Background
Asthma is a leading non-communicable disease (non- contagious disease) with a rising burden in Africa. Asthma is a long term (chronic) disease of the airways (breathing tubes).
In Low- and Middle-Income countries children living with asthma are faced with many challenges which has long term impact (effects) on the child, their families and in some cases the community as a whole. In this article we highlight some challenges that relate to childhood asthma management as well as discuss some myths and misconceptions that relate to childhood asthma in Ghana. Addressing the myths and misconceptions relating to asthma has been the focus of this year’s world asthma awareness creation.
The Delays
The diagnosis of asthma in childhood is often delayed. Most children remain in communities with symptoms of cough, difficulty in breathing, wheezing, chest tightness and chest pain, without been assessed by a healthcare personnel early enough, other children are also sent late to the healthcare facilities for medical assessment although they remain symptomatic and continue to suffer significantly. (Delayed Diagnosis)
Children in our communities usually don’t reach us because their parents or caregivers refuse to seek help for them or they are offered many options which do not necessarily help them. Delayed presentation is a major barrier in childhood asthma management in Ghana.
Another very worrying aspect of delay, is in initiating medical treatment or therapy. In some children although they have a formal diagnosis of asthma their parents or caregivers refuse to accept the diagnosis or remain in denial hence the children are never initiated on treatment or are only offered treatment late. (Delayed initiating of asthma treatment).
The Wrongs
The focus of asthma management is commonly wrongly placed. Asthma can only be effectively treated if the medication used (controller) is targeted at reducing the swelling in the breathing tubes (inflammation in the airways). Medications that provide only quick relief of asthma symptoms (Short Acting B-2 Agonists (SABA) e.g. Ventolin inhalers or tablets or syrup) only provide temporary symptom relief. They don’t not suppress the main problem of asthma which is the swelling in the breathing tubes.
In order to sustain the complete resolution of the swelling in the breathing tubes, controller therapy which is prescribed by the doctor must be used. The correct place of short acting B-2 agonists in asthma management is only during emergencies. In addition, over the counter (OTC) purchase of oral steroids (prednisolone) for asthma treatment is wrong. Prednisolone is a prescription only medication, it can only be used upon request by the attending clinician. (Wrong medications).
The second aspect of the wrongs is in relation to technique in the use of asthma medications (devices). Wrong devices (medications) contribute to poor outcomes in childhood asthma management. Most children with asthma struggle to use their asthma devices correctly. Most asthma medications get delivered into the mouth instead of inside the lungs. A lot of emphasis must to be placed on teaching children the correct technique for delivery of asthma medications into the lungs.
Further, asthma medications for children are age specific, not all children can use all asthma devices correctly, eg. a parent with asthma cannot offer his medication to the child with asthma. Parents and caregivers need to talk to their doctor about correct devices (age-appropriate devices) and correct technique in order to achieve full control and to sustain control of asthma symptoms. Children with asthma need spacer devices to help them use their inhalers correctly (Wrong devices and wrong technique).
The Lacks
Generally, in Ghana there is a lack of access to asthma medications for children due to cost. In smaller towns, asthma medications are not easily accessible. Asthma medications for children remain expensive and some families are unable to sustain the need for continuous care. Commonly a child will need a refill every month. Additionally, some asthma medications for children are not on our Health Insurance list. Cost of asthma medications contribute in some cases to poor treatment outcomes.
Another important lack is in the area of access to emergency management of asthma. In some health care facilities, the required resources to provide emergency management for children with asthma exacerbations are not readily available.
Myths and Misconceptions in childhood asthma
Myth and Misconception # 1- Children with asthma cannot exercise
Truth- Although exercise can trigger asthma symptoms, children with well controlled asthma effectively achieve a normal life in which they can maintain a good activity level. Preventing a child from engaging in some daily exercises like walking is not helpful. Total activity limitation in childhood can lead to obesity which can make asthma symptoms worse. Obesity has other health implications. Children with asthma can be taught how to take medications correctly so they can at least participate in some specific and appropriate physical exercises in school.
Myth and Misconception- # 2 Children will outgrow their asthma
Truth- If the diagnosis of asthma at the very onset is correct then the child will not outgrow the asthma. When asthma treatment is started and there is good compliance and adherence to treatment most children up to 95% plus, will have good symptom control, they would lead normal lives in school and at home, however it does mean asthma is cured.
In young children, many conditions may look like asthma. Commonly children can have recurrent wheeze from viral infections. This usually improves as the child grows, but this condition is not the same as childhood asthma.
Myth and Misconception- # 3 Children need high doses of steroids to control their asthma
This is not true; it is mandatory in childhood asthma management to treat the child with the lowest dose that controls asthma and keeps the child symptom free while maintaining good quality of life. Inhaled corticosteroids are made in very low doses compared to oral steroids such as prednisolone. Once control is achieved treatment is “stepped down†to reduce the dose of the inhaled steroids.
In all instances low doses of inhaled steroids are maintained. Long term use of oral steroid is not helpful, families are always advised against this practice.
Myth and Misconception # 4 Medicines used in treating asthma (asthma inhalers) produce dependence
This is also not true. Asthma medications do not produce dependence (addiction) even with long term use. Parents and caregivers of children with asthma can be assured that asthma medications have no dependence (addictive) side effects. Children commonly rather develop complications from asthma when they don’t use their medications as prescribed
Myth and Misconception # 5 Asthma medications are only needed when asthma symptoms worsen.
Truth- Asthma is a long-term disease, regular use of daily controller medications is the best way to effectively control asthma. Even when the child appears to be symptom free, the swelling in the breathing tubes continue. If the swelling in the tubes remains sustained and uncontrolled over the time the breathing tubes commonly get damaged in adulthood, this is a condition called airway remodeling. The best advice is to keep a low dose of inhaled steroids on going even if it is a few doses a week. For children who have achieved control, they are maintained on a very, very low dose of inhaled steroids.
In conclusion this article has focused on the challenges in childhood asthma management in Ghana- the Delays, the Wrongs and the Lacks which remain major barriers. Further, there are myths and misconceptions about exercise, asthma medications and children outgrowing their asthma. Although asthma can remain quiescent for a long time it is not cured. Children living with asthma can be supported by parents, caregivers, teachers and friends to live a good quality life in which they achieve their God given potential.
By Dr Sandra Kwarteng Owusu
Paediatric Pulmonologist and Paediatrician
Department of Child Health, Komfo Ankoye Teaching Hospital Kumasi
Member Ghana Thoracic Society
Member Pediatric Society of Ghana.