Childhood Asthma

Asthma is the most common serious chronic disease of childhood, affecting nearly five million children in the United States. Characterized by coughing, chest tightness, shortness of breath and wheezing, asthma is the cause of almost three million physician visits and 200,000 hospitalizations each year. In infants and children, asthma may appear as a cough, rapid or noisy breathing in and out, or chest congestion, without the other symptoms seen in adults.

Diagnosis

Proper diagnosis and management of childhood asthma requires a physician who recognizes the unique characteristics of childhood asthma. To make a diagnosis, a physician will consider: the child’s family history of asthma and allergies as well as personal medical history, which is often given by the parent rather than the child; allergens and irritants to which the child is exposed; frequency and severity of symptoms; other factors such as respiratory infections, which may be considered as explanations for wheezing ;objective measurements of breathing, usually through use of a machine called a spirometer. For children, asthma symptoms can interfere with many school and extracurricular activities. Parents may notice their child has less stamina during play than his or her peers, or they may notice the child trying to limit or avoid physical activities to prevent coughing or wheezing, which occurs when the air must move through the narrowed airways typical of asthma. Regular breathing should be quiet; a child with asthma has noisy breathing. More subtle signs of asthma, such as chest tightness, are often not identified as such by children because they are so used to living with it. Often, recurrent or constant coughing spells may be the only observable symptom in young children. Up to 80% of children with asthma develop symptoms before age five. Thus, a child’s physician must rely heavily on parents’ observations to determine the signs of asthma and make a proper diagnosis. Some children wheeze from respiratory infections, which they may outgrow. Differentiating between these infections and asthma may involve having an experienced physician observe the child over the first few years of life to determine whether episodes of wheezing persist or resolve in a few years. Persistence of wheezing may indicate asthma, which should be treated as soon as possible to avoid future complications and long-term effects. Asthma may also be triggered by a family history of allergy and the child’s exposure to allergens—any substance that can trigger an allergy. Common allergens include dust mite and cockroach droppings, animal dander (dead skin flakes), pollens and molds. If you suspect that allergens are triggering your child’s asthma, take him or her to an allergist for proper testing and suggestions on how to limit the child’s exposure to allergens. It is essential that children be protected from irritants such as tobacco smoke since this causes chronic irritation of the airways. Studies have documented that children born to a mother who smokes or who live with a smoker have a much higher incidence of asthma and respiratory infections. Based on a child’s history and symptoms, a physician must consider various conditions and the child’s environment when making a diagnosis of asthma.

Management

Goals for managing childhood asthma are: to control asthma by reducing environmental triggers, promoting a healthy lifestyle including proper rest, exercise and nutrition, and ensuring proper medication use to foster emotional health so the child thinks of himself or herself as a healthy person, not a sick one, and is confident of his or her ability to confront challenges and succeed,to prevent symptoms from affecting the child’s energy levels, concentration, attention span, peer relations, physical activity and overall well-being. Once asthma is diagnosed, the child’s physician and parents or caretakers will work with the child on an effective management and treatment plan. If the child is very young, parents or caregivers must assist by observing for possible asthma symptoms, helping the child use a tool called a peak flow meter to measure the ease or difficulty of breathing objectively and ensuring the child receives appropriate medications when needed. Older children can follow a management and treatment plan on their own with less supervision. However, if a child’s asthma becomes difficult to manage, it may be that he or she requires closer supervision by parents. When their child is diagnosed with asthma, parents frequently ask questions such as: What is the natural course of asthma? Will my child outgrow it? Will the symptoms improve? Since asthma is a disease that does not follow a set course, predicting a particular child’s symptoms and clinical progress is not possible. Some children have asthma symptoms that improve during adolescence while others worsen. Often, symptoms in young children seem to resolve, but their asthma may flare up later in life. However, for most children, asthma can be controlled with appropriate management and treatment. While asthma is a chronic illness, it should not be a progressively debilitating disease—a child with asthma can have normal or near-normal lung function with appropriate management and medications. It is also very possible for a child with asthma to have healthy endurance and even excel in athletics—many Olympic athletes have asthma. Parents may have the urge to restrict their asthmatic child’s physical activity to prevent wheezing. However, once a child is taking proper medications, aerobic exercise needs to become part of his or her daily activities, because it improves airway function. Children must be encouraged to participate in normal activities as much as possible.

Devices and Medications

As part of an effective asthma management plan, the child’s physician may prescribe specific medications and devices. These can include a peak flow meter to measure ease of breathing, metered dose inhalers, spacers that attach to inhalers, nebulizers that deliver medication in a mist, dry powder inhalers, or oral (tablet) medications. The physician should not only prescribe these medications and devices but should teach children and parents how to use them correctly.Metered dose inhalers and dry powder inhalers can be used by older children, and can deliver several types of medications. Nebulizers are particularly useful for young children or for those whose asthma is not well-controlled with other medications. For severe asthma, oral medications may be necessary. It is important for parents to be aware of the way certain drugs work as well as their side effects. For example, oral medications are more likely to result in side effects than inhaled medications. Depending on the drug used, side effects may include a headache, hand tremors, stomachache or tiredness (also caused by night asthma). These side effects may impair the child’s concentration level, handwriting or ability to learn in school. Teachers and parents must work in partnership to identify these symptoms. Parents can then work with the child’s physician to determine if a change in medication or dosage is needed. An asthma specialist will prescribe the medication that is best and most efficient for the child. It is important that the child continue to take medications as instructed, even if he or she feels "fine." Many must be taken on a regular basis, even if there are no symptoms, to maintain optimal airway function. For more information on asthma medications, please see the Tip brochure in this series.

ASTHMA AT SCHOOL

The child, family, physician, and school personnel must work together to prevent and/or control asthma symptoms at school. Many children with asthma are embarrassed about their need for medication. In some cases, children may have difficulty because they are required to go to another part of the school building, such as a nurse’s office, to take their medication. School officials and parents must create a supportive environment. With the approval of physicians and relatives, school-age children with asthma should be allowed to carry metered dose inhalers with them at all times and use them as appropriate.

To ensure optimal care at school, parents can also take the following proactive steps:Inform all relevant school personnel of the child’s asthma; meet with teachers, the school nurse, coach and perhaps the principal at the beginning of the school year.Have your child’s doctor explain the asthma medications the child must take and possible side effects. Emphasize that the child must be allowed to take required medications on schedule. Ask them to assist when asthma flare-ups require immediate treatment, but that they treat the child with asthma "normally" like other children.Before a child with asthma starts a physical education class, ask the child’s doctor to write a letter to the teacher/coach outlining the nature of exercise-induced asthma, prevention techniques, caution signals, and explaining the child’s asthma management program. Because certain environmental conditions—such as cold and dry air, wind, pollution, or high airborne pollen or mold levels—may increase a child’s asthma symptoms, the child and teacher/coach should know which medications to administer to prevent exercise-induced asthma.

For children with asthma to function normally, school personnel, families, and health care providers must effectively communicate and work together to encourage them to participate fully in activities with their peers. This team effort will help create an active, healthy and safe environment for the child—both in and out of school—and ensure optimal care.