Starting a new school with asthma – what to advise

Care from a knowledgeable and supportive general practice nurse (GPN) can be crucial when a child changes school, to enable them to stay well so that they can learn and achieve. In this way, GPNs are vital to improving a child's life chances and overcoming any social and emotional disadvantages.

Emma, aged 11, from a disadvantaged part of Greater Manchester is one such child. This article illustrates the challenges that she faced and the role of a GPN in her care. The events are real, but the description of her care has been added and the child's name changed.

Back to school exacerbations

GPNs are more than alert than most health professionals to the rise in number of exacerbations of asthma as children start school or go back to school each September.

There are several reasons for this:

• Children are mixing with lots of other children and passing on common colds and respiratory viruses that are prevalent in the autumn
• After a summer of being outdoors, cooler weather can not only trigger some children with asthma, but others may be triggered by house dust mite droppings as they begin to spend more time indoors
• There may be autumn spikes in the growth of plant moulds
• Children's routines in taking their preventers daily may have been disrupted over the summer, meaning that airways are more sensitive
• The school may have been deep cleaned over the summer, meaning that asthma may be triggered by increased cleaning product exposure
• Starting, returning or changing school can be both exciting and daunting. Stress, fear and excitement can all trigger asthma
• A return to regular exercise at school after a summer break may trigger those with exercise-induced asthma
• The journey to a new school may mean being faced with new environmental triggers such as more traffic pollution or past more highly allergenic plants and trees, such as silver birch (Henry, 2021)
• Children starting secondary school may be introduced to new chemical triggers in science or technology classes. (Asthma and Lung UK, 2022)

Emma's back-to-school asthma review

Emma's GP practice prioritised asthma reviews for those at most risk, in children of school age during the late summer. The GPN was aware of Emma's frequent exacerbations, meaning courses of oral steroids and trips to A&E several times a year. The GPN knew that Emma's asthma triggers were anxiety and infections. Previously she had referred Emma to the asthma specialist nurse who had reviewed and changed her treatment. The GPN called Emma in as a high priority for an asthma review. This was done face to face rather than remotely, so that the GPN could see not only verbal but non-verbal cues and could review inhaler technique more easily. Emma's grandmother spoke of her concern regarding transition to secondary school, some miles from home and not round the corner, as her primary school had been. The GPN noted the anxiety in the grandmother and in Emma and focused the consultation on instilling confidence in Emma's self-management of her asthma, which to date had very much been managed by her grandmother.

BOX 1.CASE STUDY: EMMAEmma's transition to secondary school didn't go smoothly as she had severe asthma. Her primary school had always been very supportive and gentle with her, but secondary school felt very different. Emma was a very anxious child and her grandmother, who was her main carer, was extremely protective of her. This reinforced Emma's self-concept that she was very vulnerable and needed lots of support.Emma's mother had been the victim of domestic abuse and could not care for her. This had traumatised Emma, who saw her mother only once or twice a year and missed her badly. She had met her father a few times in her life and it had not been a positive experience.Emma started to experience real difficulties at her new school, because her teachers were unaware (they said) of how bad her asthma was, and the anxiety that accompanied it. They didn't allow her to keep her inhaler with her and they sometimes didn't give her permission to leave class to go and take her inhaler. Emma had appointments with the child and adolescent mental health service (CAMHS). This meant missing school again and Emma told her GPN that the school didn't like it. She would lie in bed and worry about school and how she would cope. On the advice of the CAMHS team, her grandmother made Emma a ‘worry jar’; where Emma would write down all her worries and place them in the jar before she got into bed every night. But it didn't help.As her anxiety rose, so did her asthma, meaning that her school absences started to creep up. Her grandmother was called into school to account for these absences. She explained how poorly and distressed Emma could get with her asthma, but the teachers took no notice, according to the grandmother.One day, Emma was disciplined at school for something that she hadn't done and according to her grandmother, she had a ‘melt down’ and was off school for a couple of weeks with acute asthma. When Emma's grandmother reported this latest episode to the GPN, this GPN knew that she had to act. With the family's agreement, she rang the local school nursing team to explain her concerns and followed this up with a written referral, giving the story from the family's point of view.After this, things got better. The school nurse explained Emma's asthma and anxiety to the school and offered the staff an asthma update. The school explained their worries about Emma missing so much school and how this might affect her learning. Together, the family and the school made a personalised plan, supported by the CAMHs team and the school nurse. The GPN was kept informed by the school nurse, so support was integrated.Take home messages

• The NMC code (2018) requires nurses to listen to people and respond to their preferences and concerns (paragraph 2) and make sure that people's physical, social and psychological needs are assessed and responded to (paragraph 3)
• Asthma can cause anxiety in adolescent children (British Thoracic Society and Scottish Intercollegiate Guidelines Network, BTS/SIGN, 2018, paragraph 11.5.1, 2018)
• The whole family had experienced trauma. There is an association between parental or caregiver stress and childhood wheezing (Reyes et al, 2011)
• Anxiety is a trigger for asthma (Asthma and Lung UK, 2023)
• Children experiencing social disadvantage are more at risk of asthma exacerbations (Asthma UK, 2018)

Emma would be taken by car to her new school and the GPN wondered if a 20-minute trip across a busy city by car would expose Emma to high levels of particulates, since travelling in a vehicle concentrates air pollution, compared to walking or cycling (King, 2017). She decided to watch and wait rather than increase anxiety by mentioning this.

The ‘ARC’ asthma review

The GPN completed an ‘ARC’ review (Hickman, Zadeh and Winter, 2020):

• Assessing asthma control, severity and risk of exacerbations using a validated or endorsed tool
• Reviewing diagnosis and management
• Collaborating with the patient to develop, maintain and review a personalised self-management/action plan

Routine care

The GPN then discussed routine care:

• Supporting Emma to be self-reliant; remembering to take her preventer each morning and night, rather than have her grandmother administer them – although the grandmother would still check this (BTS/SIGN, 2018).
• Emma knew to tell her grandmother if she is getting symptoms or using her reliever inhaler three or more times per week, then her grandmother could book a review with the GPN
• The school should now allow Emma to carry her own devices, unlike at primary school where they were stored but were easily accessible if needed
• Inhaler technique with a spacer was excellent. The GPN asked if Emma was self-conscious about taking her inhaler in front of others. She was. The GPN prescribed a smaller spacer that was more discreet but knew that confidence would take much longer to achieve
• They discussed the idea of an ‘asthma buddy’ that would help Emma and speak up for her. She couldn't identify anyone but said she'd try to find a new friend to help her
• The GPN arranged for the prescription of an extra reliever inhaler in its original packaging with a prescription label alongside the new spacer, to take to school, so staff would know exactly what she had been prescribed.
• Emma was advised to tell staff if she took her inhaler in school and it didn't help, or if symptoms come back.
• Together they completed a school asthma card (School Asthma Card), giving details of asthma management and permission for the school to administer Emma's inhaler, or for Emma to take it under supervision – and to let the grandmother know if she had needed it

Box 2.Recommended school protocol for the use of emergency reliever inhalers

• arrangements for the supply, storage, care, and disposal of the inhaler and spacers in line with the schools policy on supporting pupils with medical conditions
• having a register of children in the school that have been diagnosed with asthma or prescribed a reliever inhaler, a copy of which should kept with the emergency inhaler
• having written parental consent for use of the emergency inhaler included as part of a child's individual healthcare plan
• ensuring that the emergency inhaler is only used by children with asthma with written parental consent for its use
• appropriate support and training for staff in the use of the emergency inhaler in line with the schools’ wider policy on supporting pupils with medical conditions
• keeping a record of use of the emergency inhaler
• supporting pupils and informing parents or carers that their child has used the emergency inhaler
• having at least two volunteers responsible for ensuring the protocol is followed

(Source: Department of Health, 2015)

Despite the careful asthma review, Emma got a chest infection shortly after starting her new school and this disrupted the transition plan that Emma's primary and secondary school had put into place. As a result, Emma felt like a stranger and the support to settle in that had been available to her peers in their first few days wasn't offered to her.

Stress of transitioning – best practice

• Children and young people experience many educational transitions:
• starting preschool, primary or secondary school,
• moving to a new class each year,
• transitioning through key stages,
• starting college or sixth form
• leaving school all together.

These transitions can be especially challenging for some, such as those with special educational needs and those with long term conditions such as asthma. Asthma is the leading cause of disease-related school absenteeism (Szefler et al., 2019) and poor experiences of transitions can lead to worsened outcomes (Demkowicz et al., 2023). Children and young people themselves see 4 themes as important:

• Helping children and young people understand what to expect. Most secondary schools and their ‘feeder’ primary schools (those in the catchment area) offer taster days where children visit their new school and are shown their classroom
• Developing and sustaining relationships and support; welcoming and ease people in and introducing them to their new form teachers, being friendly and building rapport with new pupils
• Schools that are responsive to individual needs and vulnerabilities. There should be universal support for all children and targeted support for children with additional vulnerabilities, such as those with long term conditions such as Emma's (Devon County Council, online)
• Managing loss and providing a sense of closure. Schools may want to creating keepsakes such as cards or books with messages or photographs from teachers/peers, hold celebratory events such as parties or discussions of next steps, and include more informal ‘fun’ time with peers and staff in the stages leading up to a move. (Demkowicz et al., 2023)

As a child who has suffered adverse childhood events: witnessing domestic abuse and being separated from her mother for most of her life, Emma experienced additional disadvantage, as do others who experience inequalities. This can lead to even higher rates of school absenteeism and loss of educational hours (Szefler, 2019). In the same city as Emma, one school academy deputy head teacher in a disadvantaged area told the author that over the course of 7 years, he had calculated that young people on the school asthma register lost the equivalent of a whole school term due to sickness.

School actions

The special educational needs and disability coordinators (SENDCOs) in primary schools are the ones that would pass on information at the times of transition (key stage 1 to key stage 2 or on to secondary schools for example) about individual vulnerabilities (Devon County Council, online). School nurses are well positioned to support asthma management and improve school attendance. However, the number of school nurses has fallen by 35% in the last five years to about 2,000 (Hall, 2023) and some parts of the country don't have a school nursing service at all. Instead, in most places there are integrated multidisciplinary teams supporting children of school age. Good liaison between GPNs, school nurses/integrated teams and SENDCOs can help them to support children like Emma with complex needs.

It is good practice for schools to hold transition planning meetings involving the primary SENDCO, secondary SENDCOs (for key stage 2 to key stage 3 transitions), parents/carers and any other agency involved in supporting the child, such as the school nurse. It is also good practice to involve parents in transition planning at every stage (Devon County Council, online).

From 1st October 2014 the Human Medicines (Amendment) (No. 2) Regulations 2014 allows primary and secondary schools in the UK to buy salbutamol inhalers, without a prescription, for use in emergencies.

Schools are not required to hold an inhaler – this is a discretionary power enabling schools to do this if they wish. Schools that choose to keep an emergency inhaler should establish a policy or protocol for the use of the emergency inhaler based on national guidance (Department of Health, 2015; Department of Education Northern Ireland, 2015; Scottish Government, 2017; Welsh Government, 2017).

Summary

Transition is often stressful and emotional but can be a potentially exciting time for a child. However, if your patient has additional needs, like a long-term condition, careful planning and support are required. GPNs need to be on the lookout for children whose schools might offer universal rather than targeted support and may prioritise school attendance and educational achievement over supporting individual children who may need extra care, like Emma. Reaching out to local school nurses or integrated teams supporting children aged 5–19 in the absence of school nurses, can help to avoid exacerbations of physical and emotional distress.