Asthma and children

Asthma is a chronic inflammatory disorder of the airways that causes narrowing of the breathing passages in the lungs. Asthma is considered a reactive airway disease (RAD), a category of illnesses that cause wheezing and is improved by bronchodilators (medications that open up narrowed airways) or anti-inflammatory medications that reduce airway inflammation, swelling and mucus.


Causes/associated factors
Asthma is the most common chronic childhood illness, affecting nearly 5 million children in the United States. Although the cause of asthma is not clearly understood, it's thought that both genetic and environmental factors play a role.
For children who have asthma, the bronchial tubes (air passages in the lungs) overreact to allergens and irritants, causing an allergic reaction or swelling. Specific allergens or irritants that cause asthma symptoms are known as asthma triggers. Common allergens include pollen, dust mites, animal dander or hair, mold spores, cockroach remnants, sulfites (a common food preservative) and tartrazine (a food-coloring agent). Although 80 percent of children who have asthma also have allergies, it's important to remember that not all people who have asthma have allergies.

Common irritants include respiratory infections, cigarette smoke, cold air, gastroesophageal reflux disease (GERD), certain medications (especially aspirin and other nonsteroidal anti-inflammatory drugs such as ibuprofen and naproxen), emotional upset, exercise or various other factors. The younger a child, the more likely a viral respiratory infection is the trigger. Often asthma attacks are brought on by a combination of these triggers. Sometimes, asthma triggers are never determined.

During an asthma attack, the breathing passages become narrower than normal. The passages begin to make too much mucus, and the lining of the passages becomes swollen with fluid. These changes work together to interfere with airflow, which leads to the classic symptoms of wheezing, coughing and difficulty breathing. Asthma attacks may last a few minutes, hours or even days, and can range from mild to life threatening.

Asthma can appear at any age, but the majority of all cases begin before age 5. Most children have a few easily treated attacks a year. For a much smaller percentage of children, asthma is severe enough to interfere with daily activities. Most children who have asthma improve or outgrow their asthma as they get older. Some continue to have persistent asthma problems, however.

Children at highest risk for developing asthma include those who:

have parent(s) with a history of asthma, allergies or eczema
live in poverty
are African American
were born to a mother younger than age 20
had a low birthweight
are exposed to secondhand smoke at home
live in a small home
live with more than six people
had heavy exposure to dust mites in infancy
had lots of respiratory infections when very young

Signs/symptoms
Some children who have asthma experience infrequent, mild symptoms. Others are affected daily. Some children have a nasal discharge and skin conditions, such as eczema. Asthma attacks brought on by environmental or allergic triggers develop the most quickly. Those related to respiratory infections tend to progress the slowest. Again, asthma attacks may last a few minutes, hours or days.
Three classic symptoms include wheezing, shortness of breath and coughing. Nighttime symptoms are common in children who have more persistent asthma. Immediate medical treatment can help prevent an asthma attack from becoming severe or life threatening.

Symptoms of a severe asthma attack may include:

severe difficulty breathing, both inhaling and exhaling
difficulty talking or walking due to shortness of breath
difficulty lying flat
sitting hunched over (This position makes breathing somewhat easier.)
sweating
bluish coloring to the lips, gums or nail beds
increased pulse rate
severe coughing
high-pitched wheezing
severe agitation
drowsiness or confusion
It's important to remember that one or any combination of the symptoms listed above may be present during an asthma attack. It's a myth that wheezing must always be present. Sometimes during a severe attack, extreme airway obstruction can prevent air from moving enough to cause wheezing.


Diagnosis
Diagnosis is based on the child's medical history, symptoms, a physical exam and diagnostic tests.
Pulmonary function tests (computerized measurements of lung capacity and airflow) can help the doctor evaluate how well the child's lungs and breathing system are working. Pulmonary function tests are probably the most useful tests for children older than age 5. Chest X-rays may show common physical changes related to asthma and help the doctor rule out other respiratory conditions. Pulse oximeters using skin sensors to measure oxygen levels and arterial blood tests can help the doctor determine how well the child's lungs are delivering oxygen and removing carbon dioxide from the body. Finally, allergy skin testing can be used to confirm an association between asthma attacks and allergies. Radioallergosorbent testing (RAST, a blood test) can be used to diagnose allergies to inhaled substances and foods.

Classification
Your child's doctor may classify your child's asthma symptoms according to severity.

These classifications include:

Mild intermittent: Symptoms occur one or two days a week. Nighttime symptoms occur once or twice a month.

Mild persistent: Symptoms occur more than twice a week, but not every day. Nighttime symptoms occur more than twice a month. Attacks can disrupt activities.

Moderate persistent: Symptoms occur daily. Nighttime symptoms occur more than once a week.

Severe persistent: Constant symptoms limit the child's physical activity. Nighttime symptoms occur frequently.
If the frequency of your child's symptoms changes over time, his or her classification may also.


Treatment
Asthma management plans
Your child's response to therapy should be carefully monitored. Once his or her symptoms are under control, the doctor may prescribe a "step down" or reduction in medications to the minimal therapy that will maintain control. Never change medication routines without first discussing it with your child's physician. It's also important to tell your child's doctor whether the medication is working and if your child is experiencing any side effects. Also let the doctor know about any of your concerns or fears.

As much as possible, children and adolescents should be directly involved in setting treatment goals, as well as developing plans to manage their asthma. In addition, the doctor should prepare an asthma management plan for staff members at the child's school, including a method for reliable, prompt access to asthma medication. The plan should also include recommendations for long-term control medications, how to handle an asthma attack, and how to prevent exercise-induced asthma episodes. The child's asthma triggers should be identified in the plan so school staff members can help the child avoid unnecessary exposure. It is common for children to use a bronchodilator (albuterol) before exertion, sports or physical education classes. School consent forms to administer such medication should be signed by the doctor and the parent.

It's important for the child to avoid irritants that cause asthma attacks, especially passive exposure to tobacco smoke at home, in the car, and in the homes of relatives and friends. In addition to avoiding asthma triggers, some type of medication treatment is standard.

Medication
Medication can be an important part of controlling asthma and relieving your child's symptoms. Medications should be taken only as prescribed by the doctor, and adult supervision is important to ensure the child is taking the medication as directed. The type of medications prescribed to treat your child will depend on the severity, persistence and frequency of your child's asthma symptoms.

Some asthma medications can be given through a nebulizer (a device that turns the medication into vapor) or a metered-dose inhaler (a handheld inhaler device). School-aged children are typically old enough to use an inhaler on their own in conjunction with a spacer (a device that helps ensure the medication gets into the lungs, and not just the back of the throat). Younger children typically breathe it in through a nebulizer. Increasing the dosage or taking the medication more often than prescribed could cause serious complications. If the prescribed dosage does not provide relief, contact the child's doctor.

There are two groups of asthma medications: those designed to get asthma attacks under control immediately (rescue medications), and those designed to provide continuous treatment to prevent attacks (controller medications). It's important to understand the difference and know when to use each medication.

Rescue inhalers

Short-acting bronchodilators
These are also known as short-acting beta-2 agonists, and they relieve sudden asthma attacks. They can also be taken before exercise to prevent asthma symptoms. These medications relax the muscles around the airway to prevent or reverse airway narrowing. They start to work within minutes, and the effect lasts four to six hours.

Common brands include:


albuterol (brand names Proventil and Ventolin)
bitolterol (Tornalate)
metaproterenol (Alupent)
pirbuterol (Maxair)
levoalbuterol (Xopenex)
terbutaline (Brethaire)
Benefits: Short-acting bronchodilators start to work within minutes, and the effect lasts four to six hours.

Risks: Side effects may include nervousness, trembling, restlessness, dry mouth, or a rapid or irregular heartbeat. It's important to discuss these side effects with your child's doctor.

Anticholinergic bronchodilators
Ipratropium (Atrovent) can provide added benefit to inhaled beta-2 agonists in severe asthma attacks.

Benefits: Anticholinergic bronchodilators start to work within minutes.

Risks: Ipratropium is not approved by the U.S. Food and Drug Administration (FDA) for children age 12 or younger. It's not appropriate for children who have allergies to soy or peanuts.

Controller medications

Anti-inflammatory medications

Corticosteriods: Inhaled corticosteriods, if taken for long periods, gradually reduce the likelihood of asthma attacks by making the airways less sensitive to various common asthma triggers.
Common brands of inhaled steroids include:


budesonide (Pulmicort Turbuhaler)
fluticasone (Flovent)
Budesonide inhalation suspension (Pulmicort Respules) has been approved for long-term asthma control in children as young as 12 months.

Oral corticosteroids such as prednisone (Deltasone) have broad anti-inflammatory effects. They can be used for short-term therapy (three to 10 days) to gain control over a severe asthma attack (often called a "steroid burst"). For children who have severe persistent asthma, oral steroids may need to be taken regularly.

Benefits: These drugs may slow the progression of severe asthma.

Risks: Long-term side effects of inhaled corticosteroids may include a cough or yeast infection in the mouth (also called thrush). To help prevent these side effects, you may want to have your child rinse his or her mouth after taking the medication.

Oral steroids have many side effects, including an effect on growth, which may be a particular concern for young children. It's important to discuss these side effects with your child's doctor.


Nonsteroidal anti-inflammatory medications: These medications can control or limit airway swelling, mucus production and sensitivity to allergic substances, which helps prevent narrowing of the airways. These medications are especially helpful for children who develop asthma from exercise. They can also be taken before exposure to a substance that may trigger an asthma attack.
Common brands include:


cromolyn sodium (Intal)
nedocromil sodium (Tilade)
These medications usually begin to work after four to six weeks of regular use. To be effective, they must be taken as directed by your child's doctor, even when your child doesn't have symptoms.

Benefits: These medications are especially helpful for children who develop asthma from exercise. They can also be taken before exposure to a substance that may trigger an asthma attack.

Risks: Side effects of cromolyn sodium or nedocromil sodium may include a cough or headache. Some children complain that nedocromil leaves a bad taste in their mouths. (Drinking a few sips of water before and after using the inhaler may help.) It's important to discuss these side effects with your child's doctor.


Leukotriene modifiers: These oral medications are a newer class of asthma medication. They decrease airway inflammation and narrowing, as well as sensitivity to asthma triggers. They're usually taken in combination with other medications.
Common brands include:


montelukast (Singulair)
zafirlukast (Accolate)
zileuton (Zyflo)
Benefits: Montelukast is approved for children as young as age 12 for preventive and chronic treatment of asthma.

Risks: Common side effects are headache, stomach upset and nausea. It's important to discuss these side effects with your child's doctor.

Long-acting bronchodilators
Salmeterol (Serevent) is also known as a long-acting beta-2 agonist and controls symptoms by decreasing airway inflammation and narrowing, as well as sensitivity to asthma triggers. The maximum benefit from long-acting bronchodilators, which provide relief for up to 12 hours, occurs after four to six weeks of regular use. These medications must be taken regularly as directed by your child's doctor, even when your child doesn't have symptoms. Side effects from long-acting bronchodilators may include nervousness, restlessness, trembling, dry mouth, or a rapid or irregular heartbeat.

Newer combination medications such as the a long-acting bronchodilator salmeterol and the corticosteroid fluticasone (Advair Diskus) are now available. These are FDA-approved for children age 12 and older.

Benefits: Long-acting bronchodilators combined with anti-inflammatory medications can help prevent nighttime asthma symptoms or exercise-induced asthma.

Risks: Side effects from long-acting bronchodilators may include nervousness, restlessness, trembling, dry mouth, or a rapid or irregular heartbeat. It's important to discuss these side effects with your child's doctor.

Methylxanthine bronchodilators
Theophylline (Theo-dur or Slo-bid) opens up narrowed breathing passages and prevents fluid accumulation in the lungs.

Benefits: When used in combination with other medications, this medication can be a helpful alternative to prevent nighttime symptoms.

Risks: Common side effects include headache, nervousness, nausea and vomiting. It's important to discuss these side effects with your child's doctor.

Peak flow meters
A small, inexpensive device called a peak flow meter can be used at home to measure lung function in children old enough to cooperate, usually age 5 and older. After a baseline normal reading is established, daily measurements are taken. A lower than usual reading signals an impending asthma attack, indicating the need for preventive medical treatment -- even before wheezing or other early symptoms appear. Follow the doctor's instructions on how to use the peak flow meter, what actions or medications to take when the child's readings are low, and when to seek immediate medical treatment.

Recommendations
The National Asthma Education and Prevention Program (NAEPP) promotes low-dose inhaled corticosteriods as the preferred treatment for infants and children who have symptoms needing treatment more than twice a week (mild persistent asthma). Inhaled corticosteriods appear to improve the overall control of mild to moderate asthma. Additional medications may also be added to provide the best control of symptoms.


Complications
A prolonged and severe asthma attack that doesn't respond to drug therapy is referred to as "status asthmaticus." This condition has the potential to include generalized seizures or lung collapse. It's considered a medical emergency. Without emergency treatment in a hospital, status asthmaticus can be fatal.

Prevention
It may not be possible to prevent a child from developing asthma. You can minimize the attacks and quickly stop those that do occur to help prevent complications, however. To help your child prevent an asthma attack, consider the following suggestions:
Help your child avoid exposure to smoke of any kind, especially tobacco smoke at home, in the car, and in the homes of relatives and friends.

As much as possible, your child should also avoid animal dander and hair, feathers (including feather pillows), aspirin, cockroach remnants, pollen, dust, mold, strong fumes of any kind and anything else that may trigger an attack. You may want to help your child keep a diary to help identify triggers.

Cover your child's mattresses and pillows in airtight covers, and wash bed linens, pajamas and stuffed toys often. It's also helpful to change the furnace filter frequently.

Make sure your child drinks plenty of fluids, continues to take prescribed medications, and remains as calm as possible.

Keep an eye out for decreased levels of play. Also, talk to your child's doctor about limits or increases in physical exercise.

If cold air is an asthma trigger for your child, try to avoid it. Also avoid anyone who has a respiratory infection, and make sure your child gets yearly flu shots as recommended by the doctor to help prevent respiratory infections.

Learn the potential seriousness of asthma, and be aware of changes in your child's airflow. Ask your child's doctor what to do when your child develops warning signs of chest tightness, coughing or wheezing.