledge
could result in changes in attitude about how future childhood transfer and ultimately behavioural change. We therefore need
asthma will be addressed.14 It is important to stress that huge a plan with a 10-year to 15-year vision for what the diagnosis
benefits can be obtained through simple, low-cost medicines and treatment of asthma in children should look like in future.
if distributed and used correctly. The basic bundle required is We are aware that to succeed, it will be essential that all levels of
salbutamol and corticosteroid inhalers, oral prednisolone and a government are enthused, engaged and involved. The plan must
plastic bottle converted into a spacer. LMIC governments do not include the educational needs of the children, their families and
need to invest huge sums of money to make a big difference to healthcare professionals; but also accessibility and affordability
asthma care. of the medicines, particularly in LMICs.
Lenney W, et al. Thorax 2018;73:662–669. doi:10.1136/thoraxjnl-2018-211626 665
 State of the art review

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Figure 1  This breaks down the comprehensive asthma training programme in Finland into five distinct segments. Following better understanding
of asthma knowledge, epidemiology and economics, there was recognition of a need for action, a better focus on patients and more effective use
of available resources. There then followed a focus on primary healthcare improvement, the development of tools to measure outcomes and the
devising of activities for diagnosis, treatment, better education and legislation.10  ICS, inhaled corticosteroid; GPs, general practitioners;  NGO, non-
governmental organisations.

Educational interventions targeted at patients have shown reached 36  000 healthcare workers, ranging from national
limited improvements in health outcomes. Any programme medical specialists to healthcare workers in the municipalities.
would need clear patient-related outcome measures.95 Initiatives In addition, the commitment of both political and regulatory
within the school setting may afford opportunities for the educa- authorities was central to the sustainability of the initiative.
tion of children with and without asthma, together with teachers Different plans will be needed for different regions. Clear defi-
and other staff members.90 96 nitions for how to measure successful implementation of educa-
We need to improve adherence to treatment and increase tional activities will need to be developed.98
correct inhaler use. This can build on the US schools initiative. We will develop comprehensive training templates from which
Health education needs to be strengthened through school-cen- countries and/or regions can select those most applicable to their
tred asthma programmes, but also within the community to locality to develop individualised training programmes ensuring
educate all local children about the management of this common continuous medical education of healthcare professionals. The
chronic disease. In addition, healthcare personnel need to be establishment of clinical educational hubs will enable healthcare
aware of the barriers to adherence at follow-up visits.97 professionals to observe and participate in learning within a clin-
We will learn from the initiatives and experiences of countries ical setting. Teamwork and communication skills are important
where successes have already been achieved and aim to iden- components. In many countries, trained nurses or other health-
tify their critical success factors, including those in infectious care personnel have been involved in asthma management in the
diseases such as tuberculosis and HIV. primary care setting. They are frequently supported by a lead
A 10-year National Asthma Programme was undertaken primary care practitioner, often with a specialist interest, but
in Finland between 1994 and 2004 to improve asthma care. the establishment of a team approach has been central to their
The programme’s success was achieved through earlier diag- success.
nosis, guided self-management, reduction of tobacco smoke Educational interventions often fail by not clarifying the
and better patient education.10 The key features are described learning context. Learning theorists99 100 suggest that adults learn
in figure 1.10 22 Central to their plan was the identification of best when the topic is immediately relevant to them—through
primary care physicians as the key facilitators with the need experience, and when the learning is problem-centred. Central
for standardised education across the country. The programme to success is an awareness that the knowledge must be turned
666 Lenney W, et al. Thorax 2018;73:662–669. doi:10.1136/thoraxjnl-2018-211626
 State of the art review

Box 2 Guskey’s five steps of professional Box 3 Paediatric Asthma Project Plan—questions to

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development101 be addressed

1. Participants’ reactions: to measure initial satisfaction with ►► Can specific biomarkers identify children most at risk and in
the process need of specific treatment strategies?
2. Participants’ learning: to evaluate new skills and knowledge ►► How best can we address poor treatment adherence?
3. Organisation support and change: the organisation’s ►► Can guidelines be simplified for practical use in the primary
advocacy, support and so on are assessed care setting?
4. Participant use of new knowledge and skills: degree and ►► What community strategies need addressing at a global
quality of implementation are measured level?
5. Student learning outcomes: assess student progress ►► What are the specific needs for low and middle-income
countries?
►► Do we really understand the disease burden at a global
level?
into a change in clinical practice. We will apply Guskey’s five ►► Can we promote the global re-establishment of an asthma
steps of professional development to encourage this (box 2).101 drug facility to enable widely accessible and affordable high-
We will also collaborate with international education groups quality asthma medications?
to improve global training and education using a face-to-face
‘Teach the Teacher’ programme in various parts of the world.
This would be a three-stage process drawing on the experience considering the child’s ability to take medications and determine
of successful programmes in other fields. The strategy will be: (1) their optimal inhaler technique. By simplifying and standardising
establish an expert faculty with experienced teachers of primary these, it might be possible to achieve better outcomes. Can we
care; (2) invite countries to participate with a group of ‘master give clearer advice about step-down therapy? There are huge
teachers’ providing the opportunity to learn about design and disparities in global views on many of these topics, leading to
implement an educational programme in their country and (3) confusion and an inability to compare outcomes from different
roll out the educational programme in their respective countries. world regions.

Web-based education; e-learning Summary and conclusions

The development of web-based programmes and the use of This overview is a global appeal to strengthen the diagnosis and
mobile telephone technology will be considered as a means of management of childhood asthma. We have an opportunity to
delivering asthma education training programmes. These could examine why we are failing to progress satisfactorily in many
be aimed at children, their families and/or healthcare profes- parts of the world. This impacts on patients’ health as young
sionals. Case-based learning can be incorporated allowing easier children and also as they become adults and indeed throughout
access and convenience for busy healthcare personnel. In addi- their adult life. We have failed to work well together on a
tion, careful observation of emerging technology may provide global scale and have failed to recognise that the umbrella term
additional strategies to address some problems currently associ- ‘asthma’ is unhelpful and probably should be abandoned or
ated with the delivery of effective education. only used to describe a clinical symptom complex. Guidelines
have been developed, but have become increasingly long and
Consensus regarding treatment, identification of research complex. They are poorly implemented by healthcare profes-
needs and advocacy sionals and have made little impact on health outcomes in chil-
Without the institution of some of the above measures, the appli- dren.63 64 Our plan, though ambitious, does not involve the use
cation of isolated initiatives will have minimal impact. There is of new expensive medicines, but builds on the knowledge and
also a need to act politically to facilitate change. Working with experience from previous educational work.101 If we implement
the relevant regulatory bodies to promote accurate diagnosis, the knowledge we have today and produce an effective training
training and patient support is essential for success. We will and education plan, we believe we will succeed. Incorporated
develop these core values and plans over the coming months, into that plan, we will attempt to provide practical solutions to
with a planned rollout in late 2018. the questions we have raised in box 3. We will do this through
The wider context of asthma treatment will be scrutinised. consultations at a global level over the coming months.
There have been many controversies and disagreements over the
years. Should SABA-only treatment be the appropriate initial Author affiliations
1
therapeutic approach in school-age asthma? Some guidelines Department of Child Health, Keele University, Stoke-on-Trent, UK
2
Department of Child Health, Royal Stoke University Hospital (RSUH), Stoke-on-Trent,
suggest a trial of ICS treatment in all probable patients with UK
asthma, but then stopped in those who show no benefit.102 3
Global Respiratory Franchise, GlaxoSmithKline, Brentford, London, UK
What is the appropriate ICS starting dose and when do we 4
Paediatrics, Imperial College London, London, UK
5
use non-ICS-containing treatments? Which patients should be Paediatrics, National Heart and Lung Institute, London, UK
6
Paediatrics, Royal Brompton & Harefield NHS Foundation Trust, London, UK
considered suitable for these approaches? A more pragmatic 7
Sydney Medical School, Discipline of Child and Adolescent Health, University of
approach may be needed for those who exhibit seasonal asthma. Sydney, Sydney, New South Wales, Australia
Clear definitions will be needed to assess when a child is eligible 8
Department of Respiratory Medicine, The Children’s Hospital at Westmead, Sydney,
for step-up treatment. Differences in clinical views are still New South Wales, Australia
9
common, compounded by lack of clinical trials in children. The Asthma UK Centre for Applied Research (AUKCAR), University of Edinburgh,
Edinburgh, UK
presentation and management of asthma differ widely according 10
Gransdalen Legesenter, Oslo, Norway
to world region and to the patient’s age; therefore, consider- 11
Pediatric Research Unit, Kolding Hospital, University of Southern Denmark, Kolding,
ation is needed to involve parents in dosing strategies and in Denmark

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12
Pediatric Asthma Research Program, Section of Pediatric Pulmonary Medicine, 13 Carroll WD, Wildhaber J, Brand PL. Parent misperception of control in childhood/

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Department of Pediatrics, University of Colorado School of Medicine, Aurora, 14 Global Asthma Network. The global asthma report. 2014 http://www.​
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Patient consent  Not required. 28 van Aalderen WM. Childhood asthma: diagnosis and treatment. Scientifica
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Provenance and peer review  Not commissioned; externally peer reviewed.
29 Jat KR, Kabra SK. Wheezing in children with viral infection & its long-term effects.
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Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which 30 Paton J, Bindels P, McMurray A, et al. A young child with a history of wheeze. NPJ
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