My name is Christine Burns I'm a clinical nurse consultant at Sydney Children's Hospital at Randwick and this my colleague Melinda Gray who's also a clinical nurse consultant at Sydney Children's and we're going to present our information session on asthma today. So Melinda and I have been conducting the Aiming for Asthma Improvement in Children Program, which is the Sydney Children's Hospital program for the past 18 years, so we're very familiar with child care training and management of children in childcare services. But also in schools out of hours school care, and of course we we manage and look after things that are happening in the acute setting with children with asthma A program...

We've developed a lot of resources for our program and I said we do provide the ACECQA approved training as well and we have a website it's actually on the Sydney Children's Hospital's network web page and you can find it by going on to the Sydney Children's Hospital's Network website. But you have to do a quite a few number of clicks before you actually find our page. But to make it easier for you. We've got our own URL. So if you just take note of www.asthmainchildren.org.au it'll take you straight to the page. Okay, just remember it's a .org not .com because there is another one that has .com and it's not us. Okay, so just make sure you go to the right one. And when you get to that page you'll notice that there's a few sections there little accordions that you can click on and you can find the relevant information. So it details all of our training sessions that we provide it also you can view different videos. You can also download resources to help you and of course, our contact details are on there, too and so, please feel free at any stage if you have any concerns or questions with children in your care in regards to the management of asthma. Give us a call email us and hopefully we can help you and if we can't we'll put you in the right direction to find that help.

So I guess today of what we really want to do is to provide you with information so that you have greater confidence in managing children with asthma in your care. Also to make sure that you are aware of the medications to use the asthma first aid be able to use the medications correctly and to be able to implement asthma first aid in regards to the nationally recognised asthma first aid procedure and I know that many of you will receive from parents your their child's asthma action plan many of you don't as well and we also know that they're very they've... they're varied you get lots of different ones but we do actually have a nationally recognised asthma first aid procedures like there is in CPR.

Okay, and this is what we really want to make sure that you you are familiar with and feel comfortable with. Also knowing when to call an ambulance because often staff get a little bit confused and worried will the parents want me to call an ambulance. Am I supposed to call the parents first? So we want to make sure that you feel confident in that and also, being able to provide any information back to staff that are not here today.

So we know asthma is quite a big problem in our community we currently have one in ten children in Australia that's diagnosed with asthma when we first started doing this training session. Oh Sorry, thank you. missed one... when we first started doing this training session it used to be one in four children, and then it went to one in five, one in six, one in eight and those of you that may done training in previous years you can probably remember those those stats and now it's 1 in 10 and that tends to give us a little bit of a false sense that maybe asthma's not as prevalent anymore. But in actual fact it is, it hasn't really changed what's changed is that we don't diagnose very very young children with asthma like they used to be diagnosed years ago and that's because it's very very difficult to diagnose children asthma and often children that might have symptoms of asthma such as wheezing and coughing we usually wait for a little while before we can really say they actually have asthma and this is an area that we really want to concentrate and make sure that we can help you today because we know that area can be quite tricky when you have children enrolled in your centers and parents say no, they don't actually have asthma but here's their puffer anyway, and I'm sure you can all relate to that as knowing where I'm coming from.

We also know that this age group that you care for is the highest cause of hospitalisation for our kids for asthma so it's um, we have lots of kiddies in this age group, but presenting to our emergency departments with asthma. We also know that it's a very, can be a very life-threatening situation. Although most children in the majority of asthma attacks or flare-ups and that is means exactly the same thing, most of them are often usually mild or moderate. You don't... every child's not always going to have a severe attack, but they can it is potentially life-threatening.

We have excellent medications. We have excellent management in Australia in regards to asthma. So when that that's all in place and when children have well controlled asthma they can lead normal healthy lives and that's what we want. We also need to be aware that as the anaphylaxis ladies pointed out in regards to anaphylaxis it's the same thing with asthma a child may be enrolled in your your service without a diagnosis of asthma that does not mean that they will not have their very first asthma attack or flare-up at your service.

So basically asthma is a condition in the child's lungs in their airways or their air pipes or air tubes and basically those air tubes. They tend to have some underlying inflammation. Just waiting to flare up and that's where we get the term flare up from they're very very sensitive to certain triggers and triggers such as allergens, dust, dust mite, changes in weather smells and most of the most common trigger in this age group is the common cold. Okay, viral infections, and so normally most people that that are exposed to those particular triggers don't have any problems with their breathing in regards to their lungs.

But with children with asthma because their airways are very very sensitive they react ok, and when they react certain things happen. Muscle tightens around the outside of the airway. We often have some inflammation flares up so the inside of the lining of the airway becomes quite red and swollen and then we get some extra fluid buildup or mucus buildup, okay. So what we have there now is a very narrow airway or it air tube so when the child breathes it becomes quite difficult.

Diagnosing asthma can be quite tricky especially in this age group, but we look at a number of factors. We basically look at the symptoms at the child's having wheezing coughing. It's generally a dry irritable cough that the child has obviously difficulty in breathing and chest tightness, although in this age group children don't go around and say I have a tight chest but they do turn around and say things like I hurt or I feel funny. Okay, so it means same sort of thing. So we look at how often a child has those particular symptoms. Are they recurrent? Are they persistent symptoms? Then we look at whether those symptoms respond to medications the asthma medications.

We also look at whether the child has any allergies and we look at the family history as well Is there a family history of asthma because we know that it often runs in families, but not always and we also know that if there is the presence of allergies in other family members that can be a trigger for asthma for that child as well. And of course we have our tests but in this age group young children cannot always perform the tests such as spirometry or breathing tests, and they're more of our definitive test to say whether it's asthma or not. So we have to look at the the big picture and some children we can pretty much say yes, it is asthma and that's what we treat them for. But we also know that lots of children wheeze and cough for a number of other reasons that is not asthma and in fact, it's a very common thing for children under the age of three to wheeze. And this is where we get a little bit confused medical people get confused because we're not sure is it asthma is it not parents get confused because all of a sudden their child's having certain signs of asthma but the doctor says no, it's not asthma but that here's, have your asthma medications anyway, and then they come to the centre and then you get confused. It gets quite quite tricky.

We classed those children that we're not 100% sure, it's not exactly asthma as viral induced wheezers. Okay, and it's because they often have these wheezes and these coughing episodes generally when they have a viral infection. And most children have around about six to ten viral infections a year. Okay as they get a little bit older they they don't have so many but as they're young as you know they're always coming to child care with coughing sneezing and all sorts of things and so when these children that have this viral induced wheeze, when they get a cold. This is what they do, so generally between their viral episodes they're well in between and this is as I said this is where it makes it a bit tricky and they may go on to still develop asthma but many don't and as you can see from some of the stats there that by the time children by the time they actually reach adulthood even if they've been diagnosed with asthma early on in the years usually by the time they reach adulthood two-thirds of them are usually symptom free.

We know that this situation with these viral induced wheezes. This is where the doctors probably don't provide a child with an action plan and I know this becomes quite difficult for the child care staff. We do have a solution to that and Melinda is actually going to talk a little bit more about that further down the track. So this is a video. I'll just see if it works. I'm not sure how well the sound will be but this is a video of a child who's obviously having difficulty in breathing, but also when wanting listen to the breath sounds and hopefully the wheeziness.

[breathing sounds]

[child crying]

[sound of wheezing breathing from inside child's body]

Did you hear the the end of the child's breath it was just a little bit of a high-pitched whistle at the end okay, so that's the wheeze sound that we're talking about. Okay, so of course we need to treat children and I said those with asthma we will treat them with asthma medications but those with viral induced wheeze, we also treat them with asthma medications. So hence, as I said, it can be quite confusing.

The most relevant type of medication that that you will come across in the child care service is the medication that fits into the asthma reliever groups. Okay, and you're probably familiar with some of those Ventolin, ASMOL, Airomir may be be quite not so much and Bricanyl. They're all reliever medications. The ones that are relevant to your age group, the five you know, under sixes goes up to over six now, doesn't it some of some of the kiddies? are generally the first three medications: Ventolin, Asmol, and Airomir and the reason why I'm saying those three is because they're the ones that come in a puffer shaped device or inhaler and they're the ones that we can use with a spacer device and in this age group that's the only device that a child can manage to have their asthma medications. The bottom one Bricanyl is also blue reliever, but it's not prescribed for children under six years or shouldn't be and if it is most children because it comes in a different type of device most children usually under about seven or eight can't actually use that device it's not used with a spacer. So yes, it's a reliever, but it's not as relevant to the child age that you care for.

So Ventolin, Asmol and Airomir in the puffer shape are the ones that you need to have in your either one of those in your services first aid kit and this is what the parents need to provide you also their own child's medication as well. They're all the same medication, Ventolin, Asmol, Airomir. Okay, they're all what we call Salbutamol. It's just different drug companies are branded them a different name. That's all. So the reason why I'm saying that is because they're interchangeable. If a child normally has or parents provide the child's medication, they normally have Airomir and all of a sudden it's missing it's been forgotten in the bag and in your service kit. You've got Ventolin, you can use it. Okay. It's exactly the same medication. And I guess what I'm going to say next is actually forget about the names. Because yeah, it's sometimes nice to know and most of us know about Ventolin the most important thing to remember here is the colour: they're all blue grey puffers. So if they're blue grey puffers, they can be used and these are medications that you use in asthma first aid.

They treat the symptoms and they treat them immediately usually within a few minutes, the child should start to show some improvement. So they work very very quickly, which is what you want when a child's having trouble breathing and they usually last for up to four hours. These are the ones that actually just open up the airways they relax the muscles. Sometimes children need them prior to exercise, but it's generally the older child. They also have side effects. Every medication has side effects. Okay, but these side effects are not harmful. This is when the child might tremor a little bit, okay usually get a bit hyperactive after they've had them that that's probably a good sign in a way and some children talk about they're feeling funny in the chest because their heart's pounding very very fast.

I want to really stress today that please do not, not give those medications because the child might be tremoring and you think that they're having trouble and you may be hurting them or making them worse you're not if that child is not able to breathe properly they need their their medication. Okay, so, please never ever stop or never be afraid. You will not overdose the child and when they come into our emergency departments, we give them huge doses of this medication. And we've never really give them anything to counteract those side effects they just resolve on their own and in medicine. We treat the most serious thing first, if something happens as a result of that treatment we sort that out later and the most serious thing with asthma is not being able to breathe, okay.

These medications are over-the-counter. Did you know that anyone can go and purchase them without a prescription? Did you also know that as the same as anaphylaxis that if a child is having an asthma attack or needing asthma first aid in your service, these medications are very very safe. And therefore you do not need a parental authority to give them. Yeah, and that's for a person that has or a child that has a known diagnosis but also with the child that it may perhaps be their first attack.

As I mentioned before that the age group that you care for we deliver these medications using a puffer and spacer. Okay, and it's the most effective way of delivering asthma medications even for adults in fact, not just for children, but we know adults don't always use their spacers. Children generally under four years of age will need a spacer device a puffer and they may also need a mask attachment because the most important thing of delivering medication using a space device is that the child can actually have a good seal either around their nose and mouth or the mask or they can make a good seal on the mouth piece. Okay, so usually over four years of age the child can make a good seal on the mouthpiece, but it's dependent it just depends on the child but that's the generally the the age group that we would either use a mask or not use a mask for.

So I've just got a video here to show you. I'm just going to demonstrate a child using a mask. Okay, with a spacer device.

Video

This is a small volume spacer and mask attachment that we use to give asthma medications to children. Not all children need a face mask. We usually use a face mask for children under four years of age or for children with special needs. So the mask fits onto the mouth piece like this and then the puffer goes into this hole here. Remove the cap, give a bit of a shake. And then place the puffer in here. So now it's important to place the mask over the child's mouth and nose to get a good seal. And then press the puffer once and then let the child breathe normally four times.

Can I put this on your face? Good girl, press it once and then we watch your breathing four times one two, good girl three four. And then if another puff of medication is required, we start again. Give it a shake. Place it back in, and the mask over the child's mouth and nose.

Good girl. One two three four, thank you. Good girl.

Christine

Okay, so the same with a child that doesn't require a mask just using the mouthpiece alone exactly the same steps most important points hopefully that you picked up on there. Shake the puffer. Always shake the puffer first. If you don't shake the puffer, you're not going to mix the medication and you may just be giving them propellant or not the correct dose of medication okay, and four breaths in between only one puff at one time and four breaths in between. With puffers and spacers hopefully the parents will be providing their child's own one, but if you need to if you've got them in your own first aid kits if you purchase a new one you need to make sure that it's prepared.

Now these days a lot of spacers now we've got a quite a few up here on the table these days a lot of spacers are made from materials which are anti-static and that's important that the spacer is anti-static because we don't want the medication clinging to the inside of the spacer when we first puff it in. But there are also spacers that are not made from anti-static material as well. So therefore it will cling to the inside so we just need to prepare them if you get a new spacer and simply just pull it apart wash it in hot soapy water. Don't rinse it because we want to leave a film of that detergent on the inside of the spacer. Okay don't dry it because if you drop with a cloth you go into a create static and then just put it all together once it's dry. Okay, so it's very important to be aware of that so just check the spacers that you purchase and if they're antistatic then that's fine but if they're not you do need to follow those instructions, otherwise, the child will not get the correct dose of meditation.

I just want to quickly go through recognising an asthma flare up and then I'm going to hand you over to Melinda and she'll get onto the nitty-gritty of actually doing the first aid. So asthma flare-ups can occur very suddenly or they can take some time. Sometimes over a few hours and sometimes over a few days. And I think one of the biggest things that we need to be aware of and especially when you're managing children in your care through through the day is observing and taking notice of how often that child may be having their symptoms and requiring their puffers because what we found in the past there's a lot of children that have actually had a very severe asthma attack or flare-up when you go back and look at what actually happened we did not always have things straight away.

Sometimes that child has shown signs two or three days beforehand so if parents drop their child off to you in center and say look, you know, they're fine now but they woke up through the night a few times and needed their puffers and and but they're fine now and then if that was happening on a regular basis two or three nights in a row that's actually a warning sign be really be careful of that child because that child is at high risk of having a very severe asthma flare up. Okay, or if the child is constantly requiring their puffers and requiring it more often than that four-hour period as I said the blue relievers generally last for four hours if they're requiring it more frequently than that that's a that's a warning sign as well.

Not all asthma attacks or flare-ups actually occur straightaway without warning generally the symptoms are a lot worse than usual all of the symptoms do not respond as they normally would or did not respond at all and it's really important to make sure that you can identify what the severity of that asthma attack because most children who have mild or moderate attacks or flare-ups in the service most of those those flare-ups can actually be managed in the service without calling an ambulance. You may still have to if the child doesn't respond to your asthma first aid but as a general rule most times, you can manage them in the service, but with a severe one definitely not and I'm sure you wouldn't because the child does look quite unwell and you would definitely need to call an ambulance for a severe attack. But they all need to be treated immediately because a mild and moderate flare-up can worsen within minutes. Okay, so just be aware that it can can happen very quickly.

So in a mild or moderate flare-up the child generally has difficulty in breathing. It's not it's not really affecting too much as to what they're doing. They often can still play. They're sitting on the floor playing around but you can see they're just working a little bit harder with their breathing generally if they are running around a little bit they might be coughing and wheezing a little bit but be aware that not all children will wheeze not all children will cough. They don't always have to have all the same symptoms. And as a general rule most children will in a mild situation be able to still talk to you without any problems when they're having a moderate attack they have a little bit more difficulty in their talking so they might only be able to get like a couple of or a few words out and then have to take a breath so it does affect their talking.

But recognising a severe flare-up is really what we want to point out to you today and you can see that the child, they're in there breathing. They're very very they're having great difficulty in breathing. They're quite distressed with it because when they have asthma the biggest problem is I can't breathe their air out they can actually get their air in they just can't breathe that out as much because the airways are so narrow and so they actually build up of air the air actually gets trapped in those airways so they can only take little short breaths when they're breathing and it's quite quite noticeable there they may have sucking into the throat so their whole throat sucks in a bit of a tug as they breathe in also their chest caves in as well and sometimes in between the ribs their skin sucks in as they breathe in and out. At this stage the child can't really say much at all.

So regardless of their age if they're crying they can't cry properly if they're able to talk, they might only be able to get one or two words out and sometimes none whatsoever. They're very distressed, they're scared. They're often pale and clammy. They may have a bluish tinge around their lips we don't really want to see that sign because it's quite a late sign but that's usually the first sign that says the child is just not getting enough oxygen to their body and also be aware of that child that all of a sudden they're having they're having trouble breathing and they're quite anxious and quite distressed and then all of a sudden they look quite relaxed. Okay, and you think oh my goodness they're okay now, but if they're still having trouble breathing just watch, and we'll show your video in a second watch the their movements of their chest and that this could be the child's becoming quite drowsy as well because they're not getting enough oxygen to their body and they're not blowing off enough carbon dioxide so just always be aware of that quiet child sitting in the corner.

Okay, and of course wheezing, okay wheezing you often hear when the child has mild or moderate attacks, but in severe we very rarely hear wheezing the airways are that narrow, so don't always wait for a wheeze It doesn't always occur. So I'm just going to show you a video of Joshua here. He's I think he's about four. He came to our emergency department and ended up in intensive care. He had a very very severe asthma attack. Obviously he was by the time you see him on this video he'd actually had treatment and he was still having treatment. So you can imagine he was a lot worse than what he is here. But I just want you to watch on the video watch his movement of his chest. Okay, and watch his throat so you can see some of the signs oh, and I have to say he recovered well, and he went home. I just need to point that out to you as well. Okay?

Video

This is Joshua and we are just watching Josh have an exacerbation of his asthma. At the moment, I'm seeing quite moderate to severe tracheal tug. We see it sucking in and being pulled backwards.

[child crying]

So his abdomen is moving out whilst his ribs are moving down. It's kind of moving in there almost like a seesaw. And that's what we call abdominal breathing he's whingy, he's moaning and he's unable to kind of express how he is feeling because he's unable to speak in full sentences.

[child crying] [inaudible dialogue from father]

Father

What movie do you want to watch?

[child crying]

What movie?

[child crying and unintelligible]

You want to watch Lightning McQueen... The cars movie? Any other movie you want to watch?

[child crying]

Just Lightning McQueen?

When when I'm looking after my son Joshua when he's unwell with asthma often initially he can have a little bit of a dry cough and sometimes he'll get a bit of a wheeze after he's been running around with him, unfortunately his symptoms tend to get worse quite quickly and the thing that I really look for is if he's having a dry cough and he's actually finding it difficult to talk as a result of that cough or his voice sounds a bit muffled because he's finding it hard to breathe that's a time when I definitely know his asthma is at a point where he really needs to go to the emergency department to get looked after.

Melinda

Okay, so I'm going to present the next half of it which is on asthma first aid so we really want this to be interactive and practical and I'll get you an opportunity to have the opportunity to practice using the spacers and placebos that you have here today. Now, you'll see on your desk that you'll have plans, which is a four-step asthma first aid plan that's called the kids asthma first aid plan. It's a nationally-recognised plan there are other plans available and they all say the same principles some are called the asthma first aid, St John's Ambulance have got their own Asthma Australia but they're all the same principles, the four-by-four which is a key number that you need to remember.

So this is actually really easy to actually learn how to do it's not complex. Is it possible to have one volunteer come up? Please with a spacer for me. Otherwise, I'm gonna have to pick someone from that table over there, huh? Thank you so much. Okay So what I'm going to do is I'm going to go through the four steps with you. And the the medication on the table was obviously not medication. It's placebo. What's your name?

Monique

Monique.

Melinda

Thanks Monique. Just take a seat. Fantastic. So I'll go through the first steps and the four steps and then what we'll do is we'll break into groups and you'll have an opportunity to practice doing it. Hopefully you can all see on this side. So I've got Monique here and let's imagine that Monique is a little bit younger. Okay, so she's let's just say she's four years old. We've always wanted to be a younger, haven't we? And so the first thing I'm gonna see is that she's having difficulty breathing I know that she's got asthma.

The first thing I'm going to do is I'm gonna sit the child upright. That might be just on a little chair some children prefer to stand against a wall. That's okay. We just you know, whatever's most comfortable for them. The next thing you're going to do is remain calm. I remember that training session that I went to I know what they did and you'll ask someone to get the asthma first aid kit or you'll ask the staff member to get that child's own medication and device which is clearly labelled with their name on it. The important thing here is don't leave the child alone. Okay, please don't leave them there and go off you need to call out and ask for help. At this point in time at step one. We really want you to start looking at the child and Christine outlined to you what the signs of a severe asthma attack were if you think that the child is having a severe asthma attack, please dial an ambulance immediately If you are in doubt you have concerns you're just not comfortable. Please dial or get someone to dial an ambulance. Okay? And also if the child is having difficulty breathing and is not known to have asthma please obviously dial an ambulance immediately also.

So step number 2 without delay. We're doing this quite quickly. Let's imagine that someone's come back with the asthma first aid kit or the child's medication what medication would I have in the event of asthma first aid? Ventolin. Ventolin remember is a brand it would be a reliever medication which is that blue cool in colouring but most likely it is Ventolin because they've got the biggest market share but yet in most cases. What else would be in that kit or what else would the child need to have? Fantastic a spacer and as I mentioned Monique is young. Monique is only three years old. So what else would she need? The mask okay to get that medication to be optimally delivered to the airways.

I want I would say to you often you get four year old girls that are actually, or three year old girls I should say sorry about the boys in the audience, but they could often pop their mouth on the mouthpiece of the spacer. That's okay. They can keep it there. That's actually really good. Okay They're going to get more medication. But in general we would have a mask. So I can't use a mask here on Monique, because obviously she's an adult we don't have the right size mask. But it's just a matter of popping the mask on the edge like so on the end. Okay like this, okay, and then I would put my and then I have my blue puffer here.

Okay, I'm giving the four puffs, I'm about to give the four puffs. What's the first thing I need to do? Shake it. Okay. We shake it. Okay. The next thing you need to do is you need to take off what's known as the dust cap. Okay? I have been known to leave the dust cap on and put it into the spacer so in a stressful situation you need to actually remember take the dust cap off. What spacer am I using? Am I familiar? Am I actually putting this the actual puffer in the right end? I have seen people put the puffers in the mouthpiece. Okay, so make sure you putting in the right end. So we've shaken it we put it up right like so okay. Let me just push it in. Okay, and then we get a good seal around the nose and mouth of the child. Okay, you're not going to get a good seal here because Monique's an adult. But let's just imagine that I've got that mask in place.

Okay, and then what I do is I'm going to give four puffs okay, so I place into our mouth like so okay just open your mouth like so. Yep, in there. It's not medication. Actually need to not bite it, fantastic. Okay, and then what I'm going to do, she's really nervous. It's actually not medication. That's fine. She's really nervous. Give one puff. Okay, one puff of the medication. Okay, and then put your mouth around it and then you're counting four breaths one breath two breaths three breaths and four breaths. Okay then I remove it from the mouth. I shake it again, okay I'm not going to do it again for you, but pop it into the mouth. Okay, push down on the puffer again I count that's the second puff. Okay, we shake it again. Okay the third puff push down on the top of the puffer again and we're counting a further four breaths one breath, two breaths, three breaths and four breaths. We shake it. We put it into the mouth like so and we do the fourth breath. Okay, so push down the top of the puffer and we count a further four breaths one breath, two breaths, three breaths and four breaths, so you heard me counting one two, three four.

I'm just not kind of counting them in my head I'm actually looking at the rise and fall of the tummy or actually placing my hand on the child's shoulder and counting that up and down, okay, so it's one puff at a time with four breaths after each puff, okay It's not all the puffs in the chamber at once. Okay one puff at a time. Sorry next one.

So step three is wait four minutes, see how the number four is coming through this so let's imagine that we've waited four minutes. If a child could not still normally breathe okay, and you're still seeing that that child is having difficulty breathing what are you going to do? You are going to go to step 2 on the chart and step 2 is give a further four puffs of which medication? Reliever medication using a? Fantastic... with four breaths after each puff. Okay, then you wait a further four minutes.

Okay, so see how I've done this twice I've gone through so effectively given eight puffs of medication. At this time you're constantly assessing the child to think do I need to call an ambulance or are they improving do I need to continue giving more? Now once you're assessing them and you're looking at them and visually see, are they talking you know? So they look better you then go to step number four, and if the child could not still breathe you're still seeing signs of that shortness of breath difficulty breathing wheezing chest tightness doesn't have to be all those symptoms the next thing you would do would be calling an ambulance. Okay, and what would you do whilst waiting for the ambulance? Fantastic you go through the four steps. Okay again, okay until the ambulance arrives and you'd assess after that four times again four puffs you've just given. Okay. Thank you so much for that. Thanks Monique. So that's the plan that you that's the plan that you should be trained when you receive training through the ACECQA training providers the four step asthma first aid plan.

So the next part of presentation I really want to talk to you about making your service what we call asthma aware. So I always say that whenever I go to a presentation I always want to take away one key thing that I can take back to my work or my or change my daily practice so hopefully in this section you can think about what you can do within your service to improve it. Okay. So the first thing I'm going to talk to you about is identifying children with asthma and ensuring accurate documentation. Now all these recommendations are really based on the education and care regulations, so it's really adhering to those and I've kind of adapted them for that but the most important thing is up upon enrolment obtain detailed asthma management information for your known asthmatics. I remember when my child started child care that they wouldn't actually allow the child to enrol unless all that documentation was filled out. So it's just one of those things that you kind of have to get parents to do.

Think about developing a risk minimisation plan, and have a medical management plan. For instance if you have a child that may be different from the four step asthma first aid plan they might be known as a High-risk severe asthmatic child that you need to be aware of that and develop that in consultation with the parents and certainly the GP. It's incredibly important to display all this information in an appropriate location and communicate this to staff including casuals and staff that may not be familiar with the service. Asthma first aid is everyone's responsibility, it's not just the director or the first aid, it really needs to be everyone's responsibility because that person may be away that day that the child has an asthma episode.

Ensure copies of plans and I've got and I'll go through the plan which is there which is one of our plans we're using across the state in the next couple of slides but that they're kept with all the child's medication and taken on excursions, if you're going on off-site excursions so that you know what to do in the event of and the child having an asthma episode. Ensure it is current and encourage review on an annual basis. Many services I know for example will send out a plan to all the parents of a child that's diagnosed with asthma at the start of the year to that to be developed in consultation with their GP. It's a great opportunity for the GP to actually review that child's asthma management. So it's a very good thing to do. Record all flare-ups on your incident injury and trauma and illness record so that's relevant to regulation 87 file and report to parents and also include a copy. So I'm sure you're aware of that.

The next thing is ensuring availability of the child's asthma medications. So basically parents need to provide the child's device and medication clearly named and labelled with a the child's name date of birth and medication expiry date. Okay, so it's important that and you have that information there check expiry dates and alert the parents, one of the most common questions that we will get is can you use an expired medication for example of I'm talking about about a reliever medication. You know if that is all you have the first thing I would do is if that's all you had. Yes, I would but it needs to be replaced. It's just not as effective as one that would be in date. Okay, but hopefully you would not get into that situation. You would have an updated one available.

Encourage access to by staff to all children's our own reliever and spacer device. We've had instance where services have actually locked them in cabinets and things such as that with the drug keys and things like that and we were just encouraged this easily accessible and it's very quickly accessible. The other thing is know how to correctly use the child's device. You all know how to use the spacer that I'm teaching you how to you we were using before but there are many different spacers are available and there can be just little things such as and I'll just show you for example this particular spacer. You need to take the cap off to expose the mouthpiece. Okay I've actually seen a lot of people put that in a child's mouth without taking the cap off so it actually does happen. So be familiar with the one that's in your asthma first aid kit.

Be familiar with where is the puffer. Where is it inserted? Does it have a spacer and the mask with it? Okay, and also self administration of preschool age. Children can self administer it's very important you get this documentation from the parent if they're happy for the child to self administer but please watch them. Obviously. It's usually only about over children about five and above, but it may be that child that's quite clever that can actually use it. Okay, you really do still need to assess them and monitor them while you're doing while they're giving the medication.

So in terms of policies and procedures I would say that Christine and myself offer a service and it's a free service where we're happy to actually review your policies if you email us through the www.asthmainkids.org.au, we'll actually go through your policy with you to ensure that it adheres to the regulations, so it's about ensuring access to child's reliever medication and their devices. It's about also nominating a staff responsible for the asthma first aid resources. We've got a fantastic checklist. They're available at our website that that staff can go through annually that they can check whether all the things are in place within their service and that can form a part of your policy.

Consider minimising potential triggers within the environment. So obviously on thunderstorm days, for example, you would you know keep the children indoors on those particular days. So they're just some of the things if you want to talk to us more about triggers there are some triggers such as you know, not you wouldn't vacuum but you know vacuuming while the children is in the room can also be you know an issue, using non-toxic things and low fume things are really important. So being aware of things such as that. Also ensure that parents and carers have a policy so you know, you hear it so many times so the parent will often say, you know, well I didn't know that was the case or you didn't tell me that so it's really important that you inform them of what we have in place within this service, so they're aware also their responsibilities as a parent and what they need to provide you with, okay?

The next one is minimising triggers. Sorry no, the next one... is ask parents to provide details of their triggers to support the development of a risk minimisation plan so if a parent knows that pollens are a particular trigger or exercise induced asthma is a trigger that you can take steps to minimise that prior to play and exercise and you can perhaps give them the medication prior to those that have exercise if that is what is listed and required for that child. Minimise exposure to environmental tobacco smoke, just a little note to say that it comes out through your pores is actually on your clothing so children can actually still be exposed to that. And so it also can be a trigger. Use products with low fumes and that a low toxic.

Consider risk minimisation for off-site excursions. Especially things like geocaching and off-site excursions. It's more of an issue with OSHC services that they often go into these, you know bush and things like that they're becoming exposed to different plants and things so just be aware of that. Aware of weather forecasts and identify trees grasses and pollens that may be a trigger. So a list of all the trees and that are available on the asthma Australia website and pollinating plants that you can consider if they're an issue within the environment that you're within that you're working within. Staff training so it's recommended that you complete ACECQA approved asthma management training every two years. We're a real advocate for delivery by you know health professionals such as all of us that are sitting around the table just because we're working in the clinical area we've had that exposure and experience with it. Encourage all staff to attend. I can't reiterate this enough more than more than one staff member needs to know what to do. It's everyone's responsibility.

Provide regular asthma first updates what you know I'd like to do is like in between those two years that you know once a year annually you go through you know your kids asthma first aid plan with your asthma first aid kit. You know in front of you know your staff and it's just team training day when you're talking about health in general. You know that little thing can take only about 15 to 20 minutes could that can make a big significant difference. And maintain individual training status. So ensure that you have up-to-date records of who has been trained within your service and that you know when they're due for updates.

The other thing is provide access to asthma first aid equipment and I can't stress this entirely enough not locking them away. We've got an example of an asthma first aid kit here. Which you can actually make up your own you don't need to have fancy bags if you want to purchase them they're available from asthma Australia. If you jump online they're available from many organisations. I've been at some services and they have it in a plastic ziplock bag with asthma first aid written or whatever is convenient for your service. But this is an example of one word that we would have in here would be your reliever puffer, your spacer, a mask and you would also need the instructions for the four step asthma first aid plan which is a mini version of the kids asthma first aid plan. So make sure that's in a prominent location.

Also make sure that the spacers are maintained according to the National Medical Research Council guidelines for infection control. So it's recommended that spacers should not be shared amongst children and adults for the purpose of asthma first aid in the community, so it's important that you have a spacer that can be replaced and/or can be given to that child and you replace it straight after. Can always say that with a caution though that if you get into any situation where you've got a couple of children having asthma episodes you've only got one spacer, to me, infection control goes out the window. The most important thing is actually getting that blue reliever medication to them. Okay. It is a priority. So make sure that you're kind of getting the ones that, the ones that are on the table there are a couple of companies out there that produce ones that we don't call them, we call them single-use. They're an example of what we would use in the hospital. But even though they're single-use they can last for up to a year on the one child. It just means it has to be replaced after you've used it on that one child. Okay.

Ensure that kits are maintained regularly because often someone will say little Joey's had asthma I've had to use a puffer out of the asthma first aid kit and then where does the blue puffer go and then you go to get it and it's not there. So make sure that someone is checking it regularly. Display asthma first aid plans, so the posters that actually you have on your tables there are available from the National Asthma Council. Okay, and they are available for free in terms of any different sizes you want. Again, you may choose to go with Asthma Australia. That's completely fine. They're all free but you can access them. If you're having problems accessing them please contact us and we'll put you in... we'll forward out your details on. But they should be in a prominent location they should be along with your CPR charts your anaphylaxis charts things such as that, they should be in that one area.

The next thing I'm going to talk to you about is the flare-up document action plan for asthma flare ups that has been developed. It was developed in 2017 and launched by the Health Minister and what we found was is that, you know, ASCIA did it really well in terms of having the action plan for anaphylaxis and services were saying when a child gets enrolled into, you know, a service or a school we are given with a multitude of different asthma record cards. Some are saying they need peak flows. Some are saying this and really, even though I'm considered a person who could understand these plans. I've actually stood there and gone I don't understand what this plan is actually saying, so how hard is it for you all? So what we’re wanting in terms of asthma first aid is a consistent message that is out there that you can identify those children with asthma and that you know exactly what to do and that is to follow the four step asthma first aid plan.

Now, this plan does not suit those children who their instructions may be a little bit different you know that five percent of the population of severe high-risk asthmatic kids then they would have a separate plan it might be you know, you've got a you've got to call an ambulance immediately. You've got to give eight puffs it may be but it's a very small percentage of the population. The majority of children that you're caring for should fit into this plan. The reason why we also promote this plan is that it promotes a four step asthma first aid plan, which is a nationally recognised plan which you're all trained in with your ACECQA training and it's whatever all the training providers are training to all schools and laypeople.

Okay, and the other thing is on the side is obviously you're identifying the child and they're also if they have anaphylaxis that you're aware that they have an ASCIA action plan that you need to refer to if that is the case. Okay, and the great thing is is that it's needs to be completed by the GP or the child's physician or a nurse practitioner so it's great because it's that opportunity for the GP to actually review the child's care so it's a good thing that they actually have to go there to actually have a review because sometimes children often only go to the ED parents only take them to ED or they only take them to their GP when they're actually unwell and really with asthma to have really good management you need to go on a regular basis to have your asthma management review and also it provides you with instructions down there on also on how to use a puffer and spacer with the mask if you are unsure of how to do it. And again, it's also signed by the parent. So the parent understands what has actually been provided and given to you and the instructions that have been given.

Now I just want to highlight to you going through the education care and regulations you’re probably like well, I know they're a really big booklet of all this information but the presentation we present today is all based on that so we're telling you that you know, what is in there? But I just want to point you to a few areas. Division two, incidents, injuries, trauma and illness. Ensuring you have appropriate documentation and notification to parents and services of the asthma flare up, so things such as you know having treatment record cards we have them if you would like them so that you can actually keep a list of you know the symptoms before symptoms after what treatment was given things such as that ensuring you've got your asthma record cards, your flare up documents making sure that the asthma first aid kit for each child is clearly labelled with the child's name date of birth and is available for access.

The next one is relevant to the division 3 which is medication policies and regulations 90 and 91. Establishing practices in the management of asthma and communicating this to all the staff one of the key things you can do in that area is develop an asthma policy and again, Christine and myself are more than happy to help you and support you in that area. We don't charge for that service so please contact us. The next one’s division four, ensuring appropriate procedures are in place and making sure you've got your asthma record cards, sorry your asthma flare up documents are displayed in a location that you've got your kids asthma first aid plan up that the medications are available The next one which I know that the previous girls talked about which you don't need authority to deliver a blue reliever, you know medication it is the same as what they were saying you don't need it, but you must obviously call an ambulance and you must notify the parent or the carer. And the other one is the first aid qualifications it outlines the requirements of a service so that you need anaphylaxis training you need asthma training. You need first aid training.

Ok so those are those three key elements. And just final in terms of the key messages and I love this little cartoon here. Excuse me. You can have can you help me? I'm a little puffin. It's this little puffin down there at the Asthma Clinic. We get a lot of puffing puffins coming into the hospital. I just wanted to say to you that asthma is a seriously life-threatening condition and a flare-up can occur without warning. When a flare-up occurs, we really need to commence asthma first aid immediately and it's best practice for all staff to know and I think that in terms of the education and childcare sector you are the leaders in terms of your training and standards that are required that all staff, you know are really engaged in this and you've got that requirement that the training needs to happen.

Ensure that you have appropriate asthma management procedures in place within your service and as I said think about one strategy that you can take away from this presentation today that you can make a real difference, it could be just the littlest things such as putting a poster up ensuring that your asthma first aid kit, you know you've got one that it's clearly labelled or if you do have it in your first aid kit that it is available quite quickly to get out. So that's it.

Just wanted to say to you that if you again training is available if you type in you know on the website on the ACECQA website education and care training asthma, and anaphylaxis providers, you know, it will come up, we come up as the Sydney Children's Hospital Network just so that you know and if you want further information the National Asthma Council is a really good point of call also Asthma Australia and the poster that you have there is called the kids asthma first aid plan and and certainly if you access our website we have lots more information on there that we're more than happy we also have a handout that we give child care staff and I believe that the department is actually going to load this up onto their website so you can actually review because you might say oh god, what did she say again? I can't remember what did she say? So it's all there for you to follow up with in our details? Thank you so much.

Any question? Great oh great... one.

Audience

Do you know if any e-learning training that can be done in the 2nd tier before you have to go and do your qualifications?

Melinda

I don't know of any e-learning, however we actually have developed an e-book for school staff okay, which you know you could actually download that it's available for free in the Apple iTunes Store and it's an evidence-based resource that has been published and a lot of the content that we use for childcare is taken from the school sector. You would need to look at your relevant, you know departmental guidelines, but it is pretty much it goes through the four step asthma first aid plan. It's me talking it's Chris talking, we actually got a scenario of a child having an asthma episode and we actually go through asthma first aid steps. So yeah, that is a great resource that you could use. It's called the Asthma First Aid Management In Schools. Yeah, and it's available in the Apple iTunes Store for free and if you can't find it we can forward you the link okay, so a lot of schools we're finding that they're not able to come to face-to-face. Yeah. It's on our website you can also look at our website.

What we found was is that staff aren't able to come face-to-face so we develop this resource and we evaluated it and it compared to be as favourable as face to face in terms of knowledge and confidence of staff in asthma first aid. So it's been taken up across the world. So we're looking at doing it at a child care also yeah, but it's a good resource in the interim. Yes

Audience

Do you have a recommendation to do the ACECQA referred training in two years for most of us we cover this training in our first...

Melinda

You cover this in first aid, yeah yeah, yeah, you can so yeah, there is a course which is HLT you might know this, Sarah, HLTPE…

Sarah

…HLTAID004…

Melinda

…004s So there is a course that actually... she knows the course codes because that she's... They're a recognised provider which actually does have components of your asthma first aid, your anaphylaxis and your asthma. Yeah

Audience

So your recommendation was every two years?

Melinda

Yeah, we would like that yeah, it would be yeah it would be

Audience

So that's your recommendation that you have, not a regulation?

Melinda

Yeah, not a regulation. Our recommendation and that's why we put in there: recommendation.

Christine

Can I just say that apparently the reason why we recommend that is everyone that develops or everyone that owns a course is the one that actually does the recommendation so it's not... there's nothing set it's simply just and we we consider three years is way too long to be quite honest. So that's our recommendation. Yeah

Audience

But I think you know as you go through within our own services we may do training and going through this more regularly, but just when you had an outline to ACECQA approved, I thought...

Melinda

Thank you any other questions? What we're talking that children that are not diagnosed with asthma

Audience

…though they bring in Ventolin because they're wheezing or they're got viruses or whatever But they don't have a plan. How do we deal with that with?

Christine

That's where that flare up document comes in place our recommendation would be that every every parent regardless of whether they say their child's got asthma or not actually be given one of those documents on enrolment to get it completed because it's actually so it's not actually saying that this child has asthma it's saying what to do if a child has an asthma flare up same as the induced wheezes. The document itself is it's very easy for GPs. So you'll find that they will actually get it back to you the parents will because the GPs don't actually have to think about it. It's all done for them.

So you won't get those odd two to six puffs, you know the subjective or [unintelligible] doses because it's actually we've actually done it all for them. So they just have to sign it make sure that they confirm any allergies and vice versa. So a child that has has not been diagnosed with asthma can still have this form completed. Okay, so you would still do the same things. And as I said we often still treat the induced wheezes with the same medications as asthmatics. Does that answer your question? Yeah

Audience

So I had a child that came in recently with this and I said that they needed to have an asthma action plan as well because they'd been in hospital diagnosed with with asthma overnight. So do... I have I done the wrong thing or is the child diagnosed with asthma or is there going to be a flare-up in the future because I can't take that risk at work if I don't have the proper medication for the child and they're on their flare-up it was like eight to ten past or something really quite high because I actually had it written in... it didn't change so it was like that? Yeah, they doctor actually had written...

Christine

On this form?

Audience

Yes.

Christine

Oh... naughty [laughs]

Audience

It was the first time I'd seen and it says flare-up so for me that's something short-term so if they're diagnosed with asthma then I need to have an asthma plan I need to create a risk management or else I'm not in... I'm not in following regulations and that causes a whole lot of issues. So what would your recommendation be?

Melinda

That's an interesting one isn't it?

Christine

Okay, so I guess really what what this form is it's the recommended form for New South Wales, okay, that's been recommended and developed by education people everywhere and it is the form to be used in New South Wales as Melinda said there will be a few children that may not fit into the four by four by four and therefore those children may require the very first time they have symptoms, eight puffs, 12 puffs at the very first time and they're the ones that will need an action plan. But as a general rule, you shouldn't need both.

So if a doctor feels that the child is not fit into this and he needs he or she needs to write out a proper asthma action plan that's developed specifically for that child and it needs to be very specific none of this two to six puffs or two to eight puffs where necessary. If you get one of those you send it back and you say hey, I want specific instructions. So... it depends on on what the doctor prescribes and what the doctor gives you but if you if the doctor sends you back that plan and then scribbles all over it makes it you need a proper action plan for that child.

Audience

So if I get if I get one that's exactly like that that can last 12 months and that if a child has a flare-up at the centre, that's what we follow?

Melinda

Yes. Yes. Yes. Unless you are provided with a different documentation from that GP But we don't want to see scribbling on there saying you're changing the puffs and changing that If they're scribbling and adding their own information that means that they need an individualised asthma action plan or education from the GP.

Christine

We would always recommend we would always recommend anyway that even in the event of a child having an asthma flare up even though you've got even though you may have an action plan then you don't want to wait for that plan to come to you before you start doing treatment so we would always recommend to start the four steps anyway, and then change if it's relevant. We're around to answer any more questions if you have... Thank you. Thank you.