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Guide to Asthma

When children have asthma, the airways leading to the lungs (called bronchial tubes) become inflamed and narrowed. These overly sensitive airways go into spasms, causing repeated episodes of shortness of breath, coughing and wheezing (a whistling sound when your child exhales). Asthma ranges in severity from the mild, intermittent form that barely interferes with kids' lives, to severe, persistent cases that require constant monitoring and can lead to frequent scary trips to the ER. Asthma can be frustrating to a kid who struggles to keep up with friends, and terrifying to parents watching their child fight to breathe.

Asthma is the most common chronic illness among children, although it can affect people of any age. Around 7 million children have been diagnosed, and about 10 to 15 percent of grade school children have or have had asthma. Asthma rates more than doubled between 1980 and 1995, and remain at historically high levels, although encouragingly, death rates from the condition have declined in recent years. About half of all young children diagnosed with asthma appear to outgrow it by adolescence, but these individuals still have sensitive airways and symptoms can reappear later in life.

Asthma can either be the allergic type, prompted by allergies to pollen, pet dander or other allergens, or the non-allergic "intrinsic" type, triggered by things like cold air, viral infections, exercise, stress or smoke. They can also have a combination of the two. Although the triggers are different, the symptoms are the same.

Although asthma is a serious, chronic disease, the old stereotype of the lonely asthmatic child trapped in the house, unable to play with friends or participate in sports is far from true. Today, thanks to advances in understanding asthma and effective treatments, kids with well-managed asthma can expect to live as active a life as their non-asthmatic peers - and being active can help improve lung function. In fact, many Olympic athletes have carried inhalers for asthma, and elite athletes like former Hall of Fame running back Emmitt Smith and marathoner Paula Radcliffe haven't let it stop them.

The primary symptoms of asthma are regular coughing (especially at night), shortness of breath, wheezing (a whistling sound when your child exhales), and chest tightness. Not all children who have some or even all of these symptoms have or will develop asthma. In fact, as many as half of children have at least one episode of wheezing before age three, yet only 15 to 20 percent of these kids go on to have lifelong asthma.

Indicators that a child may develop asthma are:

 

  • Allergic rhinitis: sneezing and runny nose triggered by pollen, pets or other allergens.

  • Atopic dermatitis: allergic rashes (usually viral) and dry skin, particularly eczema.

  • Frequent respiratory infections: ask your pediatrician if your child gets infections like bronchitis more often than her peers

  • A family history of asthma and allergies

 

CAUSES

 Doctors aren't sure why some children develop asthma and others don't, or why the disease increased so alarmingly during the last decades of the 20th century. Research also shows that some groups—like boys, African-Americans, and kids who live in Northeastern cities—are more likely to get asthma, but again it does not tell us why. The primary risk factors for asthma are

 

  • Heredity: Both a family history of asthma, particularly in parents, and a family history of allergies predispose children to asthma. If one parent has asthma, the chances are 1 in 3 that a child with develop asthma. If both parents have asthma, the chance rises to 7 in 10.

  • Living in an urban area: Poor air quality and more exposure to indoor irritants may be the reason cities seem to have more children with asthma, but researchers aren't sure - it could be the concentration of high-risk populations as well.

  • Frequent respiratory infections, especially respiratory syncytial virus (RSV): Some infections, however, help children develop a healthy immune system, so it's not necessary to take extreme steps to prevent illness. In fact, there is a theory, called the "hygiene hypothesis," which suggests that overprotecting children from germs and other environmental factors can lead to increased rates of asthma.

  • Regular exposure to secondhand smoke

  • Regular exposure to chemicals used in agriculture, hairdressing or manufacturing

  • Low birth weight (less than 5.5 pounds)

  • Reflux or GERD (gastroesophageal reflux disease)

  • Proximity to areas with a lot of vehicle traffic

  • Being overweight

  • Being African-American or Puerto Rican

  • Being male: Though in adulthood, more women have the condition.

  • Living in the Northeast: Asthma rates are highest here. Researchers aren't sure if this is due to climate, urbanization, concentration of certain populations or all of the above.

  • Poverty: Sub-par medical care, exposure to triggers, and less ability to modify the environment to make it healthier are some of the reasons experts think asthma has been linked to low income.

 

Triggers

While the above factors may contribute to your child being at risk for asthma, the triggers below actually cause attacks. Asthma triggers differ from person to person—if you have two kids with asthma, one may get an attack after petting a neighbor's dog, while the other may instead start coughing on a cold, windy day. Common asthma triggers include:

 

  • Airborne allergens: These include pollen, animal dander, mold, cockroach droppings, dust mites, mold

  • Air pollutants: These include smoke (especially from cigarettes), air pollution like ozone and smog, chemicals (common household versions include paint fumes, cleaners, spray glues), hairspray

  • Physical activity

  • Cold air, wind, rain, sudden air changes

  • Medications: These include beta blockers, aspirin and other non-steroidal anti-inflammatory drugs

  • Strong emotions and stress: Temper tantrums and crying can bring on an attack (as if they weren't bad enough)

  • Sulfites and preservatives in food: Artificial sweeteners like Aspartame and additives like sulfites can trigger an attack

  • Episodes of GERD, gastroesophegal reflux: Stomach acid backing into the throat

  • Allergic reactions to food: This can include peanuts and shellfish, and even eggs and cow's milk

DIAGNOSIS

Studies show that as many as 50 to 80 percent of kids who develop asthma have symptoms before their third birthday. Most children, however, are diagnosed with asthma at age 5 or older because these symptoms can be confusing to parents and even doctors. Fussy babies with frequent colds are not uncommon, and many toddlers continue to be active and happy despite wheezing and chest tightness (and keep in mind they don't realize this isn't a normal way to feel). Younger children also cannot describe how they are feeling and cannot perform the lung function tests needed for diagnosis. There are, of course exceptions; some doctors will diagnose even infants with severe symptoms, although they might call is reactive airway disease (RAD). See our Age-by-age Guide if you think your infant or toddler falls into this category.

However, if you have a child of any age with frequent wheezing (four or more episodes in one year that lasted longer than a day and disrupted sleep), you will want to call your pediatrician and set up an appointment (and if they are struggling to breathe, don't wait—call 911). You may also want to consult your ped if your child has one or more of the major asthma indicators or at least two of the minor listed below.

Major

 

  • A parent with asthma

  • A sibling with asthma

  • Eczema

  • Has tested positive for airborne allergens

 

Minor

 

  • Allergic rhinitis

  • Wheezing in the absence of a cold or virus

  • Food allergies, especially to eggs, milk or peanuts

 

PREVENTION

Experts say there isn't a hard and fast way to prevent asthma from starting in children, so parents should not go on a guilt trip if their children develop the condition. However, there are ways to reduce your child's risk factors, especially during pregnancy and infancy.

 

  • Quit smoking! If you know you need to kick the habit but just can't seem to do it, get help at smokefree.gov. Also, minimize your child's exposure to environments where other people smoke, even if they don't light up while you're there. Even smokers' clothes and hair carry irritants that could be dangerous to your baby. This is a tough situation if Grandma is a pack-a-day gal, but maybe this can be her incentive to quit. www.smokefree.gov

  • Follow your OB's advice to prevent preterm labor and avoid cigarettes, alcohol and drugs (duh!) during pregnancy. Low birth weight is not only a risk factor for asthma but other health problems.

  • Don't spend every second cleaning, but do try to minimize asthma triggers, like mold, roaches, pet dander and dust, in your home. Avoid exposing your baby to irritants like perfume, hairspray, paint or fumes from household cleaners. This likely will not prevent a child from developing asthma, but may reduce the frequency and severity of attacks if it develops—and could even stave off the condition for a few years.

  • Watch your child's weight. Multiple studies have shown a link between obesity and asthma at all ages, but research is also showing that accelerated weight gain in the first few years of life significantly increases a child's chance of asthma. It's not just that extra weight causes kids to huff and puff when they run; overweight children also have more allergies. The theory is that an excess of fat kicks off an inflammatory process at the cellular level that puts kids at risk for a host of diseases, including asthma, diabetes and hypertension.

TREATMENT

Asthma cannot be cured, but it can be successfully managed. Good asthma control will reduce your child's need for "quick-relief" medicines like emergency inhalers, and will minimize chronic symptoms like coughing and shortness of breath. With careful management, your child will be able to maintain good lung function, get enough sleep and keep up with friends. Management can also help prevent scary trips to the ER.

The first step will be for you and your doctor to develop an asthma management plan that includes daily treatment as well as strategies for dealing with attacks and emergencies. Your plan and treatment will depend on the type and severity of your child's asthma, as well as her age. But some common strategies include:

 

  • Medication: Most children will need some form of medication to manage their symptoms. Some children will require several medications on a daily basis, while others may only need a "rescue" inhaler or other medication during allergy or cold season. Medications come in pill and inhaled forms.

  • Monitoring: Many children will use a peak flow meter at home to regularly measure their breathing, since lung function can decrease before symptoms are noticeable.

  • Avoidance and Control: This means discovering what triggers your child's asthma and, as much as possible, avoiding or controlling it. This might translate into things like allergy testing and shots during pollen season, annual flu shots, keeping family pets out of a child's room, or having her skip recess on cold, windy days.

 

When To Seek Emergency Treatment

Every parent knows his or her child and is the best judge of when to seek immediate help, either by calling a doctor, driving to the emergency room, or calling 911. When talking about your asthma management plan, be sure to discuss emergency care with your doctor as well. However, here are some general signs that an asthmatic child needs immediate medical help:

 

  • Rib retractions, or the pulling in of the skin between the ribs (this is especially alarming in infants, who have weak muscles and may get too tired to breathe)

  • Babies will flare their nostrils when breathing in order to increase oxygen intake

  • A peak flow reading below 50% that doesn't improve with medication

  • Bluish or gray lips or fingernails

  • Difficulty speaking

  • No improvement with the use of rescue inhalers, or only short-term improvement of symptoms

MEDICATION (Discuss all potential side effects with your doctor)

The most common types of asthma medications are long-term medications that help get chronic airway inflammation under control, and short-term medications that bring relief during an attack.

Medications are given in pill, liquid and inhaled form. Because kids often let medication escape from an inhaler, your doctor may advise you to use a nebulizer, an electrical machine that converts meds into a mist that is inhaled through a face mask. Inhaled meds work quickly and produce fewer side effects.  Nebulizers can deliver larger doses of asthma meds than other devices, although more slowly, and need to be administered more frequently. Some children can get a quicker fix by using a spacer, a hollow tube that attaches to a metered dose inhaler to ensure your child's medication makes it into his mouth and lungs. Medication in pill form may be used once a child is able to swallow them.

Short Term Medications

Bronchodilator inhalers (albuterol (Ventolin, Proventil), levalbuterol (Xopenex) These drugs instantly open airways during an attack, but unless your child suffers from exercise-induced asthma, they should not be used daily. If your child uses her rescue inhaler more than twice a week, her asthma is not under control.

Long Term Medications

Inhaled corticosteroids (Azmacort, Vanceril, AeroBid, Flovent, Pulmicort, Asmanex, Respules)These are the first line of treatment for asthma because they reduce inflammation over the long term. About two thirds of children with either intermittent or chronic asthma have good control over it using an inhaled steroid once a day. Children who have seasonal asthma due to allergies or colds also have good success using these drugs during their high-risk seasons, although they might take a while to kick in.

Side Effects: Mild side effects can include upset stomach, oral thrush and body aches. Over the long term, steroids may slow a child's annual growth rate, although this is thought to be reversible if the child stops taking the medication.

Leukotrien modifiers (Singulair, Zyflo, or Accolate): Anti-leukotriens can block chemicals that contribute to airway spasms and swelling, and reduce mucus production. They're often prescribed if corticosteroids alone aren't sufficiently controlling asthma.

Side Effects: Although most side effects are mild, like cough, upset stomach and ear pain, in rare cases these drugs have been linked to behavior and mood changes, including hallucinations and suicidal thinking.

Combination inhalers (Advair, Symbicort): These combine corticosteroids plus a long-acting beta agonist (LABA), which relax airway muscles. LABA medications should only be used when combined with inhaled corticosteroids. The use of LABAs alone has been link to worsening of asthma symptoms.

Cromolyn sodium (Intal): This anti-inflammatory non-steroid medication may help prevent mild to moderate bronchial asthma attacks. Cromolyn needs to be taken two to four times a day; it can be taken along with an inhaled corticosteroid, sometimes helping to reduce usage of other meds and even phasing them out. It may take up to four weeks to be effective.Side Effects: Throat irritation, headache, bad taste, cough and stuffy nose.

 

COMPLEMENTARY/ALTERNATIVE TREATMENTS

Because asthma is a serious and potentially life-threatening disease that usually requires conventional medication, and because many alternative treatments like herbs and supplements are not well-regulated, have side effects and interact with medications, you should not use them without consulting your doctor. However, some complementary "treatments"—like breathing exercises, yoga for relaxation, and a good diet—are healthy and beneficial to all children, not just those with asthma. Here are a few to try:

 

  • Feed your child more fruits and vegetables. These foods contain antioxidants that boost the immune system. Since asthma may be an immune disorder, this is key—and a healthy immune system can better fight off colds and viruses that can trigger attacks.

  • Eat more foods that contain Omega-3 fatty acids. Scientists believe Omega-3s help the body reduce inflammation. Fish high in fatty acids are a good source (if you can get your kids to eat them). Try this tot-friendly recipe: salmon patties.

  • Reduce your child's intake of foods high in saturated fat. Research indicates that high-fat foods increase inflammation in the body. They can also lead to obesity, which has been linked to asthma.

  • Avoid foods that have caused allergic symptoms in your child. This one's a no-brainer.

  • Avoid foods with certain preservatives. Some artificial sweeteners (like Aspartame) and food additives (like sulfites) may cause reactions in some children.

  • In some cases, give up dairy. For some children, milk products make asthma worse by increasing mucus production. You may want to eliminate milk products for a trial period to see if it helps. If you do cut milk products out of your child's diet, make sure she's getting plenty of calcium and vitamin D from other sources, like calcium-fortified OJ or soy milk.

  • Keep your child active. Don't make your child give up exercise and outdoor play, because aerobic activity increases lung capacity and reduces a child's risk of obesity. Consider allergy shots or alternatives like heading to an indoor playspace when pollen or weather conditions make outdoor activity too risky.

  • Try yoga breathing techniques. Yoga can help with stress, a trigger for intrinsic asthma, and may help improve breathing for some children. Try a fun family yoga class.

 

Lifestyle Tips

Here are some simple at-home adjustments that you can make to keep asthma in check.

 

  • "Asthma-proof" your child's room. Get rid of rugs, carpet and dusty curtains in favor of wooden floors and washable blinds or curtains. Use dust-proof pillow and mattress covers. While some docs recommend you say no to stuffed animals, parents (and their kids!) naturally balk at that suggestion. A reasonable alternative is to keep fuzzy friends out of bed and away from your child's face while he's sleeping. (You can also tumble them regularly in the dryer to remove dust.) Vacuum and dust the room frequently, and wash sheets and pillowcases weekly in 130-degree water to kill dust mites.

  • Keep indoor air clean. Use your air conditioner during pollen season even when it's not hot outside. Change the filters for your air conditioner and furnace frequently, and have them serviced annually to avoid buildup of dust, pollen or mold in the system. Keep the humidity levels low to reduce mold.

  • Control pet dander. Again, lots of docs may recommend that you get rid of the family cat or dog, but depending on the severity of your child's asthma, there are options. Keep pets groomed frequently (but don't let your asthmatic child wash or brush them) and keep them out of your child's room and off the furniture as much as possible. If you don't have a pet and are considering one, remember that dogs trigger fewer allergies than cats, and certain breeds are less allergenic than others. (The Obamas supposedly selected a Portuguese Water Dog because the breed, which doesn't shed much, is better for children with allergies.)

 

AT THE DOCTOR

Your appointment will begin with a physical examination. Along with listening to your child's breathing, the doctor will want to ask you about your child's symptoms, what triggers them and makes them worse, if any medications have been tried. He'll also want to discuss your family history of allergies and asthma. Although asthma is the most common cause of episodic wheezing and cough, there are other conditions, many of them rare, that produce these symptoms. They include:

 

  • Cystic fibrosis: a hereditary disease that changes secretions in the body and often causes frequent lung infections in young children. Parents may first notice coughing and excessive mucus, which can turn into pneumonia.
  • Congenital heart disease: a problem with the heart's structure, present at birth, that affects its ability to pump enough blood to supply oxygen throughout the body. Some times babies appear blue or have low pressure shortly after birth.

  • Foreign-body aspiration: i.e., inhaling an object such as a raisin or pebble

  • Tracheomalacia: a malformation of the windpipe that causes breathing difficulties, which get worse with coughing, crying or respiratory infections

  • Primary immunodeficiency: inherited disorders of the immune system that leave babies and children vulnerable to repeated infections, like pneumonia, strep and bronchitis

 

After the exam and family history, your doctor will test your child's airway function (if she is old enough, usually around age 5), most often with a device called a spirometer. A spirometer measures how much air a child can exhale after a deep breath and how fast he can breathe out. Doctors may instead use a peak flow meter on younger children because it has a larger straw for them to blow into and is therefore easier for them to use. The test is scored based on averages for children of similar height and sex.

If your child is not sick or wheezing at the time of your appointment—say it's just a checkup, but you raise the issue—and her lung function test is normal, your doctor may use a chemical irritant called methacholine to bring on mild constriction of the airways. The airways of asthmatic children will react more quickly and dramatically to this "challenge test."

When a child's lung function tests indicates breathing problems, a doctor may do a "reversibility" test by giving your child a dose of a medication that relaxes airways, like albuterol, in mist form using a nebulizer. In most cases, children with asthma see immediate improvement. If not, your doctor may want to test your child for other conditions that could be making her asthma worse, such as hay fever, sinus infection or reflux.

Once your child is diagnosed, your doctor will develop a treatment plan based on how severe your child's asthma is and what triggers it. Levels of asthma severity are:

 

  • Mild intermittent: Mild symptoms up to two days a week and two nights a month.

  • Mild persistent: Symptoms more than twice a week, but no more than once in a single day.

  • Moderate persistent: Symptoms once a day and more than one night a week

  • Severe persistent: Symptoms throughout the day and on most days and frequently at night.

 

Your doctor may also refer you to one or more specialists, including pediatric allergists or pediatric pulmonologists.

 

AGE-BY-AGE GUIDE

Infants

It is very difficult to diagnose an infant with asthma, but in severe cases doctors may diagnose and treat babies (although he might call is reactive airway disease). Signs of asthma in a baby may include:

 

  • audible wheezing during normal activities

  • chronic cough

  • rapid breathing (normal respiration rates in newborns are 30-60 breaths a minute, breathing increased 50 percent above normal could indicate asthma)

  • rib retractions (the pulling in of the skin between the ribs)

  • difficulty sucking or eating

  • crying sounds that are softer and different than normal

  • recurring respiratory syncytial virus (RSV) may increase the risk of asthma later in childhood

 

The same medications used to treat older children are used in infants, only in smaller doses, and most often delivered via a nebulizer. Because babies spend up to 18 hours a day in their bedrooms, "asthma-proofing" that room is especially important.

Toddlers and Preschoolers

As babies transition into toddlers, some may outgrow wheezing as bronchial tubes mature. If your toddler develops or continues to experience some or all of the symptoms above, your doctor may be more willing to diagnose asthma. Additional signs your toddler or preschooler may have asthma might include:

 

  • Inability to keep up with playmates

  • Repeated episodes of wheezing or coughing triggered by specific things, i.e., a visit to a relative who has multiple cats, or a windy day on the playground

  • Seasonal allergies

  • Chronic sinusitis (sinus infections)

 

School Age

Most children are diagnosed at around age five or older when doctors are able to effectively administer lung function tests. In addition to the symptoms listed above, school-age kids have the language skills to describe their symptoms, like chest tightness and inability to draw a breath.

When parents develop an asthma management plan with their doctor, they should provide a copy to their child's school as well. Each child's plan will be different, depending on the type and severity of asthma and treatment, but most will include basics such as:

 

  • Permission to give ongoing/emergency medication

  • Details on when and how to treat symptoms (i.e. signs that your child needs rest, conditions that may require your child take indoor recess, when to administer regular medication or emergency treatment)

  • Asthma triggers (i.e. the class hamster, cold, windy days, high pollen count)

  • Emergency contacts and phone numbers

 

PARENTS' AND CHILD'S EXPERIENCE

Parenting a child with asthma can be a scary experience, but many parents find relief when medications and other strategies bring asthma under control.

"We've adjusted pretty well," says Julie Stoll, 35, a Normal, IL, social worker and mother of Nicholas, 5, who has asthma. Nicholas was diagnosed at age two after suffering from repeated respiratory infections beginning at six months. The biggest difficulty, Stoll says, is toting the nebulizer everywhere they go, especially on trips. "But now we have it under control enough that we can go places and just bring his rescue inhaler."

"Keep working with your doctor," Stoll advises. "We haven't needed to go to a specialist because our doctor is proactive and works with us. We also do our own research and ask about other options."

Monica Fyfe, 27, an Indianapolis, IN, homemaker, recalls that her son began having breathing issues at 8 months, but it took a year and two trips to the emergency room - one with an admission to the hospital—before doctors were willing to diagnose him with asthma. "Now he is on preventive medicine everyday," she says of Jace, 2, including Flovent and Albuterol. A new pediatrician has also ordered allergy tests for Jace. Fyfe has created a color-coded asthma action plan to give to relatives when they watch him so they know when to give him medication and are prepared for possible emergencies."He takes medicine in the morning and at night, and if he starts wheezing or having difficulty breathing he gets his nebulizer treatments. But asthma doesn't prevent him from being active or running around with his sisters."

Theresa Zoro, 38, of Brooklyn, NY, director of publicity at a publishing house, took asthma-proofing to a whole new level after her son Wyeth, 4, was diagnosed with asthma as a baby. "We moved!" says Zoro, whose daughter, Olive, 22 months, also has asthma. "We were living in an old building with exposed brick and we moved to a completely renovated apartment." Her new home has fewer problems with dust and other environmental triggers. Like many asthmatic kids, Wyeth had a rough first few years in terms of respiratory infections. "He was on antibiotics every month for the first year, and at nine months they put him on Singulair and he got ear tubes," says Zoro. She was so concerned about his breathing, she'd let him sleep in his car seat so his head was elevated, and would sleep on the floor beside him. Because Olive didn't have the same traumatic first year as Wyeth, Zoro assumed she was out of the woods until at 16 months she developed a high fever and coughing and was rushed to the hospital with bilateral pneumonia. But now that both kids are using preventive medication, Zoro says she doesn't let fear of asthma factor into their activities. "Asthma is really misunderstood. It's not like they can't do normal things."

SUPPORT

National Heart Lung and Blood Institute
This division of the National Institutes of Health has solid information on asthma, including links to clinical trials, recent research, and information on asthma in schools.

Asthma and Allergy Foundation of America http://www.mayoclinic.com/health/childhood-asthma/DS00849"> The Mayo Clinic
A non-profit with comprehensive information on all things allergy and asthma, including an "ask the allergist" feature, and links to support groups, clinics and health professionals.

Healthy Children
Great, user-friendly information with the stamp of approval of the American Academy of Pediatrics. Unlike other sites, information focuses strictly on pediatric asthma.

The Mayo Clinic
Comprehensive medical information on asthma in an easy-to-understand format from one of the country's top medical clinics.

Allergy & Asthma Network Mothers of Asthmatics
This advocacy organization follows the latest asthma news and features tons of coping tips for parents.

Parents of Children With Asthma
On Facebook, become a fan of Parents of Children with Asthma, a group site run by a mother of two girls with asthma, for support and conversation with other parents.

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