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Narrative Review
Long-term management of asthma in First Nations
and Inuit children: A knowledge translation tool
based on Canadian paediatric asthma guidelines,
intended for use by front-line health care
professionals working in isolated communities
Tom Kovesi MD1, Brenda Louise Giles MD2, Hans Pasterkamp MD2
T Kovesi, BL Giles, H Pasterkamp. Long-term management of
asthma in First Nations and Inuit children: A knowledge translation
tool based on Canadian paediatric asthma guidelines, intended for
use by front-line health care professionals working in isolated
communities. Paediatr Child Health 2012;17(7):e46-e64.
Asthma is a serious health problem for First Nations and Inuit children. In children younger than one year of age, asthma needs to be
distinguished from viral bronchiolitis, which is unusually common in
Canadian Aboriginal children. In children younger than six years of
age, the diagnosis depends on the presence of typical symptoms, the
absence of atypical features and the documentation of response to
therapy – particularly a rapid, transient response to bronchodilators. In
older children, the presence of reversible airway obstruction should be
determined using spirometry whenever feasible to confirm the diagnosis. Environmental triggers should be evaluated and corrected whenever
possible. Regular use of inhaled steroids is the most important measure
for maintaining good asthma control in children with asthma. Clients
and their families should receive asthma education. Control should be
regularly reassessed at follow-up visits in health centres, with therapy
adjusted to the lowest level capable of maintaining good control.
Key Words: Asthma; Bronchiolitis; Bronchodilator agents; Glucocorticoids;
Indians, North American; Inuits
sthma is the most common chronic disease in Canadian children (1,2). Asthma can be defined as an airway obstruction
that varies over time, which can be exacerbated by triggers, such as
irritants and allergens, and improved by asthma medications. The
symptoms of asthma are caused by bronchial inflammation that
leads to some combination of coughing and wheezing, and respiratory distress, chest tightness or dyspnea (3).
The present document is a knowledge translation tool based on
recent Canadian paediatric asthma consensus guideline summaries, with special consideration of the circumstances relevant to the
health care of First Nations and Inuit children and youth living
in communities distant from major medical centres. It is intended
for use by health care professionals, including nurses, nurse practitioners and physicians who treat these populations. The present
document was not developed using the ADAPTE guidelines adaptation methodology endorsed by the Canadian Thoracic Society to
formally adapt an existing guideline(s) (4). The documents used
to describe asthma diagnosis and management were primarily the
Canadian Thoracic Society Asthma Management Continuum –
2010 Consensus Summary for children six years of age and over and
adults (3), and the 2012 update (5), the Canadian Pediatric Asthma
Consensus guidelines, 2003 (updated to December, 2004) (6) and
La prise en charge à long terme de l’asthme chez les
enfants inuits et des Premières nations : un outil de
transfert du savoir fondé sur les lignes directrices
canadiennes pour l’asthme pédiatrique, conçu pour
être utilisé par les professionnels de la santé de
première ligne qui travaillent dans des
communautés isolées
L’asthme est un grave problème de santé pour les enfants inuits et
des Premières nations. Chez les enfants de moins d’un an, il faut
distinguer l’asthme de la bronchiolite virale, anormalement fréquente
chez les enfants autochtones du Canada. Chez les enfants de moins de
six ans, le diagnostic dépend de la présence de symptômes classiques,
de l’absence de caractéristiques atypiques et de la consignation de la
réponse au traitement, notamment la réponse rapide et transitoire aux
bronchodilatateurs. Chez les enfants plus âgés, il faut, dans la mesure
du possible, déterminer la présence d’une obstruction réversible
des voies aériennes par spirométrie afin de confirmer le diagnostic
ainsi qu’évaluer et corriger les déclencheurs environnementaux.
L’utilisation régulière de corticoïdes en aérosol est la principale
mesure à prendre pour maintenir un bon contrôle de l’asthme chez les
enfants asthmatiques. Les clients et leur famille devraient recevoir une
formation sur l’asthme. Il faut réévaluer régulièrement le contrôle aux
visites de suivi dans des centres de santé et rajuster le traitement à la
dose la plus basse possible pour le maintien de ce contrôle.
the case-based summary of the management of Canadian preschoolers with asthma entitled ‘Achieving control of asthma in preschoolers’ (1). A focused literature search on asthma in First Nations
and Inuit individuals and a manual search of relevant materials was conducted. (Two authors conducted structured literature
searches for asthma in North American Aboriginal children and
adults using PubMed Medline. One search [TK] used the search
terms: [“Indian”, “North American” OR “Inuits”] AND “Asthma”;
76 articles were found, of which 23 were included in the present
document, and an additional nine abstracts were reviewed and were
not included because of their limited relevance to the subject matter. The other search [HP] used the terms [“American Indian/Alaska
Natives” OR “Canadian Aboriginal” OR “North American” AND
“Indigenous”] AND “Asthma”. An additional 52 articles were found,
of which six were included in the present document.) The present
document was developed as the result of a consultation process on
asthma held in Canada’s Aboriginal children following an Asthma
Expert Advisory Forum in Winnipeg (Manitoba), December 8 to 9,
2009, which was sponsored by the Chronic Disease Prevention Unit
of the First Nations and Inuit Health Branch, Health Canada.
The information in the present document, based on the best
available asthma research, should be used to help enhance your
Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario; 2Winnipeg Children’s Hospital, University of Manitoba, Winnipeg, Manitoba
Correspondence: Dr Thomas Kovesi, Children’s Hospital of Eastern Ontario and the University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 8L1.
Telephone 613-737-7600 ext 2868, fax 613-738-4886, e-mail
©2012 Pulsus Group Inc. All rights reserved
Paediatr Child Health Vol 17 No 7 August/September 2012
Asthma in First Nations and Inuit children knowledge translation tool
knowledge of paediatric asthma in this population. This information should be used in conjunction with the advice and recommendations of your medical team. The present article does not
contain information on the management of acute asthma exacerbations – acute asthma attacks should be managed in accordance
with your health centre’s protocols. Please note that international
guidelines on asthma are available at the Global Initiative for
Asthma website <>.
Asthma in First Nations and
Inuit children
On average, approximately one Canadian child in 10 has asthma
(1). Earlier studies suggested that prevalence rates in First Nations
and Inuit children were lower (7,8); however, more recent data,
including data from the First Nations Regional Health Survey, suggest that the prevalence rate is similar to other Canadian children,
at approximately 12% (9-11). Allergies may be less common in
Aboriginal children, although the data on this are also conflicting
(2,8,12,13). However, asthma in this population can be very serious
(14), and there is evidence that because of reduced access to asthma
specialists, the level of asthma control in this population may be less
than in urban populations, causing increased numbers of emergency
department and other unscheduled visits for asthma exacerbations
(15), which may be associated with the reduced use of anti-inflammatory therapies (16-18). It is possible that asthma is being underdiagnosed in Aboriginal peoples who live in isolated areas (19).
In contrast to asthma, rates of respiratory infections in infancy,
including bronchiolitis, pneumonia and tuberculosis (20), are much
higher in Aboriginal infants and children than in other Canadian
infants and children, and this is particularly the case for Inuit
infants. For example, admission rates in southern Canada for respiratory syncytial virus (RSV) bronchiolitis are approximately one
per 100 babies born each year, whereas reported rates of hospitalization for RSV for Inuit babies born in the Qikiqtani (21) or
Kitikmeot (22) regions of Nunavut, Nunavik (23), as well as
Alaskan Aboriginal children (24) are ≥40 per 100. These rates vary
widely from year to year, and between various First Nations communities and communities in Inuit Nunangat. The high rates of
bronchiolitis may make it difficult to distinguish asthma from respiratory infections in these populations (1,25-27).
While the reasons why allergies and asthma seem to be less common in Aboriginal children are not exactly known, one likely
explanation may be the ‘hygiene hypothesis’. The hygiene hypothesis suggests that children exposed to more microorganisms, typically in rural rather than urban settings, keep their developing
immune systems ‘busy’, steering it away from the development of
immunoglobulin E and allergic diseases (9,28). There is evidence
that as Aboriginal people adopt a more urbanized lifestyle, rates of
allergies are increasing (29).
Special considerations – the indoor and outdoor environment
Many aspects of the outdoor and built environment may increase
the risk of respiratory disease in First Nations and Inuit children. It
is extremely important not to generalize: there are enormous differences in the indoor and outdoor environments among various
First Nations reserves and between reserves and Inuit Nunangat,
although there are also some common issues.
Some of the common issues relate to housing. Overcrowding
is common in most First Nations reserves and Inuit Nunangat.
Overcrowding increases the risk of respiratory infections, which
in turn are the most common causes of asthma attacks in people
with asthma. Inadequately constructed housing is another common
issue. Inadequate ventilation has been shown to increase the risk of
respiratory infections in First Nations and Inuit children (30,31).
Paediatr Child Health Vol 17 No 7 August/September 2012
Inadequate ventilation is common in houses in Nunavut (30), but
less information is available regarding how common reduced ventilation and other indoor air quality problems are in houses on First
Nations reserves and the rest of Inuit Nunangat. Lower household
income, houses in need of major repairs and older housing have been
associated with a higher risk of asthma in Aboriginal children (9).
Poorly maintained housing is also common. Studies have shown
that 29% of housing on Canadian First Nations reserves (32) and
32% of houses in Nunavut (33) are in need of major repair(s).
Poorly constructed or maintained housing can lead to loss of the
vapour barrier, which can lead to contamination of housing by mold
(34,35). Problems with mold are strongly associated with local
environmental conditions. Mold may be a particular problem in
reserves where houses are prone to flooding and/or were built in
damp, low-lying areas. Mold also appears to be a particular problem
in coastal British Columbia, where high outdoor humidity levels
promote mold growth (36). In contrast, mold appears to be uncommon in some other reserves, such as the Elsipogtog Reserve in New
Brunswick (37). One study found that mold is less common in
Nunavut, where indoor humidity levels are low and inhibit the
growth of mold (38). However, mold problems, based on self-report,
appear to be common in Inuit Nunangat, affecting 20.8% of households with children younger than 18 years of age overall, with the
highest reported rates occurring in Nunatsiavut, where a prevalence
of 33.6% was reported (39). Mold contamination is generally related
to poor maintenance and disruption of the vapour barrier, which
allows indoor dampness to develop, thus providing good conditions
for mold growth. Indoor mold can cause allergies and asthma in
children allergic to mold (34,40). Mold also increases the risk of
wheezing in young children (41), possibly due to the release of various chemicals by an as yet incompletely understood mechanism.
Outdoor molds can also cause allergies and asthma in children allergic to these molds. Alternaria grows in rotting leaves and can cause
severe asthma attacks, especially in the fall, and Aspergillus and
other molds can also cause allergies (42). Outdoor molds can also
cause lung infections in certain parts of Canada. Blastomycosis
occurs in rural central Canada (areas of northwestern Ontario/eastern prairies) (43), histoplasmosis occurs particularly along the St
Lawrence and Ottawa Rivers (44), and Cryptococcus gattii infections
can occur on Vancouver Island (British Columbia) (45). These
pulmonary infections will not be discussed further.
Another common concern is the use of, and exposure to, smoke
from commercial (ie, nontraditional) tobacco. Rates of first-hand
(ie, cigarette smoking by children and youth), second-hand (ie,
exposure to environmental tobacco smoke) and third-hand (ie,
exposure to the gases and small particles from smoking that are
deposited on surfaces and in clothing) smoking are markedly higher
for First Nations and Inuit children than other Canadian children
(46,47). Smoking may be initiated before adolescence in this population (48). Commercial tobacco (ie, cigarette smoke) increases
the risk of developing bronchiolitis, pneumonia and asthma, and
worsens asthma in children who already have this condition (7,38).
With traditional use of sacred tobacco, the inhalation of smoke is
discouraged (49), but second- and third-hand exposure should still
be considered as risks to the lung health of children.
Other indoor air contaminants tend to be specific to particular
parts of the country. In areas where wood-burning stoves are used (26),
wood stove combustion products have been associated with increased
cough and wheeze in children (50-52). It is important that wood stoves
are properly sealed and maintained. Houses on many First Nations
reserves do not have fresh running water. Lack of potable water (26)
has been associated with an increased risk of respiratory infections in
children, probably because hand washing occurs less often when clean
water must be transported manually (53). An increased frequency of
Kovesi et al
respiratory viral infections increases the frequency of asthma exacerbations in children and bronchiolitis in infants. In some communities,
pets such as dogs and cats, can cause allergies, as can indoor dust mites
(34). Inuit and most First Nations families do not keep dogs indoors.
Research observations in Nunavut noted that houses tend to not be
carpeted and indoor clutter levels and humidity levels are low, all of
which discourage the growth of dust mites (38), which has also been
observed on the Elsipogtog Reserve (37). Some houses probably have
significant dust mite concentrations, particularly if carpets are present,
and this can increase the risk of allergies and asthma (34). In Inuit
Nunangat, soapstone carving can increase indoor stone dusts.
Community programs are in place to strongly discourage carvers from
working in their homes. Some First Nations and Inuit adults may
choose to perform small engine repair and maintenance of snowmobiles and all-terrain vehicles indoors, which can release volatile
organic compounds that can worsen asthma. Curing animal hides may
increase various indoor contaminants and indoor humidity levels. Gas
space heaters and kerosene heaters are associated with a higher risk of
cough and wheeze in infants (54).
In some communities, outdoor air pollution may also be a
concern. Forest fires can cause serious asthma exacerbations and
worsen asthma symptoms and lung function (55,56). While many
communities are concerned about road dust in the summer, the
exact effects of this on lung function are not well understood (57).
Similarly, in some communities, garbage is burned upwind of the
community. The precise effects of this are currently unclear.
Special considerations – adherence
Poor adherence to regular administration of maintenance asthma
medications is common and is related to numerous factors (58,59).
Some traditional cultures tend to view medication as something
given when someone is sick, rather than to prevent illness. In
addition, one study suggested that the Navajo may view asthma
in a child as “a series of distinct, transient episodes” rather than a
chronic disease with recurrent symptom flares, and that reduced
adherence may be related to concerns about side effects (60).
Reduced adherence is often more common among families
facing social challenges. Families that are disorganized, living in
poverty or where there are issues with depression may have difficulty giving medications regularly (61). There may be unrealistic
expectations that an immature child or youth can be expected to
remember to take preventive therapy regularly.
Reasons for reduced adherence should be explored sensitively,
with the intent of problem solving and searching for ways to
overcome the barriers that have been identified. Many Canadian
Aboriginal cultures see health holistically; therefore, suggesting
that asthma therapy can help restore balance to the body and
reduce exaggerated responses to irritants and other triggers may be
helpful. It may be helpful to remind patients and families that better asthma control will improve exercise tolerance and the ability
to participate in sports and outdoor activities including traditional
activities (62). In addition, it is important to provide education
that asthma is a chronic disease due to chronic airway inflammation, which is why chronic anti-inflammatory therapy is needed to
prevent attacks. Health care providers should check whether the
child is being expected to take medications on his or her own, or
whether treatment is being supervised by a caregiver.
Diagnosis and Patterns of
Asthma in Children
Asthma and bronchiolitis
In children younger than six years of age, diagnosing asthma
requires a clinical picture consistent with asthma and the exclusion of other conditions that can resemble asthma (1). Diagnosing
asthma in young Aboriginal children is made more difficult by the
frequency of respiratory infections that can also cause wheezing
(7). Most commonly, in children younger than one year of age, the
first episode of wheezing associated with an acute viral respiratory
tract infection is considered to be due to bronchiolitis, with RSV
being the most common virus (63). Other viruses that commonly
cause bronchiolitis include rhinovirus, influenza virus, parainfluenza virus and adenovirus. Approximately one-half of the children
in southern Canada who are hospitalized with bronchiolitis will
eventually develop asthma (63). Some Aboriginal children with
bronchiolitis will also later develop asthma, although the proportion is probably lower. Studies of Inuit children in Nunavut (21),
Nunavik (23), and Greenland (64), as well as Alaska Native (65)
children have observed that it is not unusual for children in these
regions to experience several episodes of bronchiolitis in the first
or second year of life. After the first year of life, bronchiolitis
becomes less common (23) and wheezing is more likely to be due
to asthma (13). Respiratory specialists tend to frown on the term
‘reactive airways disease’, which simply implies that someone’s
airways are abnormally reactive – constricting in response to a
noxious stimulus or dilating in response to a bronchodilator.
Airway reactivity is due to airway inflammation; however, airway
reactivity can be caused by asthma, airway infection (eg, bronchiolitis or bronchiectasis) or aspiration of hydrochloric acid (from
gastroesophageal reflux). Thus, reactive airways disease is really a
symptom, rather than a diagnosis (66). If you suspect a child has
asthma, you should use this term when talking to families and in
your documentation (67).
Intermittent asthma
In young children, approximately 90% of asthma exacerbations are
precipitated by viral upper respiratory tract infections (ie, colds).
Typically, a child will start with a runny nose, cough, and fever,
and then develop wheezing, shortness of breath and/or severe cough
approximately two to three days later. In most of these children,
there are no respiratory symptoms between colds. This pattern
of asthma is known as intermittent asthma. In many children,
symptoms disappear as the child ages, although families should
be warned that asthma may resurface in adulthood. This pattern
is particularly common in young boys and children whose mother
smoked cigarettes during pregnancy. Intermittent asthma can
either be mild – with mild exacerbations associated with colds,
or severe – with recurrent exacerbations leading to health centre
visits and/or hospitalizations. Because asthma is usually triggered
by viral infections that often also cause fevers, and because asthma
causes mucous plugging of the airways that can cause crackles
and changes resembling ‘pneumonia’ on chest x-ray, asthma is
the most commonly unrecognized cause of ‘recurrent pneumonia’
and ‘recurrent bronchitis’ in children. In these children, treating
asthma will usually solve the problem of ‘recurrent pneumonias’
(1). A key part of diagnosing asthma, particularly in young children, is confirming response to treatment. The easiest way to do
this is by assessing the response to a bronchodilator such as salbutamol. Salbutamol starts working in 5 min, maintains its peak
effect for approximately 30 min, and wears off in 2 h to 6 h. Thus,
in a child with asthma, one should see a significant, albeit transient, effect within this time frame. It is, therefore, essential to note
whether objective signs, such as respiratory rate, breath sounds,
air entry or wheezing improve, within approximately 15 min.
Make sure you document what you find – either the presence of a
significant response or the lack of one. You can also ask whether
the child has a significant but transient response to salbutamol at
home. A significant response strongly supports the diagnosis of
asthma. A few children with asthma do not respond acutely to
Paediatr Child Health Vol 17 No 7 August/September 2012
Asthma in First Nations and Inuit children knowledge translation tool
bronchodilators but will respond after anti-inflammatory therapy,
either over a couple days with an oral steroid, or over a couple of
weeks with an inhaled steroid (3).
Persistent asthma
The other common pattern of asthma in children is persistent
asthma. Children with persistent asthma typically experience exacerbations triggered by colds and/or allergens, and have symptoms
between exacerbations. This can be determined by asking whether
the child has night-time cough, and/or cough, wheeze and/or dyspnea
with exercise, even when they are ‘well’. Children with persistent
asthma often have evidence of allergies, such as eczema during
infancy or hay fever, and often have a family history that is positive
for asthma, eczema, allergies and/or hay fever. Children with persistent asthma are significantly more likely to continue experiencing
asthma symptoms throughout adolescence and adulthood (1).
Differential diagnosis
The most common mimic of asthma in infants and very young
Aboriginal children is noisy breathing due to retained oropharyngeal secretions that the child has not yet learned to swallow. As air
travels back and forth over and through the secretions, it leads to
rattly breathing that can sometimes lead to palpable vibrations over
the chest. Many parents and health care professionals mistake noisy
breathing for wheezing, which is not a rattly but a whistling sound
(68). This is complicated by the fact that the Aboriginal language
used in your community may not have a word for wheezing (69).
Rattly breathing is more prominent during colds. If you are ever
unsure whether a noise is a wheeze, administer a bronchodilator
and check whether the sound disappears after the treatment.
Many other conditions can cause recurrent wheezing in children. Gastroesophageal reflux can potentially cause cough and
wheezing, through several incompletely understood mechanisms,
and, less often, can cause aspiration, particularly in infants or
children with neurodevelopmental delay (3). In children who
persistently have a wheeze localized to one part of the lung with
persistent infiltrates on chest x-ray in the same area, a foreign body
should be suspected, particularly if the parent recalls the child
choking on something, and bronchoscopy should be arranged (1).
Some Aboriginal children experience recurrent pneumonia due to
abnormal swallowing and aspiration, and some of these children will
have a history of choking during feeding (70). Alaska Native children have been reported to have a chronic wet cough (71) due to
persistent bacterial infection in the airways. This may improve with
a three- to six- week course of antibiotics (72). It is unclear how
often this occurs in children in Inuit Nunangat. In children with a
persistently abnormal x-ray, chronic cough and sputum production,
bronchiectasis should be considered (73,74). Bronchiectasis is more
common in Aboriginal children than in other Canadian children
(75), and usually occurs after severe pneumonia occurring early in
life – particularly adenovirus (76) or RSV pneumonia (74).
Diagnostic tests
A diagnosis of asthma can often be made with a directed history
and physical examination. However, in Aboriginal children who
have a history of recurrent pneumonia or who have atypical signs
and symptoms (eg, chronic productive cough, persistent localized
crackles or clubbing), a chest x-ray should be performed to rule out
other conditions such as chronic atelectasis or bronchiectasis (1).
If there are any doubts about the diagnosis, referral to a paediatric
asthma expert should be considered for further evaluation,
obtaining more sophisticated pulmonary function testing and/or a
computed tomography scan of the chest.
If pulmonary function testing (ie, spirometry) is available, it
should be used to confirm the diagnosis. Children six years of age and
Paediatr Child Health Vol 17 No 7 August/September 2012
older should be able to cooperate with spirometry. A forced expiratory
volume in 1 s (FEV1) less than 80% of predicted, with an FEV1/forced
vital capacity ratio below 0.8, suggests the presence of obstructive lung
disease. These findings along with an improvement in FEV1 of 12% or
more following bronchodilator strongly supports a diagnosis of asthma
(3). It is important that spirometry be performed in accordance with
recommended standards, and that any recommended maintenance
and calibration schedules for the spirometer be adhered to (77).
When spirometry is not available, peak flow measurement can also be
used to support the diagnosis. Many tools with normal values for peak
flow for Caucasian children are available online and for handheld
devices, including the United Kingdom’s Midlands Asthma and
Allergy Research Association tool <
asthma_PEFCH.htm>. An increase in peak flow of 20%, particularly
in the presence of a low initial peak flow value, supports the diagnosis
of asthma (78). The Ontario College of Physicians and Surgeons has
released guidelines for cleaning office peak flow meters. They recommend using disposable mouthpieces and disposable filters, and recommend cleaning the entire instrument in hot water and mild detergent
or disinfectant, then immersing it in a 1:50 dilution of household
bleach for 20 min, before finally rinsing it well with tap water.
Disposable mouthpieces and filters must be used with office spirometers (79). The device’s instruction manual will indicate whether further cleaning is required.
Research suggests that current ‘norms’ for pulmonary functions
developed in Caucasians many not apply to Inuit and northern
First Nations children (80,81). Inuit children tend to have shorter
legs and relatively longer torsos for a given height (82). Spirometry
results in Inuit patients may therefore be 10% greater than
expected for a given height (80,83,84). It may be more accurate to
enter two times the sitting height (distance from the top of the
chair to the top of the head) into the spirometer as the ‘height’
rather than standing height. Such corrections may not be needed
for other North American Aboriginal children because, for
example, American data suggests that Caucasian norms are
adequate for Aboriginal children from the Navajo Nation (85)
and Aboriginal adults in several American states (86).
Spirometry and peak flow measurement are not currently available
in all First Nations and Inuit primary care facilities, and obtaining
spirometry may require referral to a larger centre. In children in whom
the diagnosis of asthma is suspected but pulmonary function tests are
repeatedly normal, a methacholine challenge test can be performed to
demonstrate the presence of increased bronchial reactivity, but this
test is generally performed only in specialized centres.
In children in whom allergies are suspected, allergy testing can
help you advise what triggers the child should avoid. Allergy testing may be especially important for Aboriginal children whose
homes appear to be infested with mold (34). Some children with
asthma have food allergies. These can be life-threatening, and
when food allergies (such as peanut, nut, fish, whale meat, seal
meat or caribou) (87) are suspected, allergy testing should be performed for confirmation. Children with anaphylactic reactions to
food must have an epinephrine injector prescribed (88).
Environmental control
The first step in asthma management is the avoidance of triggers.
All children with asthma need to avoid exposure to cigarette
smoke. Family members should be advised to quit or instructed to
smoke entirely outdoors. Inuit families may consider the enclosed
porch that contains the furnace to be ‘outdoors’, but families
should be informed that smoking in the same room as the furnace
intake will result in recirculating the cigarette smoke inside the
home. Family members should be encouraged to smoke entirely
Kovesi et al
outdoors instead. It is preferable that children with asthma be
offered alternatives to attending sweet grass ceremonies and other
ceremonies that use tobacco, if possible. School-age children and
teens should be asked about first-hand smoking. They should be
counselled to never smoke and assisted with quitting if they are. In
houses heated by wood stoves, measures to minimize exposure to
wood smoke combustion products should be undertaken, such as
burning only dry wood, cleaning ashes from the stove regularly and
ensuring that there is a good seal on the stove door.
Other environmental measures may also be helpful. Improving
ventilation will reduce respiratory infections in children. This can
be performed by ensuring kitchen and bathroom fans are well
maintained and keeping them on, or asking the housing board (if
possible) to install a heat recovery ventilator (89). Reducing
indoor mold may reduce wheezing illnesses in young children and
in children with mold allergies. This can be accomplished by fixing any cracks in the exterior envelope of the house that allows
moisture to enter and mold to grow, and cleaning areas of mold in
the house (especially in bathrooms and around windows) using
baking soda. Keeping humidity levels inside the house below 50%
will discourage the growth of dust mites and mold (34).
Further environmental control measures will depend on what
the child is allergic to. More drastic measures should be reserved
for children with more severe allergies and/or asthma. For children
with mold allergy, mold remediation may require significant home
renovations (see above). For children allergic to plant pollens,
installing an air conditioner and using it while keeping doors and
windows closed during pollen season will reduce pollen exposure
(90). For children allergic to animals, the relevant pets should be
kept outside or given away, if possible. For children allergic to dust
mites, humidity levels should be kept below 50%. Impermeable
covers that encase the mattress and pillow should be recommended if they can be afforded, because beds are the major source
of dust mite exposure for children (78). Impermeable plastic covers
are effective and relatively inexpensive. If running water and laundry facilities are available, laundering bedding regularly in hot
water, and/or drying in a hot dryer is also helpful. Carpets and
excess clutter in the bedroom should be removed, if possible.
Children who have allergic rhinitis may experience troublesome
respiratory symptoms directly related to their rhinitis, including
cough and difficulty breathing because of blocked nasal passages. In
addition to allergen avoidance, treatment of their allergic rhinitis,
including nonsedating antihistamines and nasal steroids, are important for reducing respiratory symptoms (3). The effect of obesity on
asthma remains an area of active research. Obesity causes exertional
dyspnea; therefore, obesity management will reduce symptoms during exercise, as well as the risk of numerous chronic diseases, including diabetes, heart disease and obstructive sleep apnea (91,92).
There is some evidence that increased body mass index is associated
with a higher rate of asthma among Aboriginal North American
children and youth – particularly among young women (93).
Initiating therapy
A common question arising in health centres that treat First
Nations and Inuit children is well summarized by the quote below,
from a nurse practitioner who has worked in this type of setting:
Our major problem in the community is when starting to
treat a patient for asthma. We often see kids for cold or
bronchiolitis, where there is no significant response to
bronchodilator (usually Ventolin). When there is a response,
we treat them for two weeks with Ventolin q4hrs prn and
Flovent BID. We are uncomfortable to initiate longer treatment without doctor advice.
Simple colds (ie, viral upper respiratory tract infections not
complicated by wheezing or respiratory distress) can be managed
symptomatically, with fluids, antipyretics and perhaps nasal normal saline nose drops.
When a child younger than one year of age presents with a
first episode of wheezing associated with a viral infection, the
child should generally be diagnosed with bronchiolitis. Therapy
is mainly supportive, including nasal aspiration, antipyretics
and hydration. The role of bronchodilators is controversial, and
American guidelines do not recommend their routine use, because
they have not been shown to influence the length of stay in hospital. When used, these guidelines suggest they should be continued
only if there is a clear clinical response (94). Studies have shown
that approximately one-half of the infants with bronchiolitis will
have a short-term response to a beta2-agonist such as salbutamol,
and approximately 80% will respond to nebulized epinephrine
(95). If the child has an objective response (see above) and is ready
to return home, it would be reasonable to prescribe salbutamol
and a spacer device for use at home. If the bronchodilator has no
acute effect, there is no reason to prescribe salbutamol for use at
home, and the child should be treated symptomatically with fluids
and antipyretics, as well as with instructions to return if he or she
worsens. Inhaled and systemic steroids are not recommended (94).
It is not unusual for Inuit children to experience two or more
episodes of bronchiolitis in the first two years of life (65). After
one year of age, a bronchodilator, such as salbutamol, may be tried,
because it may be more likely to be effective in older patients.
Again, the child should be carefully evaluated for an objective
response, and this therapy should be discontinued if no response is
observed. Studies in non-Aboriginal populations have suggested
that up to one-half of the children hospitalized with bronchiolitis
will subsequently develop asthma (96,97), and recent data have
suggested that bronchiolitis due to rhinovirus is a greater risk factor for subsequent development of asthma than bronchiolitis due
to RSV (98). The risk of developing persistent asthma after bronchiolitis is related to personal and family history of atopy, and a
predictive index is available to help assess this (1).
In a child older than two years of age who presents with wheezing or who experiences recurrent (ie, three or more episodes)
wheezing associated with colds or other asthma triggers, the likeliest diagnosis is asthma, (although other conditions that can mimic
asthma should be excluded – see above). A trial with a beta2agonist bronchodilator should be given in the health centre – a
rapid response is extremely helpful in confirming the diagnosis of
asthma. In a child six years of age or older (if spirometry is available at your health centre) performing a pulmonary function test
before and after bronchodilator administration is recommended to
confirm the diagnosis. For a child who experiences recurrent but
mild and infrequent asthma episodes, simply prescribing salbutamol as needed is appropriate, and giving a short course of inhaled
steroid is neither useful nor effective. In a child with more severe
exacerbations (eg, needing transfer to a hospital or needing oral
steroids) or who has frequent symptoms between colds (eg, at
night or with exercise), low or moderate doses of inhaled steroids
should be prescribed, although the family should be instructed to
give the inhaled steroid regularly, for at least the rest of the season.
Most children will respond to regular therapy with a low or moderate dose of inhaled steroid (Table 1).
Another common question is whether asthma medications
such as bronchodilators should be prescribed for children with
pneumonia. The bacteria that cause lobar pneumonia, such as
Streptococcus pneumoniae, do not cause bronchospasm (99), and
children with bacterial pneumonia do not need asthma
Paediatr Child Health Vol 17 No 7 August/September 2012
Asthma in First Nations and Inuit children knowledge translation tool
Table 1
Starting doses of inhaled steroids for paediatric asthma
Delivery system
Minimum age licensed
for use in Canada
Low dose
Moderate dose
High dose
5 years
50 μg to 100 μg BID
150 μg to 200 μg BID*
>200 μg BID*
>400 μg BID
Dry powder inhaler (Turbuhaler†) 6 years
100 μg to 200 μg BID‡
200 μg TID to 400 μg BID
Wet nebulizer
3 months
250 μg BID
500 μg BID
1000 μg BID
6 years
100 μg to 200 μg once
400 μg once daily (or
200 μg BID)*,‡
>200 μg BID* (maximum
400 μg BID)*
1 year
50 μg to 100 μg BID
125 μg BID
250 μg BID† or more
4 years
50 μg to 100 μg BID
200 μg BID
Dry powder inhaler
250 μg BID† or more
Adapted from references 1 and 5.
doses are not approved for use in children in Canada;
for once daily dosing; however,
if asthma remains poorly controlled, then twice daily dosing may be more effective; §GlaxoSmtihKline, United Kingdom. BID Twice daily; HFA-MDI Hydrofluoroalkane
propellant metered-dose inhaler; TID Three times daily
medications. However, there are several caveats to this statement.
The first is that in children who do have asthma, most exacerbations are triggered by viral infections, and the mucous produced
during an asthma attack can cause atelectasis, which can mimic
pneumonia. In children with known asthma who have atelectasis,
treatment should be directed toward the asthma, rather than for
‘pneumonia’. The second caveat is that invasive pneumococcal
diseases do appear to be more common in both people with asthma
(100) and Aboriginal persons (101), so if you strongly suspect
pneumonia in a child with asthma, antibiotic therapy should be
initiated. Finally, there is evidence that Mycoplasma species can
both cause asthma exacerbations and may even initiate asthma
(102), so for the older child who has evidence of an asthma
exacerbation and interstitial pneumonia on chest x-ray, consideration may be given for prescribing both asthma therapy and a
macrolide antibiotic to treat a concurrent mycoplasma
Inhaled steroids for asthma
Except for children with very mild intermittent or persistent
asthma, regular treatment with inhaled steroids is the cornerstone
of medical therapy. Inhaled steroids are effective in the great
majority of children with asthma. Inhaled steroids take one to
six weeks to start working, so it is essential to counsel parents to
administer inhaled steroids during the entire season(s) the child
has asthma symptoms – not just during asthma flares. All inhaled
steroids appear to be equally effective. Fluticasone, budesonide and
beclomethasone-HFA are recommended to be given twice a day
to be effective. The lower doses of ciclesonide are effective when
administered once a day. Starting doses for inhaled steroids are
provided in Table 1. Most children will respond to regular therapy
with a low or moderate dose of inhaled steroid (Table 1). Once
good asthma control has been achieved, you can attempt to reduce
the dose of inhaled steroids by 25% to 50% at each follow-up visit.
Visits may be scheduled every two to three months to assess how
the child has coped with known triggers in the interim. If control
worsens after the dose has been reduced, the previous dose should
be resumed. Conversely, if control is maintained, the dose can be
reduced again, with this potentially continuing until the child
is off maintenance inhaled steroid therapy altogether. If at the
follow-up visit control remains inadequate, the dose should be
increased or a second ‘controller’ medication added (see below).
The most common reasons why treatment with inhaled steroids
fails are poor compliance, use of an inappropriate inhaler device
for the child’s age and poor inhaler technique. It is important
to carefully evaluate children for these problems when therapy
is unsuccessful (1). The 2010 Asthma Management Continuum
provides a graphic approach describing how to augment therapy
for children who are inadequately controlled despite regular
Paediatr Child Health Vol 17 No 7 August/September 2012
therapy with inhaled steroids <> (3).
During asthma flares, doubling the dose of inhaled steroid has
not been shown to be effective. For more severe exacerbations, the
best way to prevent the attack from further worsening is with oral
prednisone, 1 mg/kg/day, for five days (1). While quadrupling the
dose of inhaled steroid has been shown to have efficacy in adults
(103), it is not currently recommended for children; it may require
multiple inhaler actuations per day (unless the inhaler is exchanged
for another with a higher medication strength) and carries an
increased risk of steroid side effects in children (104). With effective asthma control, exacerbations should be infrequent.
Low or moderate doses of inhaled steroids rarely cause side
effects in children. Using a spacer device will usually prevent
thrush (ie, oropharyngeal candidiasis). Rinsing of the mouth is
suggested, although it is probably less important when a spacer
device is used. A single study suggested an increased risk of caries
in newly-erupted permanent molars (105). While this finding is
controversial, it is important to stress the importance of good dental hygiene, including avoiding nursing bottle caries (106) and
tooth brushing, because Aboriginal children are at increased risk
for dental caries (107). A toddler who receives a bottle in your
clinic for non-nutritive purposes is at risk for night-time bottle
caries, and you should ask whether this child has a bottle placed in
his or her bed at night (106).
Children may grow 1 cm less during the first year of therapy
with budesonide or beclomethasone. Growth velocity usually normalizes after the first year, and because children with asthma have
delayed puberty, final adult height is normally not affected. All
children on inhaled steroids should have their growth monitored
with a paediatric growth chart at every visit. If growth seems
unusually affected, efforts should be made to lower the inhaled
steroid dose as rapidly as possible, using, if needed, a second controller agent (see below). Very high doses of inhaled steroids occasionally cause adrenal suppression, and children on high doses
should be monitored by a paediatrician or other asthma expert.
Leukotriene receptor antagonist
The leukotriene receptor antagonist montelukast blocks leukotrienes, which are molecules that worsen asthmatic inflammation.
Montelukast has the advantage of being given by mouth; therefore, inhaler technique is not an issue. In addition, it is administered only once a day. Finally, it starts working in a single day and
reaches peak effect in three weeks. Montelukast may provide
adequate monotherapy in children with mild asthma, but it is
considered to be a second-line agent by Canadian guidelines
because inhaled steroids are more effective (3). It can be considered in patients unwilling or unable to use inhaled steroids. If
montelukast alone does not provide adequate control, the family
Kovesi et al
should be encouraged to switch the child to an inhaled steroid.
Children with moderate or severe asthma should start therapy
with an inhaled steroid, rather than with montelukast (1).
In children with relatively severe asthma, combined therapy
with both an inhaled steroid and montelukast can be helpful.
Montelukast may be used as an add-on therapy in children with
asthma who are inadequately controlled on low-dose inhaled corticosteroid therapy. In symptomatic children on a moderate or
high dose of inhaled steroids (Table 1), adding montelukast may
improve symptoms by approximately 33%. Conversely, in children
who are well controlled on inhaled steroid but who need a moderate or high dose (Table 1), adding montelukast may allow you to
maintain control while reducing the inhaled steroid dose by
approximately 33% (1). Montelukast and zafirlukast are on Health
Canada’s Non-Insured Health Benefit (NIHB) Program Drug
Benefit List (Table 2). Both drugs are limited use benefits and,
therefore, require special approval from the NIHB Program.
Side effects with montelukast are uncommon. A few children
experience headaches or abdominal pain (108). Rarely, children
develop insomnia, nightmares, behaviour problems or depression
(109). If any of these occur, montelukast should be discontinued.
Not all jurisdictions provide automatic coverage for montelukast.
Short-acting bronchodilators
All children with asthma must have a short-acting beta2-agonist
bronchodilator, such as salbutamol, available to them. Shortacting bronchodilators start working in less than 15 min, and the
effect lasts 2 h to 6 h. There are several appropriate ways to use
salbutamol. Two puffs of salbutamol every 4 h to 6 h as needed,
may be used for sporadic asthma symptoms. Two puffs of salbutamol four times a day may be used for brief periods during colds to
keep the airways dilated. Two puffs of salbutamol may be administered 15 min before exercise to prevent exercise-induced bronchospasm. Finally, parents should be instructed to administer two puffs
of salbutamol every 4 h during asthma exacerbations and to bring
their child to a health centre if the child needs salbutamol more
frequently (3). A few children with more severe asthma who
appear to have very shallow breathing and who appear to not
respond well to salbutamol given by inhaler devices (even with
good technique) may benefit from having a home nebulizer. In this
situation, the family should be instructed to see a health care professional if treatments are needed more than every 4 h and to carefully keep the nebulizer equipment clean (1).
All beta2-agonist bronchodilators can cause jitteriness, tremor,
headache and tachycardia. Regular use of a short-acting bronchodilator without concurrent use of anti-inflammatory therapy can
cause worsening of asthma. If a short-acting bronchodilator is used
four or more times per week, this should lead to an assessment by a
health care professional and an increase in anti-inflammatory
medication. Children do not need to take salbutamol before each
dose of inhaled steroid (78).
Long-acting bronchodilators
Two long-acting beta2-agonists are available in Canada: formoterol,
which starts working in 15 min or less, and salmeterol, which starts
working in 30 min. Both last 12 h. Similar to short-acting beta2agonists, long-acting beta2-agonists should not be used regularly by
themselves because this can lead to worsening asthma. Instead, they
should be given with an inhaled steroid. The safest way to prescribe
them is in a combination inhaler, which ensures the client also
receives the inhaled steroid. Combination inhalers available in
Canada include Advair (GlaxoSmithKline, United Kingdom)
(which contains fluticasone and salmeterol), Symbicort
(AstraZeneca, United Kindom) (which contains budesonide and
formoterol) and Zenhale (Merk and Co Inc, USA) (which contains
mometasone and formoterol). Adding a long-acting beta2-agonist
to regular therapy with an inhaled steroid may reduce symptoms,
improve pulmonary function and reduce the frequency of asthma
exacerbations in adolescents (and some children) with persistent,
moderate or severe asthma (110). There is less research demonstrating their effectiveness in children than in adults (1). Combination
inhalers are on Health Canada’s NIHB Program Drug Benefit List
(Table2); they are limited use benefits and therefore require special
approval from the NIHB Program. Advair (salmeterol/fluticasone)
and Serevent (GlaxoSmithKline, United Kingdom) (salmeterol)
are licensed for use in children four years of age and older; the other
long-acting beta-2 (formeterol) and combination (formeterol/
budesonide) inhalers are licensed only for children 12 years of age
and older. Because Symbicort contains a rapid-acting, long-acting
bronchodilator, additional doses may be taken during an exacerbation, rather than taking a short-acting bronchodilator such as salbutamol (3). Giving Symbicort regularly and additional doses as
needed during flares is an appealing new way of managing asthma
with a single inhaler (111). Increasing temporary Symbicort dosage
up to four inhalations twice a day can thus be suggested to appropriate clients 12 years of age and older.
The short-term side effects of long-acting beta2-agonists are the
same as short-acting beta2-agonists – they just last longer. There are
ongoing concerns that long-term use of long-acting beta2-agonists
appear to be associated with a higher risk of serious adverse asthma
outcomes. The risks appear to be particularly high in younger children (primary-school-age children or preschoolers). Whether this
increased risk is mitigated by concomitant inhaled corticosteroid use
is a topic of ongoing research. Given the evidence suggesting an
adverse effect on asthma control and limited evidence of efficacy,
long-acting beta2-agonists should only be used in children (especially before adolescence) who have failed other asthma therapies
and should always be used in conjunction with an inhaled corticosteroid, ideally as a combination inhaler (3,5).
Asthma Education
The families of all children with asthma need to be provided with
asthma education, as do older children themselves. Families need
to understand what asthma is, what the symptoms are, what the
signs of a severe asthma attack are, how to manage exacerbations
and when to seek medical attention, and how to avoid triggers.
They also need to know what their child’s medications are for
(60), when to use their medications, how to use the child’s inhaler
device(s) and what the side effects of the medications may be
(78). See Table 3 for suggestions on which devices are suitable
for use in children of various ages. Videos with directions on how
to use inhaler devices have been produced by the Ontario Lung
Association and are available on YouTube <
Archives/inhaler-videos.pdf> and written instructions are available at <
ctl00_TheMenu-menuItem005>. Families should receive a written
asthma action plan to help them remember this information,
including when to give the medications and how to manage exacerbations (3). The action plan should be kept somewhere prominent
in the house (eg, the refrigerator door), so it can be found during
an emergency. A sample asthma action plan can be downloaded
from <
pdf?mid=ctl00_LeftMenu_ctl00_TheMenu-menuItem006subMenu-menuItem003> and given to your clients.
A small percentage of children with asthma who are six years of age
or older will benefit from a peak flow monitor – a simple, portable pulmonary function monitoring device. Most children do not need a peak
Paediatr Child Health Vol 17 No 7 August/September 2012
Asthma in First Nations and Inuit children knowledge translation tool
Table 2
List of drugs covered by Non-Insured Health Benefits, First Nations and Inuit Health Branch, Health Canada. Also available
at <>
A) NIHB Open Benefits
Beta adrenergic agonists (short acting)
5 mg/mL inhalation solution (multi-dose)
02213486 VENTOLIN GSK§
0.5 mg/mL inhalation solution (unit dose)
1 mg/mL inhalation solution (unit dose)
2 mg/mL inhalation solution (unit dose)
100 μg/inhalation inhaler
02232570 AIROMIR MMH‡‡
*Pharmascience Inc, Canada; †Ratiopharm Inc, Canada; ‡Sandoz, Germany; §GlaxoSmithKline, United Kingdom; ¶Dominion Pharmacal, Canada; **Nu-Pharm Inc,
United Kingdom; ††Mylan, Canada; ‡‡3M Healthcare Limited, United Kingdom; §§Apotex Inc, Canada; ¶¶Teva Pharmaceutical Industries, Israel
Inhaled steroids (steroids)
0.125 mg/mL inhalation solution
100 μg/dose dry powder inhaler
0.25 mg/mL inhalation solution
200 μg/dose dry powder inhaler
0.5 mg/mL inhalation solution
400 μg/dose dry powder inhaler
*AstraZeneca, United Kingdom
50 μg/inhalation inhaler
02244291 FLOVENT* HFA 50 GSK
50 μg/dose dry powder inhaler diskus
125 μg/inhalation inhaler
02244292 FLOVENT HFA 125 GSK
100 μg/dose dry powder inhaler diskus
250 μg/inhalation inhaler
02244293 FLOVENT HFA 250 GSK
250 μg/dose dry powder inhaler diskus
500 μg/dose dry powder inhaler diskus
*GlaxoSmithKline, United Kingdom
Beclomethsaone dipropionate
50 μg/inhalation inhaler
02242029 QVAR* MMH
*3M Healthcare Limited, United Kingdom
100 μg/inhalation inhaler
02242030 QVAR MMH
100 μg/inhalation inhaler
02285696 ALVESCO* NYC
*Nycomed, Switzerland
200 μg/inhalation inhaler
02285614 ALVESCO NYC
B) NIHB Limited Use Benefits
Leukotriene modifiers
4 mg chewable tablet
02243602 SINGULAIR FRS* and generics
5 mg chewable tablet
02238216 SINGULAIR FRS and generics
4 mg granules
02247997 SINGULAIR FRS and generics
10 mg chewable tablet
02238217 SINGULAIR FRS and generics
and Co Inc, USA
20 mg tablet
02236606 ACCOLATE‡ AZC
*Limited use benefit (prior approval required); †For treatment of: a) asthma when used in patients on concurrent steroid therapy; b) asthma patients not well controlled with or intolerant to inhaled corticosteroids; ‡AstraZeneca, United Kingdom
Paediatr Child Health Vol 17 No 7 August/September 2012
benh or
Kovesi et al
Table 2 – continued
List of drugs covered by Non-Insured Health Benefits, First Nations and Inuit Health Branch, Health Canada. Also available
at <>
Beta adrenergic agonists (long acting)
Formoterol fumarate
12 μg/capsule powder for inhalation
02230898 FORADIL NVR*
*Merck and Co Inc, USA
Formoterol fumarate dehydrate*†
12 μg/dose dry powder inhaler
6 μg/dose dry powder inhaler
*Limited use benefit (prior approval required); †For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough
symptoms requiring regular use of a rapid onset, short duration bronchodilator. Foradil and Oxeze are not intended for the relief of acute asthma symptoms: patients
must have access to an inhaled fast-acting bronchodilator (beta2-agonist) for symptomatic relief; ‡AstraZeneca, United Kingdom
Salmeterol xinafoate*†
50 μg/dose dry powder inhaler diskus
50 μg/dose dry powder inhaler diskus
*Limited use benefit (prior approval required); †a) For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough
symptoms requiring regular use of a rapid onset, short duration bronchodilator. Serevent is not intended for the relief of acute asthma symptoms: patients must have
access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief. b) For the treatment of chronic obstructive pulmonary disease (COPD) in
patients not adequately controlled with ipratropium; ‡GlaxoSmithKline, United Kingdom
Beta adrenergic agonists (long acting) and inhaled steroids (steroids)
Formoterol fumarate dihydrate, budesonide*†
6 μg & 200μg/dose dry powder inhaler
6 μg & 100 μg/dose dry powder inhaler
*Limited use benefit (prior approval required); †For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium
doses of inhaled corticosteroids (eg, fluticasone 250 μg to 500 μg daily, or the equivalent) as the sole agent and require addition of a long-acting beta agonist.
Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief; ‡AstraZeneca, United Kingdom
Salmeterol xinafoate, fluticasone propionate*†
25 μg & 125 μg/inhalation inhaler
2245126 ADVAIR‡
50 μg & 100 μg/dose dry powder inhaler diskus
25 μg & 250 μg/inhalation inhaler
02245127 ADVAIR
50 μg & 250 μg/dose dry powder inhaler diskus
50 μg & 500 μg/dose dry powder inhaler diskus
Table provided by courtesy of Health Canda’s Non-Insured Health Benefits Program. *Limited use benefit (prior approval required); †For treatment of reversible
obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (eg, fluticasone 250 μg to 500 μg daily, or the
equivalent) as a sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief. ‡GlaxoSmithKline, United Kingdom
Table 3
Asthma inhaler devices for children of various ages
Recommended age
10 years or older
Increased risk of candidiasis if medication is an inhaled
steroid. For inhaled steroids, a spacer should be used with
the MDI at any age. Many patients find coordination difficult
Infant-sized mask and
spacer + MDI
0 to 1 year
Suitable for use in infants. Easy to
Child-sized mask and spacer 1 to 5 years
Suitable for use in children. Easy to
Spacer with mouthpiece* +
6 years and older
Reduces risk of thrush for inhaled
steroid MDI. Easy to coordinate.
Dry powder inhaler*
Approx 6 years and older
Portable. Easy to coordinate.
Wet nebulizer and
Any age
No coordination needed. Sometimes
helpful for patients when none of the
other devices are effective.
Not very portable for youth
Expensive device and medications are more expensive as
well. Slow. Risk of environmental contamination with
infectious aerosols, medication
*Adequacy of technique should be checked carefully in children. Many children older than five years of age are unable to consistently perform a proper manoeuvre with a
dry powder inhaler or even a spacer with mouthpiece – in such cases, a mask with spacer may be used in children older than five years of age. MDI Metered-dose inhaler
flow monitor because they will sense their symptoms before their peak
flow changes and also because adherence with peak flow monitoring is
poor. However, a few children who really are unable to sense their symptoms, or who panic easily, do benefit from peak flow monitoring (78).
Instructions for using a peak flow monitor are available at <www.cheo.
menuItem005>. These children should be instructed to check their
peak flow occasionally while they are well, to know their ‘personal
best’. They can then recheck their peak flow when they believe they
may be experiencing an exacerbation – a peak flow below 70% of
their personal best is a good indicator of an asthma exacerbation. If
spirometry is not available at your health centre, you may wish to
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Table 4
Normal ranges for peak flow (PEF)
Table 5
Criteria for acceptable asthma control
Approximate lower
limit of normal for PEF
Definition of control
Daytime symptoms
<4 days per week
Boys and girls
Avg PEF = 5.25×Ht (cm) - 426 Min PEF = Avg PEF×0.8
<140 cm to 150 cm
Night-time symptoms
<1 night per week
Boys >150 cm
Avg PEF = 3.65×Ht (cm)
Min PEF = Avg PEF×0.8
Physical activity
Girls >140 cm
Avg PEF = 2.76×Ht (cm)
Min PEF = Avg PEF×0.8
Use of rapid-acting bronchodilator
<4 times per week (unless before
exercise only)
Mild, infrequent
School, preschool or child care
None missed
Average PEF
Adapted from, ‘Normal Peak Flow Meter Readings’ <www.ivillage.
com/asthma-normal-peak-flow-meter-readings/6-n-145258>. Note: 1) Measure
height accurately in centimetres without shoes. 2) You can also find a chart
with normal ranges for peak flows at: <
asthma_PEFCH.htm>. 3) For a given client, changes in peak flow (PEF)
should be based on the client’s PEF when he or she is well, which is the client’s personal best PEF. Avg Average; Ht Height; Min Minimum normal
consider using a peak flow meter as a simple pulmonary function testing device (78). Normal ranges are available for children of different
heights and sexes (Table 4). An improvement in peak flow of 20%
or more is considered a positive bronchodilator response (3). Keep
in mind, however, that peak flows are highly effort dependent and
measurement of FEV1 with spirometry is preferable. Peak flow meters
must be sterilized between clients.
All children with asthma require the immunizations recommended
for Canadian children. Particular attention must be devoted to ensuring that children with asthma are immunized against S pneumoniae
and influenza virus. Influenza is a known risk factor for asthma exacerbations in children. In addition, both asthma (112) and Aboriginal
ancestry (113) are risk factors for death from influenza, as was
observed during the 2009 influenza A (H1N1) pandemic (114,115).
Children with asthma should receive an annual influenza immunization because vaccination has been shown to prevent asthma exacerbations (116). Asthma is a risk factor for invasive disease due to S
pneumoniae (100) and, in addition to the pneumococcal conjugate
vaccines administered during infancy according to the recommended
schedule for Canadians, consideration should be given to administering the pneumococcal polysaccharide (23-valent) vaccine between
two-to-five years of age, with the possibility of a booster dose three
years later for children 10 years of age or younger at the time of initial
vaccination, and five years later for children older than 10 years of age
when initially vaccinated (117). Children who may require oral steroids or who are receiving inhaled steroids should receive the varicella
vaccine. Individuals on high-dose oral steroids (2 mg/kg/day for two
weeks or longer) must not receive the varicella vaccine until they
have been off oral steroids for six to 12 weeks (118).
Evaluation and Follow-Up
All children with asthma should be reassessed every several
months (1). At each visit, asthma control should be assessed using
Canadian consensus guidelines control criteria (Table 5), including specific questions about exacerbations since the last visit,
missed school and whether symptoms are present at night or with
activity between exacerbations (3). Older children should be questioned directly about symptoms – particularly whether symptoms
occur with sports, at play or at school (1). If control is inadequate,
environmental control, adherence and inhaler technique should
be assessed (1,3); if these are adequate, maintenance therapy
should be augmented (1). If there have been minimal symptoms
for three to six months, consideration may be given to reducing
maintenance therapy (1). If it is available, spirometry may help
provide objective evidence of whether chronic airflow limitation
and obstructive lung disease are present (3).
Paediatr Child Health Vol 17 No 7 August/September 2012
Adapted with permission from reference 1
Indications for referral will depend on your health centre’s
protocols and may need to be made in consultation with the region’s
physician. Depending on the community and available resources,
the specialist may be a paediatrician, paediatric or adult respirologist,
paediatric or adult allergist/immunologist, or an internist. Indications
for referral to an asthma specialist may include the following:
• Asthma that remains inadequately controlled despite
moderate doses of inhaled steroids, possibly including the need
for add-on therapy – particularly when adherence is adequate
• Uncertainties about the diagnosis
• Need for additional asthma education
• Possible bronchiectasis or other lung disease
• Atelectasis lasting more than four to six weeks
• Recurrent, radiographically-confirmed pneumonia despite
effective asthma management (see Diagnosis and Patterns of
Asthma in Children)
Indications for referral specifically to a paediatric or adult allergist/immunologist include the following:
• Persistent asthma, suggesting a high risk of allergic triggers
and/or control is difficult to achieve
• If allergens appear to trigger symptoms or if control is worse in
seasons other than the winter
• Concomitant allergic rhinitis and/or atopic dermatitis
Treating a child with asthma can often be challenging. Table 4
provides a list of drugs covered by NHB, First Nations and Inuit
Health Branch, Health Canada. Appendix 1 contains treatment
care maps you can copy and use in your health centre if your
health care team believes that these will be helpful to you. After
establishing a precise diagnosis and with the effective use of medications, regular and accurate evaluation of asthma control, and
careful attention to environmental and cultural issues specific to
your community, it should be possible to achieve excellent control
in most of the children with asthma that you see.
Acknowledgements: This document has been endorsed by:
The Canadian Pediatric Society and The Canadian Thoracic Society.
The authors acknowledge the development and support of this project
by the First Nations & Inuit Health Branch, Health Canada. In addition, the authors acknowledge the helpful advice and reviews from: Dr
Patrick Daigneault, Centre hospitalier universitaire de Québec
(CHUQ), Québec, and the Canadian Pediatric Society; Nathalie M
Lapierre NP(PHC), MScN, Nurse Consultant, Office of Nursing
Services, Health Canada, First Nations and Inuit Health Branch;
François Poulin de Courval RN MSc Wemotaci First Nation Health
Center, Québec; Jessica Demeria, Research and Policy Analyst Health
and Social Secretariat, the Assembly of First Nations; Selma Ford,
Policy Advisor, Inuit Tapiriit Kanatami
Kovesi et al
1) Asthma Care Map Initial Assessment. Dx Diagnosis; HCP Health care practitioner
Patient’s Name: ____________________________________
Date: D
D // M
D // M
Initial Assessment and Diagnosis (mark ‘x’ if yes)
Asthma Diagnosis:
Objectively Confirmed
(History, physical, and objective measures) Date: D
D // M
Perform & attach spirometry/PEF if child 6 yrs & older, and testing is available
12-15% change in FEV1 post bronchodilator (min. 180 mL) or
20 % change in FEV1 after 10-14 day course of prednisone or ICS trial (min. 250 mL)
symptoms, no other Dx, immediate response to bronchodilator confirmed by HCP
symptoms, no other Dx, immediate response to bronchodilator confirmed by history
symptoms, no other Dx, gradual but clear response to anti-inflammatory therapy.
Subjectively Confirmed, particularly for children below 6 years of age
(History, physical, and lack of alternative diagnosis – see Warning Signs, below)
Date: D
D // M
symptoms, no other Dx, immediate response to bronchodilator confirmed by HCP
symptoms, no other Dx, immediate response to bronchodilator confirmed by history
symptoms, no other Dx, gradual but clear response to anti-inflammatory therapy.
Compatible symptoms but uncertain response to therapy, and/or atypical symptoms
Warning Signs
Recurrent pneumonia, chronic wet cough/sputum
production: unusual infections, Failure to thrive,
chronic diarrhea
Choking/cough with meals, regurgitation
Constant wheeze or noisy breathing
Bronchiectasis, Immunodeficiency, Cystic
Heart Murmur, cyanosis
Oral Aspiration or GERD
Upper airway disease
Transmitted upper airway sounds, foreign
body, congenital lung anomaly
Congenital heart disease
Past History
Bronchiolitis: total number of times_____ Admitted locally_____ Admitted major center______
Pneumonia: total number of times_____ Admitted locally_____ Admitted major center______
Latent tuberculosis: when diagnosed________ completed therapy? Yes ___ No____
Active Tuberculosis: when diagnosed_______ completed therapy? Yes ___ No____
Prednisone use ever,
ED visits ever,
Hospitalized ever
Intubated ever
Details (number of episodes, dates, locations)
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2) Asthma Care Map Follow-up Assessments Flow sheet. PEF Peak expiratory flow; S Scheduled; U Urgent
Allergy History: See below for details
Allergy Tests: D
D // M
Positive for:
Tree/grass/weed pollen
Dust mite
Family History of allergy or asthma:
Smoking History:
Ex-smoker, quit when? D
D// M
Current-smoker, number of cigarettes you smoke/day on days you smoke___________________
Pack Years:___________(packs/day x # yrs smoked)
Occupational History:
Occupational Work Occupational asthma symptoms____________________
Asthma Precipitants:
Risk Factors
Medical Conditions
Gastroesophageal Reflux
Medications (Non-steroidal antiinflammatory, Beta-blocker)
Exposure to second-hand smoke:
Colds/chest infections
Paediatr Child Health Vol 17 No 7 August/September 2012
Smokers quit
No smoking inside house
No smoking at work
Home ventilation
optimized (bathroom,
Kitchen fan working,
Kovesi et al
Heat Recovery Ventilator
(if available)
Cold air
Changes in weather, windy days
Fireplace/wood stove
Outdoor pollution
Chemicals at home
Occupational exposure to
chemicals, dusts
Home exposure to dusts, gases
Wood stove leak-checked
Chemicals removed
Wear mask or respirator as needed
for work
No carving, engine repair,
furnace maintained
Regular furnace filter
Mattress, pillow covers
Wash linens weekly in
hot water (if feasible)
Mold remediation
No animal hide preparation in
pets removed
Wash pets weekly (if feasible)
Pollens/trees /grasses
cockroaches eradicated
birds removed
Medication History:
Medication Type:
Short-acting Reliever
Inhaled Steroid
Leukotriene receptor
Inhaled steroid/long-acting
beta-2 combination inhaler
Drug Name / Dose:
Prescribed frequency:
Actual Use:
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Patient’s Name: _________________________________
Date: D
D // M
D // M
Identified Barriers:
Financial issues
Lack of family/friend/school/work support
Client has communicated diagnosis/asthma management plan with:
Issues and Plan:
Written Asthma Action plan: Yes___ No___
Coping Strategies _____________________________________________________________________________________________ _______
Trigger Avoidance: ___________________________________________________________________________________________________
Asthma Medications: Reliever____________________ q4h PRN
Inhaler Device: Metered dose inhaler _____ Pediatric Spacer______ Adult Spacer________ Dry
Powder________ Nebulizer_____
Referrals: Asthma Educator ________ Specialist____________________________________________
Indications for referral:
Indications for referral will depend on your health center’s protocols, and may need to be made in consultation
with the region’s physician. Depending on the community and available resources, the specialist may be a
paediatrician, pediatric or adult respirologist, pediatric or adult allergist/immunologist, or an internist.
Indications for referral may include:
o Asthma that remains inadequately controlled despite moderate doses of inhaled steroids, possibly
including need for add-on therapy – particularly when adherence is adequate
o Uncertainties about the diagnosis
o Possible bronchiectasis or other lung disease
o Atelectasis lasting more than 4 – 6 weeks
o Recurrent, radiographically-confirmed pneumonia despite effective asthma management
Signature: __________________________ Professional Designation: __________________
Paediatr Child Health Vol 17 No 7 August/September 2012
Kovesi et al
Patient Name:______________________________________
Circle: S/U, Yes/No, or enter value /comment; note additional dated comments below; initial sections completed
D /// M
D /// M
D /// M
D /// M
M ///
M ///
M ///
M ///
Scheduled or Urgent (S/U)
Asthma Control
(yes = uncontrolled asthma)
 Physical activity limited due to asthma
 Needs Reliever
( 4 doses/wk – yes; < 4/wk – no)
 Dyspnea, cough, wheeze, or chest
( 4 days/wk – yes; < 4 days/wk – no)
School/work absence since last visit
 Night time symptoms (>1/wk – yes;
none – no)
 FEV1 or PEF ≤ 90% predicted or
personal best
 Exacerbations since last visit (hospital
admission, Emergency Department visit,
Health Center)
 Spirometry (min. 2x/yr)
 PEF (L/min)(every visit),
Value (best of 3)
Follow-up Assessments : (If child 6 yrs & over: Predicted FEV1:_________L, Personal Best PEFR: _________L/min)
 Definition of asthma
 Medications
 Adherence to medications
 Device technique optimal
 Smoking cessation
 Immunization (flu)
 Triggers/Environment control
Action plan: written
Action plan: revised
Action plan: reviewed
Coping Strategies
Asthma Medications:
 Reliever_________________
 Controller_______________
 __________________________________
Medication changes?
 Asthma Education
 Specialist
 Other
Signature and Professional
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3) Asthma diagnosis and management algorithm. (Adapted from the Primary Care Asthma Program. Reproduced with permission of the Ontario Lung
Association). References 1,118,119, 120. Adapted with permission from the Canadian Asthma Consensus Guidelines (1999),; by the Design Task Force for the Ontario Asthma Primary Care Pilot 2002; revised by the Asthma Care Program Revision Advisory
Committee 2006. CF Cystic fibrosis; CXR Chest x-ray; FEV Forced expiratory volume, GERD Gastroesophageal reflux disease
Paediatr Child Health Vol 17 No 7 August/September 2012
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