Background and aim We report the case of a child with difficult and life- threatening asthma whose control improved with directly observed therapy (DOT). School based DOT improves adherence ¹ but to date there are no publications of combined home and school DOT.

Case report The child was commenced on Beclomethasone aged 4 years following repeat admissions with asthma. Clinic attendance was erratic. Occasionally she arrived in clinic with wheeze and saturations in the 80’s. Health behaviour did not change despite warning parents about risk of death. A common assessment framework (CAF) was initiated.

Following a life threatening asthma episode (aged 6 years) maintenance therapy was increased to Seretide 250 mcg bd (spacer) and Montelukast 5mg od. IgE was 1556 and House Dust Mite RAST positive. Clinic attendance and asthma control temporarily improved. Following another two admissions with life threatening attacks SloPhylline 250mg am/125mg pm was added. Theophyline levels were found to be <2 mg/l after a further serious admission. Maintenance oral prednisolone was commenced and she was referred to tertiary hospital for consideration of Omalizumab. She was concurrently referred to Social services.

At case conference she was put under a child protection plan for reasons of child neglect. DOT service at home and school was commenced. Non-attendance to clinics immediately ceased. There were no further hospital admissions. She was weaned off prednisolone. SloPhylline was reduced to 125mg bd. A lower dose of Seretide was attempted but unsuccessful.

DOT was funded by Social services. The cost was £24.24 per week term- time and £37.66 per week during school holidays.

Discussion Before starting regular oral prednisolone or Omalizumab in difficult paediatric asthma a trial of DOT could be worth considering. It is safer and cheaper.

References

1. Halterman JS et al. Randomized controlled trial to improve care for urban children with asthma: results of the School-Based Asthma Therapy trial. Arch Pediatr Adolesc Med. 2011 Mar;165(3):262–8. doi: 10.1001/archpediatrics.2011.1.