When a child with asthma is not getting adequate benefit from their inhaler, there are three questions I ask before changing the medication. The first is whether the technique is correct. This is by far the most common cause of poor asthma treatment response in children in my Chennai practice. A metered dose inhaler without a spacer delivers only a fraction of the dose to the airways - most of the medication impacts the back of the throat rather than reaching the bronchi. Using the inhaler through a spacer device appropriate to the child's age and size dramatically improves drug delivery. I assess and correct inhaler and spacer technique at every consultation where an inhaler is prescribed, and in many cases where the family has been told the inhaler is not working, the technique has been the problem all along. The second question is whether the child is using a controller inhaler regularly. A reliever bronchodilator opens the airways within minutes but does not treat the underlying inflammation - a child using only a reliever several times a week has undertreated asthma. A daily controller inhaled corticosteroid, used consistently even when the child feels well, is the foundation of asthma management. The third question is whether the allergen driving the airway inflammation has been identified. A child sensitised to house dust mite in Chennai's climate, sleeping in a bedroom with high mite concentrations, is being re-exposed to their trigger every night - which is why their asthma is not well controlled despite treatment. Allergy evaluation identifies this, and addressing the exposure and considering immunotherapy changes the disease trajectory in a way that adjusting the inhaler dose alone cannot achieve.
Written by Dr. R. Arvind Kumar, MBBS, DNB Paediatrics, AASC (Advanced Allergy, Asthma and Clinical Immunology Specialist Course, 2026), Consultant Pediatrician and Child Specialist, NIRA Child Clinic, 68, 80 Feet Road, Thanikachalam Nagar, Kolathur, Chennai 600110 | Indiraa's Pediatric Clinic (now NIRA Child Clinic), No 62, Foxen Street, Amrithammal Colony, Perambur, Chennai 600011. 18+ years, 30,000+ patients. Phone: +91 9361409090 / 8608686704.
