Asthma in children
What is asthma?
Asthma is a common chronic lung disease that causes variable symptoms such as wheezing, cough, shortness of breath or chest tightness due to reversible narrowing of the airway tubes. The frequency and intensity of symptoms tend to vary over time.
Asthma is the most common chronic disease of childhood and the No. 1 reason that children miss school, go to emergency rooms, and are admitted to hospitals. About 5 million American children are estimated to have asthma.
Factors leading to increase in symptoms are called triggers. Some examples of triggers include: upper respiratory viral infections, allergies, irritants, weather changes and exercise (details below). These triggers cause the airway tubes to become narrow, making it hard to move air in and out of the lungs. The narrowing is caused by two features:
- There is tightening of the muscles surrounding the airways (called bronchospasm or bronchoconstriction)
- Extra mucus and swelling of the airway linings, which all add to the narrowing. This narrowing is called inflammation.
Airways become super-sensitive or hyper-reactive to things that do not bother people with normal lungs. The "twitchy" lungs overreact even to cold air, exercise and smoke. The airway narrowing or obstruction and "twitchiness" cause the asthma symptoms to come in "waves" called flares or attacks. The more inflammation in the airways, the more sensitive the airway tubes are to triggers and the more likely you are to have a flare or other symptoms, like nighttime cough or shortness of breath with exercise. That’s why treating the airway inflammation is so important in caring for your child’s asthma.
There are many different patterns of symptoms. Some people start having problems very early in life, others much later. Many asthma patients have asthma attacks, or flare ups. Some patients have little to no symptoms between attacks or flares, while some have symptoms a few days a month, week or even every day.
What causes asthma in children?
Anyone can develop asthma but certain genetic and environmental factors might increase the risk, such as:
- Having family members, especially a parent, with asthma or allergies
- Premature birth or lung injury from premature birth
- Exposures to viruses or allergens at early ages
- Cigarette smoke or pollution exposure during pregnancy or early on in life
People with asthma have airways that are super-sensitive to things that do not bother other people with normal lungs. These “triggers” start lung inflammation and asthma symptoms.
There are three major groups of triggers:
- Infections such as colds and sinus infections. Every asthma patient has a problem with this trigger.
- Allergies to pollen (tree, grass, weeds), molds, pets, dust mites and cockroaches
- Irritants such as tobacco smoke and chemical fumes from heaters
If asthma is not well controlled, simple things like exercise, weather changes, cold air and emotion (showing strong feelings like laughing and anger) can trigger asthma symptoms in irritated lungs.
Your child may have additional problems that can make asthma worse or harder to control. For example, gastroesophageal reflux disease (GERD) can make the lungs more twitchy and tight.
Asthma can affect anyone — young or old, male or female, and people of all races and ethnic backgrounds. When one or both parents have asthma or allergies, their child has a greater chance of also having asthma. Still, some children develop asthma even though there is no family history of the disease.
The number of children with asthma continues to rise worldwide. We don't know why this is happening even though many asthma experts are researching to find out. Some of the reasons for the increase may be that asthma is better recognized and diagnosed than in the past; increased air pollution; homes with less ventilation and more moisture; more indoor pets; and children spending more time indoors.
Asthma symptoms in kids
The most important asthma symptoms in children are:
- Cough: caused by the need to cough up extra mucus in the lungs or from the irritation of the airways (twitchiness)
- Wheezing: the musical noise made by air coming out of narrow lung passages (like whistling)
- Shortness of breath
- Chest tightness or pain
Asthma attacks or flares come and go. When an attack begins, you will notice that your child's symptoms become worse and may worsen rapidly. During an attack, you will likely notice that:
- Although asthma symptoms may occur throughout the day and night, they are often worse during sleeping hours, usually after midnight. New night-time symptoms are signs that a new flare, or worsening of asthma control, has started.
- The lungs are making a lot of mucus. Your child may try to cough it out. Some children may even gag or vomit after their coughing spells.
- The lungs become very twitchy. It will be a lot easier for cough, wheeze, and shortness of breath or chest pain to come on with exercise, cold air, excitement, laughing or rough-housing.
If the attacks become more severe, breathing can be very difficult, like trying to breathe through a straw. Your child may become less active and appear tired.
It is important to know that some children do not show many symptoms even when their lungs become tight. If your child has such a tendency, your asthma specialist will help you learn about important symptoms to watch out for and may suggest you use a peak flow meter to help catch flares early and/or help you monitor improvement during flares.
Testing and diagnosis of asthma
Your child's asthma specialists will first look for classic asthma symptoms. It's important to know that not everyone with asthma will have wheezing. This is a common reason for failure to diagnose asthma. Also, when the airways get very narrow and tight, wheezing may stop. When this happens, the patient is worse, not better. Using "wheeze" alone to diagnose and follow asthma attacks can be unreliable and tricky.
Your asthma specialist will also look at how your child's symptoms cause a typical pattern of problems. Do they come in cycles or attacks? Do asthma medicines help relieve the symptoms? Sometimes this provides your asthma provider with enough information to make the diagnosis.
We will also check for other conditions that might look like asthma. For example, we will evaluate your child for cystic fibrosis, disorders of the immune system and others if your child's history and lung function tests hint that other problems might be present.
Lung tests may be important to help make the diagnosis. For children 5 years and older, a breathing test called spirometry can measure the obstruction in the airways and also show that obstruction can be relieved with asthma medicines. It is common for children to have normal breathing tests when they are well. If your doctor is has questions about your child’s diagnosis, other tests may be done to can show if the lungs are extra "twitchy" and typical of asthma. For example, lung function can be measured before and after exercise. Finally, daily use of a peak flow meter at home can reveal that your child's lungs are going in and out of periods of obstruction or tightness either during attacks or even after exercise.
Treatments for asthma
You will need to work closely with your primary care provider and asthma specialist team to control your child's asthma. Because asthma is a chronic disease, to keep your child’s symptoms well controlled, certain treatments need to be given every day — even when the child feels fine and has no symptoms. Some children need medication year-round, while others need to be on treatment during certain times of the year (for example, viral season in the fall and winter or allergy season in the fall and spring). Your doctors will work with you to make sure your child is on the lowest dose of medicine possible to keep their symptoms under control.
Anti-inflammatory medicines for asthma
These medications help prevent and reduce the bronchospasm, swelling, extra mucus and "twitchiness" of the airways. When first started, they usually take time to work, sometimes weeks. They are used as a controller medicine to heal the lungs and prevent symptoms. They will do two things:
- Prevent frequent symptoms (night cough, frequent need for quick relief medication) during the times between flare-ups or attacks
- Reduce attacks, both the number and severity, and reduce hospital admissions, emergency room visits and the need for oral corticosteroids
Your child should not stop taking daily anti-inflammatory medications until your asthma specialist recommends it. If you stop these medicines after your child gains control, inflammation might return, along with risk of increase in symptoms and more asthma attacks.
Examples of controller medicines include inhaled steroids (e.g., Flovent®, Asmanex®, Qvar RediHaler and Pulmicort®). There are also non-steroid drugs. These include "leukotriene modifiers" (Singulair®).
Bronchodilators for asthma
These medicines work very differently from anti-inflammatory medicines. They open the airways by relaxing the muscles that surround them. There are two kinds:
- Short-acting bronchodilators (called short-acting beta agonists) are used for quick relief of asthma symptoms. They are also called reliever or rescue medicines. Examples include Proventil®, Ventolin (or albuterol) and Xopenex®. These medications start working in 5 to 15 minutes (“quick relievers”) and last about four hours.
- Long-acting bronchodilators (long-acting beta agonists) help control asthma symptoms for a longer time (about 8 to 12 hours). They are given in one inhaler combined with an inhaled corticosteroid to improve long-term asthma control and are sometime called “combination” inhalers since they have two medications in them.
Your asthma specialist team will discuss how these medicines work, when to use them, what to expect and how to recognize any side-effects.
There are pros and cons that go along with each medication delivery method. Most studies suggest that giving inhaled medicines with an inhaler and chamber (spacer) is as effective as using a nebulizer. Inhalers with chambers are also easier to carry with you and are faster to use than the nebulizers, so most asthma specialists and families prefer this method of taking inhaled medications.
Whichever device is prescribed, it must be used correctly to be effective. For example, if you use a nebulizer, it should be used with a facemask or mouthpiece; don't just blow the mist into the child's face. Research has shown that metered dose inhalers work well for infants if used with a spacer and facemask.
When you get new equipment (such as an air compressor, filter, nebulizer tubing or mouthpiece) keep the instruction booklet and contact information for the manufacturer that supplied the equipment. The manufacturers of any piece of equipment will include information about how long it should last and how it should be cleaned.
To replace equipment, you will need a prescription. In order for the equipment to be covered by insurance, make sure that you order from a pharmacy or equipment company that has a contract with your child's insurance provider.
Outlook for children with asthma
Asthma is not a condition that can be cured, but most children and adolescents can gain good control of their asthma. With proper treatment for asthma, the goal is to have minimal or no asthma symptoms between flares and reduce the frequency and severity of asthma flares.
Another important goal of asthma treatment is for your child to have no or only minimal limits in physical activities. When the asthma is effectively managed, they should be able to participate in exercise and sports. In fact, 10% to 20% of U.S. Olympic athletes have asthma and are on various treatment plans to participate in the highest level of sports. Children should also eventually have fewer absences from school and work and gain the ability to self-manage asthma to the greatest extent possible.
You should know that asthma can be fatal, but fortunately this is rare. When asthma is the cause of death, it's usually because patients didn't take their medicines properly (when and how they were supposed to), or they didn't get help in time because they didn't take their symptoms seriously.
Follow-up care for asthma
When a child hasn't had a flare for a while, it's easy to assume everything is OK. But follow-up visits are important to be sure your child is on the correct treatment for them for the season and to adjust medication if needed. Sometimes the medication needs to be reduced (“stepping down”) as your child heads into their good season and sometimes medications need to be increased (“stepped up”) prior to their bad season.
Remember, like you we want your child to be on the lowest dose of medicine to have the asthma controlled. It’s what we call “being on the right medicine at the right time.” Over time, your child’s medication needs might change so these periodic visits are needed to help you make the proper adjustments.
Follow-up appointments can also help determine whether lung function tests are remaining stable or improving or whether daily controller medicines might need adjusting.
At follow-up visits, your asthma care provider can also discuss any side effects and your concerns, make sure your child is taking their medicines properly, and identify any problems you may have getting the care you need. Common hurdles are: insurance coverage, access to appointments, ability to get medicines and organizing the medicine schedule. So it's important to keep those follow-up appointments as part of your on-going effort to keep your child healthy.
How can you help get the most out of your follow up visits? Bring in your medications and spacers with you. Asthma medication names and colors can be confusing. By bringing in your medications you can more easily tell us what medications you are using, what you felt was helpful or not, and we can make sure you are using the inhaler properly.
Reviewed by Jeffrey M. Ewig, MD, Sarah Taub, MD