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AI-Generated response:

When should a child with asthma be referred to Pulmonology?

Answer generated on June 4, 2024

The AI-generated responses are for illustration purposes only and should not be used for medical purposes.

A child with asthma should be referred to Pulmonology under several circumstances including severe or difficult-to-control asthma, requirement of step 4 or higher drug therapy, or if specialized treatments like immunotherapy or monoclonal antibodies are considered.[1-3]

  • Refer if the child is receiving step 4 or higher drug therapy, or if younger than 4 years and receiving step 3 therapy.[1-2]

  • Refer if the child has required more than two courses of oral steroids in the past year or has been hospitalized for asthma in the past year.[1]

  • Refer if the diagnosis is uncertain, symptoms are atypical, or there are comorbid conditions complicating asthma management.[1]

  • Consider referral if the child might benefit from allergen immunotherapy or monoclonal antibody treatment.[1-2]

  • Refer if there are issues with asthma control despite adherence to prescribed therapy, especially in cases considering biologic treatments.[2-3]

Additional info

Referral to a pulmonologist or asthma specialist is crucial for optimizing asthma management in children who show signs of severe or uncontrolled asthma despite standard treatment efforts. This includes children who do not respond adequately to the usual stepwise approach recommended in asthma guidelines, those who experience frequent exacerbations, or those who require higher levels of care such as step 4 or 5 treatments. Early referral can also be important for children under 4 years old requiring step 3 treatments, as their condition might need more specialized management strategies.[1-2] Additionally, considering the complexity of asthma, especially with comorbid conditions or atypical symptoms, specialist involvement ensures a comprehensive approach to diagnosis and management, potentially including advanced therapies like biologics.[1-3] This approach aligns with expert recommendations to optimize care and potentially improve outcomes in pediatric asthma management.[3]

References

Reference 1

1.

Elsevier ClinicalKey Clinical Overview

Treatment Refer the following to an asthma specialist (usually a pulmonologist or an allergist): Patient receiving step 4 or higher drug therapy Patient younger than 4 years receiving step 3 drug therapy Patient possibly requiring immunotherapy or monoclonal antibody treatment Patient who has required more than 2 oral steroids in past year Patient who has required hospitalization for asthma in past year Patient in whom diagnosis is uncertain, whose symptoms are atypical, with other conditions that complicate asthma, or for whom additional testing is indicated Patient who requires additional education or has issues with adherence or allergen avoidance History of life-threatening asthma exacerbation Refer to an allergist for allergy desensitization treatment

Treatment Other alternatives include daily medium-dose inhaled corticosteroid plus leukotriene receptor antagonist tiotropium Consider adjunct treatment with subcutaneous immunotherapy Children aged 12 years and older Daily medium-dose inhaled corticosteroid plus formoterol in a single inhaler, as both maintenance therapy and reliever as needed to alleviate symptoms (preferred treatment for EPR-4 and GINA) Daily medium- or high-dose inhaled corticosteroid plus formoterol as maintenance therapy with as-needed short-acting β₂-agonist to alleviate symptoms (alternative treatment for GINA) Other alternatives include medium- or high-dose inhaled corticosteroid plus add on long-acting muscarinic antagonist leukotriene receptor antagonist theophylline (with Consider adjunct treatment with subcutaneous immunotherapy Step 5 (severe persistent asthma) GINA recommendations for children and adolescents aged 6 years and older with persistent symptoms or exacerbations despite good adherence to step 4 treatment (GINA does not make recommendations for this step for children younger than 5) Referral to an asthma specialist if available As-needed inhaled short-acting β₂-agonist to alleviate symptoms Daily medium- or high-dose inhaled corticosteroid plus inhaled long-acting β₂-agonist Daily medium- to high-dose corticosteroid plus inhaled long-acting β₂-agonist plus tiotropium bromide Refer for assessment of asthma phenotype (for type 2 airway inflammation) to guide add-on therapy for patients aged 6 years and older who required step 5 treatment Guidelines have been developed to aid evaluation and management of difficult to treat and severe asthma Type 2 airway inflammation is defined by the presence of 1 or more of the following: Blood eosinophil count 150/μL or greater FeNO (fraction of exhaled nitric oxide) 20 ppb or greater

Reference 2

2.

Liu, Andrew H., Bacharier, Leonard B., Fitzpatrick, Anne M., Sicherer, Scott H. (2025). In Nelson Textbook of Pediatrics (pp. 1385). DOI: 10.1016/B978-0-323-88305-4.00185-1

Referral to an asthma specialist for consultation or co-management is recommended if there are difficulties in achieving or maintaining good asthma control. For children ≤4 years, referral is recommended if the patient requires at least Treatment Step 3 care, and should be considered if the patient requires Treatment Step 2 care. For children ≥5 years, consultation with a specialist is recommended if the patient requires Treatment Step 4 care or higher, and should be considered if Treatment Step 3 is required. Referral is also recommended if allergen immunotherapy (AIT) or biologic therapy is being considered.

Reference 3

3.

Pijnenburg MW, Rubak S, Skjerven HO, et al. BMC Pediatrics. 2024;24(1):218. doi:10.1186/s12887-024-04707-0.

Publish date: March 3, 2024.

Severe asthma in children carries an unacceptable treatment burden, yet its rarity means clinical experience in treating it is limited, even among specialists. Practical guidance is needed to support clinical decision-making to optimize treatment for children with this condition.This modified Delphi convened 16 paediatric pulmonologists and allergologists from northern Europe, all experienced in treating children with severe asthma. Informed by interviews with stakeholders involved in the care of children with severe asthma (including paediatricians, nurses and carers), and an analysis of European guidelines, the experts built a consensus focused on the gaps in existing guidance. Explored were considerations for optimizing care for patients needing biologic treatment, and for selecting home or hospital delivery of biologics. This consensus is aimed at... (truncated preview)

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