DISEASES

Is It Asthma?

Consider asthma if any of the following signs or symptoms are present:

	Frequent episodes of wheezing- more than once a month
	Activity induced cough or wheeze.
	Cough particularly at night during periods without viral infections.
	Absence of seasonal variation in wheeze
	Symptoms that persist after age -3
	Symptoms occur or worsen in the presence of:
		1. Aeroallergens (house dust mites, companion animals, cockroach, fungi) 2. Exercise 3. Pollen 4. Respiratory (viral) infections 5. Strong emotional expression 6. Tobacco smoke
	The child colds repeatedly "go to the chest” or take more than 10 days to clear up.
	Symptoms improve when asthma medication (short acting bronchodilator or inhaled corticosteroid) is given.

Differential Diagnosis of Asthma in children 5 years and younger

Infections:-
	Recurrent respiratory tract infections
	Chronic rhino-sinusitis
	Tuberculosis
Congenital Problems:-
	Tracheomalacia
	Cystic Fibrosis
	Bronchopulmonary dysplasia
	Congenital malformation causing narrowing of the intrathoracic airways
	Primary ciliary dyskinesia syndrome
	Immune deficiency
	Congenital heart disease
Mechanical Problems:-
	Foreign Body Aspiration
	Gastroesophageal Reflux

Levels of asthma control in children 5 years and younger

Characteristic	Controlled (All of the following)	Partly controlled (Any measure present in any week)	Uncontrolled (Three or more of features of partly controlled asthma in any week)
Daytime symptoms: wheezing cough, difficult breathing	None (Less than twice / week typically for short periods of on the order of minutes and rapidly relieved by the use of a rapid-acting bronchodilator)	More than Twice / week (typically for short periods on the order of minutes and rapidly relieved by the use of a rapid-acting bronchodilator)	More than Twice / week (typically last minutes or hours or recur, but partially or fully relieved with rapid-acting bronchodilators)
Limitation of activities	None child is fully active, plays and runs without limitation or symptoms)	Any (May cough, wheeze, or have difficulty breathing during exercise, vigorous play or laughing)	Any (may cough, wheeze, or have difficulty breathing during exercise, vigorous play or laughing)
Nocturnal Symptoms / awakening	None (including no nocturnal coughing during sleep)	Any (typically coughs during sleep or wakes with cough, wheezing and/or difficult breathing)	Any (typically coughs during sleep or wakes with cough, wheezing and/or difficult breathing)
Need for reliever / rescue treatment	<= 2 days / week	> 2 days / week	> 2 days / week

Asthma Management Approach Based on control for children 5 years and younger
Asthma Education
Environment Control
As need rapid-acting beta₂ agonist

Controlled on as needed rapid-acting beta2 agonists	Partly controlled on as needed rapid-acting beta2 agonists	Uncontrolled or only partly controlled on low-dose ICS*
Continue as needed rapid-acting beta2 agonists	Low dose ICS Leukotriene modifier	double low dose ICS Low dose ICS plus leukotriene modifier

  *Oral glucocorticosteriods should be used only for treatment of acute severe exacerbations of asthma.
Shaded boxes in this table represent the preferred treatment options:

Low daily doses* of inhaled glucocorticosteriods for children 5 years and Younger

Drug	Low Daily Dose(µg)
Beclomethasone Dipropionate	100
Budesonide MDI † spacer	200
Budesonide Nebulized	500
† Ciclesonide	NS
Fluticasone Propionate	100
† Mometasone Furoate	NS
† Triamcinolone Acetonide	NS

Age Group	Preferred Device	Alternative Device
Younger than 4 years	Pressurized metered dose inhaler plus dedicated spacer with face mask	Nebulizer with face mask
4-5 years	Pressurized metered dose inhaler plus dedicated spacer with mouthpiece	Pressurized metered dose inhaler plus dedicated spacer with face mask or Nebulizer with mouthpiece or face mask

Initial management of acute severe asthma in children 5 years and younger

Therapy	Dose and Administration
Supplemental Oxygen	Deliver by 24% face mask (flow set to manufacturer instructions, usually 4L/min) Maintain oxygen saturation above 94%
Short acting beta2 agonists	2 puffs salbutamol by spacer or 2.5 mg salbutamol by nebulizer Every 20 minutes for first hours
Ipratropium	2 puffs every 20 minutes for first hour only

When to call the doctor?

	Repeated vomiting, especially if it upsets the child.
	Frequent loose or abnormal motions.
	Persistent crying, indicating pain somewhere.
	Sudden shrieks of pain, even if not repeated in a short while.
	Difficulty with breathing.
	Any abnormal discharge, especially from the ears.
	Any sudden change in the child’s appearance making him look ill.

Safety Tips

	Keep all medicines out of your child’s reach in a closed compound.
	Check all electrical wires to see that they are not frayed or damaged.
	Fit safety socket covers on all electrical points.
	Lock away all pins needles scissors, matches, lighters, knives or other sharp object.
	Never leave your child unattended in a high place, kitchen or bathroom.
	Keep aerosol cans, sprays, toilet cleaners etc. out of your baby’s reach.
	Don’t leave plastics bags lying around. Once over a child’s head, they could cause suffocation.
	Breast Feeding is the best feeding. It should be started as soon as possible after Delivery. Colostrums  (Breast milk for first 2 Days) is very important for the child’s health. Exclusive Breast feeding is recommended for the first 4-5 months. Feed in a position with the baby’s head held higher. Burp the baby  after every feed. No additional water or supplements are required for the first 4-5 month.
	Bottle feeding is dangerous for the child in many ways. Use cup and a spoon instead.
	Keep the body (especially the newborn) warm.
	Avoid, oil/buds instillation in nose/ ears & kajal application to eyes.
	Weaning ( addition of semisolid feeds) is recommended from the 5th month onwards. Soft rice, kanji, thin       dal, mashed boiled potatoes, soft mashed banana etc., are recommended weaning feeds. Vomiting may occur in the initial stages till the child gets used to the feed. Hence introduce only one feed at a time.
	Gradually add semisolid and solid feeds, including green leafy vegetables.
	Generally cereals, pulses, green leafy vegetables, eggs, fish, jiggery & groundnuts are required for a          balanced diet.
	Keep medicines , kerosene and other poisonous product away from the reach of children ( especially            toddlers)
	Follow up the growth pattern of your child regularly.

Table1 : Blood Pressure levels for the 90th and 95th Percentiles of blood pressure for boys aged 1 to 17 years by percentiles of height

Table2 : Blood Pressure levels for the 90th and 95th Percentiles of blood pressure for girls aged 1 to 17 years by percentiles of height

Table3 : Centile table for girls

Table4 : Centile table for boys

Table5 : Surface Area nomogram