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The Global Initiative for Asthma (GINA) estimates that more than 300 million people worldwide have asthma. Locally, a national health interview survey carried out by the Department of Health Information and Research in 2002 reports that seven per cent of men and eight per cent of women over 16 complained of asthma while 14.9 per cent of six- to seven-year-olds and 14.6 per cent of 13- to 14-year- olds were reported to be asthmatic in the ISAAC study of 2002. Given these statistics the probability of us knowing an asthmatic is quite high and yet, how many of us understand the condition and know what to do in case of an emergency?

Asthma is a chronic condition of the upper respiratory system and during an asthma attack, patients have difficulty breathing as the lining of the airways swell, the surrounding muscles tighten and mucus clogs the tiny airways in the lungs. Asthma symptoms include breathlessness, wheezing, tightening of the chest and coughing.

Despite the prevalence of the condition, the causes of asthma are still unclear but are thought to include diet, pollution, allergies, maternal smoking, exposure to certain infections and extreme emotional states. Exposure to a "trigger" may set off an asthma attack - and "triggers" vary from one asthmatic to another.

Previously, asthmatics were limited by their condition, but nowadays effective treatment means patients can live life to the full; footballer Paul Scholes and marathon runner Paula Radcliffe are both asthmatics. Effective treatment is the key word here; without it asthma can be fatal, causing 255 deaths worldwide in 2005.

In general, asthmatics are usually prescribed two types of inhalers to treat their condition. Controller medication is taken daily on a long-term basis to prevent the onset of an attack while reliever medication is used to treat an attack or relieve symptoms rapidly. The reliever inhaler must be kept at hand at all times to be used as soon as it is needed.

While adults and adolescents learn to recognise their symptoms and triggers, young children need a watchful eye and adult assistance to use their medication effectively. Although parents and carers are vigilant at home, children spend a large portion of their day at school, when parents must trust the school to watch over their children.

Currently, there is no general policy governing the administration or storage of medicines in schools and practices vary from one school to another and, in some cases, even from one teacher to another. As with any medical condition, the school authorities and child's class teachers must be informed that a child is asthmatic. Parents are often asked to provide a medical certificate when the child starts school, and adding a list of known triggers would also be advisable to help staff be aware of the potential dangers to the child.

When David* started kindergarten, his parents informed the head teacher and class teacher about his asthma. In the early years, the class teachers kept his inhaler in class out of the children's reach but instantly accessible if needed. By the time he was seven David could use the inhaler unaided and it was kept in his schoolbag; and so it continued throughout his school life.

Other families, unfortunately, have been less fortunate.

Karen's son Kyle*, now eight, has had a mixed response from his teachers since starting school. Prior to every school year, Karen makes an appointment with Kyle's head teacher and class teacher to ensure they are fully aware of Kyle's condition, medication and triggers.

"When he was in kindergarten, we used to keep him home if he was ill but when he started primary school we didn't want him to miss school needlessly. During my initial meeting with Kyle's teacher in Year 2, I was really taken aback when she bluntly informed me that she would not take responsibility for him if he had an attack in class. My husband and I discussed this afterwards and decided we would still ensure Kyle didn't miss out on his education," Karen explains.

That winter, Kyle had a particularly severe asthma attack and needed treatment with the nebuliser at the local polyclinic twice a day. Karen took him to the clinic before school and, following the doctor's advice that Kyle could go to school, she dropped him off slightly late.

"The assistant head was at the door when we arrived so I explained our tardiness and asked her to keep a close eye on Kyle and to call me or my husband if he started coughing so that we could take him to the polyclinic immediately for treatment. I left assured that he would be taken care of and was outraged at what happened later," she recalls, anger ringing in her voice.

That morning, Kyle started coughing but the teacher, deciding it was a play for attention and an attempt to get sent home, delayed calling his parents for an hour and a half. By the time Karen got to school her son was barely conscious and was ultimately rushed from the polyclinic to the hospital where he spent the next three days recovering.

"We couldn't believe that despite the school having been warned that very morning they still didn't act promptly. Regardless of what the teacher thought, in the circumstances we should have been called straight away." Years later, Karen is still perplexed at the risks taken with her son's health that day.

This year, Kyle's teacher is extremely supportive and prompts him to use his inhaler before PE and lunch break as exertion can trigger an asthma attack. The difference this has made to Karen's state of mind is clear to see; her face softens and her voice is calmer as she describes the current situation.

"My husband and I are at ease knowing that his teacher is keeping a watchful eye over our son. We don't expect the teacher to be responsible for Kyle's health; that is our job. But just knowing she will call immediately if she had the slightest concern about him is enough for us."

At 14, Stephen* is nearing the end of his secondary education and his condition has been a hindrance throughout his senior years as Sara recalls:

"Dust is one of Stephen's main triggers and with all the construction going up around our house and near his school he has had a very difficult time over the past few years. I always speak to the school administration about Stephen's condition at the beginning of the year and stress that we don't want him to miss school unless it's absolutely necessary. The head is very cooperative, agreeing Stephen can go to school late if he wakes up unwell and recovers during the morning. The problem is that teachers have no notion of what to do during an attack."

During his first year at secondary school Stephen had a severe asthma attack when a classmate sprayed deodorant in class. Although he used his inhaler immediately, it failed to do the job and he asked for his parents to be called. Despite the fact that he was wheezing, the teacher sent him down to the staff room to ask his form teacher's permission on his own. The form teacher then sent the boy back up to administration to make the call.

By now, Stephen was struggling to breathe and was dismayed to be told that the telephone was not for students' use".

"Luckily, he had memorised the PIN number of my "easyline" card and was allowed to make the call," says Sara, shaking her head in disbelief. Stephen spent the next five days in hospital; the exertion combined with his rising panic made his attack more severe than it may otherwise have been.

Since then, Stephen has missed quite a few days of school and sometimes goes to school late or has to leave early due to an asthma attack. Some teachers are sympathetic and understanding, accepting his work after it falls due and helping him when he finds it hard to keep up due to lessons he missed.

Other teachers have lost patience and as Sara puts it "seem to think he's making it up to skive off school". One teacher, as she was disciplining Stephen on an unrelated matter, suggested he should stay at home instead of "coming and going as he pleases".

"We have spoken to Stephen's doctor about achieving better control of his asthma but the environmental factors combined with the stress he feels at school make it an uphill struggle. There is nothing we can do about the ever present building works but if all the teachers understood Stephen's condition, he wouldn't be so stressed and since stress compounds his asthma it's a vicious circle." The despair in Sara's voice is palpable.

A policy outlining appropriate responses when children fall ill at school would ensure that the children's welfare is safeguarded with teachers and school staff secure in the knowledge that they are following an established procedure.

Unfortunately, the Ministry of Education and Culture and the Malta Union of Teachers seem to be a long way off from coming to an agreement about this issue.

Josephine Ellul, of the Soċjetà Ażmatiċi Maltin, says these two cases highlight the difficulties children can face in schools. "Some schools have established guidelines for staff to follow in case of an emergency and either allow children to keep inhalers in their schoolbags or keep them locked up in the head's office.

"Although the latter is not ideal, it is preferable to the schools that refuse to give the children an inhaler at all; in these cases if a child has an asthma attack, the school will call the parents who have to go to school to administer the inhaler. With more parents working now, this is no longer a feasible solution; parents may not work in the same locality as the school and not all families have grandparents conveniently nearby either."

While some teachers are undoubtedly at ease monitoring children with various conditions, others are not. The anomaly in children's experiences would be removed if there were a clear policy governing the administration of medication as well as outlining procedures for staff to follow if a child falls ill.

In the UK, patient support groups including Asthma UK, The Anaphylaxis Campaign, Diabetes UK, Epilepsy Action and the Long Term Condition Alliance have collaborated together to create a "Medical Conditions at School Policy" which is also supported by the Department for Children, Schools and Families. This outlines various emergency procedures for each condition as well as forms to ensure effective communication between parents and schools.

Presently, our education ministry is at loggerheads with the teachers' union about medication in schools although both seem willing to find a solution.

A spokesman for the ministry said "at present teachers are directed by their union not to administer medication to their pupils. As inhalers too are a type of medication, using them incorrectly or overdosing could cause problems. Therefore we are currently finding ad hoc solutions to ensure children do not suffer.

The ministry is currently in the process of appointing a board to advise on this issue with the aim of developing an effective policy about the administration of medicines in schools."

MUT president John Bencini explains the union's position, saying "there is a variety of medical conditions which children suffer from in schools and asthma is just one of them. Teachers are not trained healthcare professionals and there is a difference between using an asthma inhaler and administering other medications such as suppositories or injections. The ministry is responsible for the children's health and should provide the necessary number of nurses in each college.

"Some teachers have administered medication when requested to do so by parents and there have been instances of parents who then blamed the teachers for resulting side effects, insisting that the teacher must have administered an incorrect dosage."

Mr Bencini concludes by saying "we need to establish a discussion between all the stakeholders including teachers, medical professionals, parents and patient support groups to work out an effective policy. I see no reason why we can't reach an equitable solution in three months or so." We are all responsible for ensuring children's health needs are met wherever they are. The time has come for all concerned to work out a solution before an unfortunate incident makes the headlines.

*Names have been changed to protect identities

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What to do in an asthma attack

According to Professor Joseph M. Cacciottolo, it is crucial for a child to have access to any properly prescribed medication at all times. There are instances when a reliever inhaler must be immediately available, if only for the child's peace of mind. An asthma attack is rarely sudden, and commonly, control of asthma is lost slowly but asthmatics usually reach for their inhaler at the first symptoms of an attack such as wheezing, coughing, tightness in the chest or shortness of breath.

If patients delay using their inhaler the attack may worsen, not least because the element of anxiety combines with the physical factors of the attack.

On the other hand, it is unusual for a person suffering from asthma to use a reliever inhaler unnecessarily.

What to do
• Keep calm.
• Encourage the child or young person to sit up and slightly forward - do not hug or lie them down.
• Make sure the child or young person takes two puffs of reliever inhaler (usually blue) immediately - preferably through a spacer.
• Ensure tight clothing is loosened.
• Reassure the child.

If there is no immediate improvement

Continue to make sure the child or young person takes one puff of reliever inhaler every minute for five minutes or until their symptoms improve.

Call a doctor urgently if:
• The child or young person's symptoms do not improve in five to 10 minutes.
• The child or young person is too breathless or exhausted to talk.
• The child or young person's lips are blue.
• You are in doubt.
• Ensure the child or young person takes one puff of their reliever inhaler every minute until the ambulance or doctor arrives.
• It is essential for people who work with children and young people with asthma to know how to recognise the signs of an asthma attack and what to do if they have an asthma attack.

Common signs of an asthma attack are:
• coughing
• shortness of breath
• wheezing
• tightness in the chest
• being unusually quiet
• difficulty speaking in full sentences
• sometimes younger children express feeling tight in the chest as a tummy ache. After a minor asthma attack
• Minor attacks should not interrupt the involvement of a pupil with asthma in school. When the pupil feels better they can return to school activities.
• The parents/carers must always be told if their child has had an asthma attack.

Important things to remember in an asthma attack
• Never leave a pupil having an asthma attack.
• If the pupil does not have their inhaler and/or spacer with them, send another teacher or pupil to their classroom or assigned room to get their spare inhaler and/or spacer.
• Reliever medicine is very safe. During an asthma attack do not worry about a pupil overdosing.
• Send another pupil to get another teacher/adult if an ambulance/pupil's parents need to be called.
• Contact the pupil's parents or carers immediately after calling the ambulance/doctor.
• A member of staff should always accompany a pupil taken to hospital by ambulance and stay with them until their parent or carer arrives.

Source: The School Asthma Pack developed by Asthma UK

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World Asthma Day 2008

Tuesday (May 6) is World Asthma Day and this year's theme, You Can Control Your Asthma, aims to raise awareness on asthma while stressing the positive aspect of proper asthma management.

Although there is no cure for asthma, effective treatment means patients can control their asthma and lead full and active lives.

In its Global Safety for Asthma Management and Prevention, GINA defines asthma control as meaning that a person with asthma:

• Has no or minimal asthma symptoms.

• Does not wake up at night due to asthma.

• Rarely needs to use "reliever" medication.

• Can undertake normal physical activity and exercise.

• Has a normal or near normal lung function test results.

• Has no (or very rare) asthma attacks.

Soċjetà Ażmatiċi Maltin will be keeping to the theme by launching a booklet detailing exercises that are thought to help relieve the condition.

Representatives of the society will be at City Gate, Valletta between 9 a.m. and 1 p.m. today with informative leaflets available to anyone who wishes to learn more about the condition.

• Membership in Soċjetà Ażmatiċi Maltin costs €5 annually. More information may be obtained by phone on 2167 2625, 2180 6092 or 2133 9779.

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