Most consultants deviate from asthma guidelines

EDITOR,--The British Thoracic Society recommends that children who need anti-inflammatory treatment should be given cromoglycate in the first instance (rather than inhaled steroids).1 We investigated our impression that few British consultant paediatricians use cromoglycate as first line treatment. We sent a questionnaire to 100 randomly selected general paediatricians. They were asked to consider “children aged between 3 and 7 years old who have never had preventive treatment before and who you think need it now.” They were asked to estimate “roughly what proportion of such children would you start off by prescribing sodium cromoglycate for?” There were four responses to choose from: almost all, more than half, less than half, and hardly any. Those who reported using sodium cromoglycate in less than half of the children described were then asked to circle one or more of five reasons for not using cromoglycate more.

Ninety two questionnaires were returned, of which 90 were complete. Respondents estimated the frequency with which they used cromoglycate as first line treatment in the proposed context as follows: almost all, 19; more than half, 30; less than half, 21; and hardly any, 20. The reason most commonly cited for not using more cromoglycate was that it was “less effective than inhaled steroids” (29/41 (70%)). Other reasons included the frequency of doses (24/40 (58%)) and problems with inhalers (12/41 (29%)).

The British Thoracic Society's guidelines state that “patients should start treatment at the step most appropriate to the initial severity.” Nevertheless, the spirit of the guidelines is that cromoglycate should be the first step in children. We found that only 21% of British paediatricians use cromoglycate as the first step in “nearly all” children in the context we proposed. Thus, according to their responses to our questionnaire, 79% of British paediatricians deviate from the guidelines.

When audit shows a gap between protocol and practice then either the guidelines or the practice, or both, should change. Unless more evidence supporting the use of cromoglycate is produced, its use seems unlikely to increase. Thus we believe that the British Thoracic Society's guidelines should be changed to match more closely what paediatricians do.