Childhood asthma

With childhood asthma, the lungs and airways become easily inflamed when exposed to certain triggers, such as airborne pollen. In other cases, childhood asthma flares up with a cold or other respiratory infection. Childhood asthma can cause bothersome daily symptoms that interfere with play, sports, school and sleep. In some children, unmanaged asthma can cause dangerous asthma attacks.

Childhood asthma isn’t a different disease from asthma in adults, but children do face unique challenges. Asthma in children is a leading cause of emergency department visits, hospitalizations and missed school days. Unfortunately, childhood asthma can’t be cured, and symptoms may continue into adulthood. But with the right treatment, you and your child can keep symptoms under control and prevent damage to growing lungs.

Common childhood asthma signs and symptoms include:

• Frequent, intermittent coughing
• A whistling or wheezing sound when exhaling
• Shortness of breath
• Chest congestion or tightness
• Chest pain, particularly in younger children

Other signs and symptoms of childhood asthma include:

• Trouble sleeping caused by shortness of breath, coughing or wheezing
• Bouts of coughing or wheezing that get worse with a respiratory infection, such as a cold or the flu
• Delayed recovery or bronchitis after a respiratory infection
• Trouble breathing that may limit play or exercise
• Fatigue, which can be caused by poor sleep

The first signs of asthma in young children may be recurrent wheezing triggered by a respiratory virus. As children grow older, asthma associated with respiratory allergies is more common.

Asthma signs and symptoms vary from child to child, and may get worse or better over time. While wheezing is most commonly associated with asthma, not all children with asthma wheeze. Your child may have only one sign or symptom, such as a lingering cough or chest congestion.

It may be difficult to tell whether your child’s symptoms are caused by asthma or something else. Periodic or long-lasting wheezing and other asthma-like symptoms may be caused by infectious bronchitis or another respiratory problem.

When to see a doctor

Take your child to see the doctor as soon as possible if you suspect he or she may have asthma. Early treatment will not only help control day-to-day asthma symptoms, but also may prevent asthma attacks.

Make an appointment with your child’s doctor if you notice:

• Coughing that’s constant, intermittent or seems to be linked to physical activity
• Wheezing or whistling sounds when your child exhales
• Shortness of breath or rapid breathing
• Complaints of chest tightness
• Repeated episodes of suspected bronchitis or pneumonia

If your child has asthma, he or she may say things such as, “My chest feels funny” or “I’m always coughing.” Asthma can be worse at night, so listen for coughing during sleep or coughing that awakens your child. Crying, laughing, yelling, or strong emotional reactions and stress also may trigger coughing or wheezing.

If your child is diagnosed with asthma, creating an asthma action plan can help you and other caregivers monitor symptoms and know what to do if an asthma attack does occur.

When to seek emergency treatment

In severe cases, you may see your child’s chest and sides pulling inward as he or she struggles to breathe. Your child may have an increased heartbeat, sweating and chest pain. Seek emergency care if your child:

• Has to stop in midsentence to catch his or her breath
• Is using abdominal muscles to breathe
• Has widened nostrils when breathing in
• Is trying so hard to breathe that the abdomen is sucked under the ribs when he or she breathes in

Even if your child hasn’t been diagnosed with asthma, seek medical attention immediately if he or she has trouble breathing. Although episodes of asthma vary in severity, asthma attacks can start with coughing, which progresses to wheezing and labored breathing.

The underlying causes of childhood asthma aren’t fully understood. Developing an overly sensitive immune system generally plays a role. Some factors thought to be involved include:

• Inherited traits
• Some types of airway infections at a very young age
• Exposure to environmental factors, such as cigarette smoke or other air pollution

Increased immune system sensitivity causes the lungs and airways to swell and produce mucus when exposed to certain triggers. Reaction to a trigger may be delayed, making it more difficult to identify the trigger. These triggers vary from child to child and can include:

• Viral infections such as the common cold
• Exposure to air pollutants, such as tobacco smoke
• Allergies to dust mites, pet dander, pollen or mold
• Physical activity
• Weather changes or cold air

Sometimes, asthma symptoms occur with no apparent triggers.

Factors that may increase your child’s likelihood of developing asthma include:

• Exposure to tobacco smoke
• Previous allergic reactions, including skin reactions, food allergies or hay fever (allergic rhinitis)
• A family history of asthma, allergic rhinitis, hives or eczema
• Living in an urban area with increased exposure to air pollution
• Low birth weight
• Obesity
• A chronic runny or stuffy nose (rhinitis)
• Severe lower respiratory tract infection, such as pneumonia
• Inflamed sinuses (sinusitis)
• Heartburn (gastroesophageal reflux disease, or GERD)
• Being male

Asthma may cause a number of complications, including:

• Severe asthma attacks that require emergency treatment or hospital care
• Permanent narrowing of the airways (bronchial tubes)
• Missed school days or getting behind in school
• Poor sleep and fatigue
• Symptoms that interfere with play, sports or other activities

You’re likely to start by taking your child to your family doctor or your child’s pediatrician. However, when you call to set up an appointment, you may be referred to an allergist, lung doctor (pulmonologist) or other specialist. Here’s some information to help you get ready for your child’s appointment, and to know what to expect from the doctor.

What you can do

Taking these steps can help you make the most of your child’s appointment:

• Write down any symptoms your child has had, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Note when symptoms bother your child most — for example, if symptoms tend to get worse at certain times of the day; during certain seasons; when your child is exposed to cold air, pollen or other triggers; or when he or she is playing hard or participating in sports.
• Write down key personal information, including any major stresses or recent life changes your child has had.
• Make a list of medications, vitamins and supplements your child takes.
• Write down questions to ask the doctor.

Preparing a list of questions can help you make the most of the appointment. For asthma or asthma-like symptoms, some basic questions to ask your doctor include:

• Is asthma the most likely cause of my child’s breathing problems?
• Other than the most likely cause, what else could be causing my child’s symptoms?
• What tests does my child need?
• Is my child’s condition likely temporary or chronic?
• What’s the best treatment?
• What are the alternatives to the primary approach you’re suggesting?
• My child has these other health conditions. How can we best manage them together?
• Are there any restrictions my child needs to follow?
• Should my child see a specialist?
• Is there a generic alternative to the medicine you’re prescribing for my child?
• Are there brochures or other printed materials I can have? What websites do you recommend?

Don’t hesitate to ask any other questions you have.

What to expect from your child’s doctor

The doctor is likely to ask a number of questions, including:

• What are your child’s symptoms?
• When did you first notice his or her symptoms?
• How severe are your child’s symptoms?
• Does your child have breathing problems most of the time or only at certain times or in certain situations?
• Does your child have allergies, such as atopic dermatitis or hay fever?
• What, if anything, appears to worsen your child’s symptoms?
• What, if anything, seems to improve your child’s symptoms?
• Do allergies or asthma run in your child’s family?
• Does your child have any chronic health problems?

Asthma can be hard to diagnose. Your child’s doctor will consider the nature and frequency of symptoms and may use tests to rule out other conditions and to identify the most likely cause of his or her symptoms.

A number of childhood conditions can have symptoms similar to those caused by asthma. To make things more complicated, these conditions also commonly co-occur with asthma. So your child’s doctor will have to determine whether your child’s symptoms are caused by asthma, a condition other than asthma, or both asthma and another condition. Some conditions that can cause asthma-like symptoms include:

• Rhinitis
• Sinusitus
• Acid reflux or gastroesophageal reflux disease (GERD)
• Airway abnormalities
• Vocal cord dysfunction
• Respiratory tract infections such as bronchiolitis and respiratory syncytial virus (RSV)

The doctor will ask for a detailed description of your child’s symptoms and health. Your child may also need medical tests.

• In children 6 years of age and older, doctors diagnose asthma with the same tests used to identify the disease in adults. Lung function tests (spirometry) measure how quickly and how much air your child can exhale. Your child may have lung function tests at rest, after exercising and after taking asthma medication. Allergy skin testing also may be needed.
• In younger children, diagnosis can be difficult because lung function tests aren’t accurate before 6 years of age. Some children simply outgrow asthma-like symptoms over time. Your doctor will rely on detailed information you and your child provide about symptoms. Sometimes a diagnosis can’t be made until later, after months or even years of observing symptoms.

If you suspect your child has asthma, it’s important to see a doctor as soon as possible. Early diagnosis and proper treatment can prevent disruptions from daily activities such as sleep, play, sports and school. It may also prevent dangerous or life-threatening asthma attacks.

For children younger than age 3 who have symptoms of asthma, the doctor may use a wait-and-see approach. This is because the long-term effects of asthma medication on infants and young children aren’t clear. If an infant or toddler has frequent or severe wheezing episodes, a medication may be prescribed to see if it improves symptoms.

Allergy skin tests for allergic asthma

If your child seems to have asthma that’s triggered by allergies, the doctor may want to do allergy skin testing. During a skin test, the skin is pricked with extracts of common allergy-causing substances and observed for signs of an allergic reaction. This test may help identify whether your child is allergic to animal dander, mold, dust mites or other allergens. This information can be useful in taking steps to help your child avoid his or her particular asthma triggers.

The goal of asthma treatment is to keep symptoms under control all of the time. Well-controlled asthma means that your child has:

• Minimal or no symptoms
• Few or no asthma flare-ups
• No limitations on physical activities or exercise
• Minimal use of quick-relief (rescue) inhalers, such as albuterol
• Few or no side effects from medications

Treating asthma involves both preventing symptoms and treating an asthma attack in progress. Preventive, long-term control medications reduce the inflammation in your child’s airways that leads to symptoms. Quick-relief medications quickly open swollen airways that are limiting breathing. Most children with persistent asthma use a combination of long-term control medications and quick-relief medications, taken with a hand-held inhaler.

In some cases, medications to treat allergies also are needed. The right medication for your child depends on a number of things, including his or her age, symptoms, asthma triggers and what seems to work best to keep his or her asthma under control.

Long-term control medications

In most cases, these medications need to be taken every day. Types of long-term control medications include:

• Inhaled corticosteroids. These medications include fluticasone (Flovent Diskus, Flovent HFA), budesonide (Pulmicort Flexhaler), mometasone (Asmanex), ciclesonide (Alvesco), flunisolide (Aerobid), beclomethasone (Qvar) and others. Inhaled corticosteroids are the most commonly prescribed type of long-term asthma medication. Your child may need to use these medications for several days to weeks before they reach their maximum benefit. Long-term use of these medications has been associated with slightly slowed growth in children, but the effect is minor. In most cases, the benefits of good asthma control outweigh the risks of any possible side effects.
• Leukotriene modifiers. These oral medications include montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo, Zyflo CR). They help prevent asthma symptoms for up to 24 hours. In rare cases, these medications have been linked to psychological reactions, such as agitation, aggression, hallucinations, depression and suicidal thinking. Seek medical advice right away if your child has any unusual reaction.
• Combination inhalers. These medications contain an inhaled corticosteroid plus a long-acting beta agonist (LABA). They include fluticasone and salmeterol (Advair Diskus,Advair HFA), budesonide and formoterol (Symbicort), and mometasone and formoterol (Dulera). In some situations, long-acting beta agonists have been linked to severe asthma attacks. For this reason, LABA medications should always be given to a child with an inhaler that also contains a corticosteroid. These combination inhalers should be used only for asthma that’s not well controlled by other medications.
• Theophylline. This is a daily pill that helps keep the airways open. Theophylline (Theo-24, Elixophyllin, others) relaxes the muscles around the airways to make breathing easier. It’s not used as often now as in past years.

Quick-relief medications

Also called rescue medications, quick-relief medications are used as needed for rapid, short-term symptom relief during an asthma attack — or before exercise if your child’s doctor recommends it. Types of quick-relief medications include:

• Short-acting beta agonists. These inhaled bronchodilator (brong-koh-DIE-lay-tur) medications can rapidly ease symptoms during an asthma attack. They include albuterol (ProAir HFA, Ventolin HFA, others), levalbuterol (Xopenex HFA) and pirbuterol (Maxair Autohaler). These medications act within minutes, and effects last several hours.
• Ipratropium (Atrovent). Your doctor might prescribe this inhaled medication for immediate relief of your child’s symptoms. Like other bronchodilators, it relaxes the airways, making it easier to breathe. Ipratropium is mostly used for emphysema and chronic bronchitis, but it’s sometimes used to treat asthma attacks.
• Oral and intravenous corticosteroids. These medications relieve airway inflammation caused by severe asthma. Examples include prednisone and methylprednisolone. They can cause serious side effects when used long term, so they’re only used to treat severe asthma symptoms on a short-term basis.

Treatment for allergy-induced asthma

If your child’s asthma is triggered or worsened by allergies, your child may benefit from allergy treatment as well. Allergy treatments include:

• Omalizumab (Xolair). This medication is specifically for people who have allergies and severe asthma. It reduces the immune system’s reaction to allergy-causing substances, such as pollen, dust mites and pet dander. Xolair is delivered by injection every two to four weeks.
• Allergy medications. These include oral and nasal spray antihistamines and decongestants as well as corticosteroid, cromolyn and ipratropium nasal sprays.
• Allergy shots (immunotherapy). Immunotherapy injections are generally given once a week for a few months, then once a month for a period of three to five years. Over time, they gradually reduce your child’s immune system reaction to specific allergens.

Don’t rely only on quick-relief medications

Long-term asthma control medications such as inhaled corticosteroids are the cornerstone of asthma treatment. These medications keep asthma under control on a day-to-day basis and make it less likely your child will have an asthma attack.

If your child does have an asthma flare-up, a quick-relief (rescue) inhaler can ease symptoms right away. But if long-term control medications are working properly, your child shouldn’t need to use a quick-relief inhaler very often. Keep a record of how many puffs your child uses each week. If he or she frequently needs to use a quick-relief inhaler, take your child to see the doctor. You probably need to adjust his or her long-term control medication.

Inhaled medication devices

Inhaled short- and long-term control medications are used by inhaling a measured dose of medication.

• Older children and teens may use a small, hand-held device called a pressurized metered dose inhaler or an inhaler that releases a fine powder.
• Infants and toddlers need to use a face mask attached to a metered dose inhaler or a nebulizer to get the correct amount of medication.
• Babies need to a use a device called a nebulizer, a machine that turns liquid medication into fine droplets. Your baby wears a face mask and breathes normally while the nebulizer delivers the correct dose of medication.

Asthma action plan

Work with your child’s doctor to create a written asthma action plan. This can be an important part of treatment, especially if your child has severe asthma. An asthma action plan can help you and your child:

• Recognize when you need to adjust long-term control medications
• Keep tabs on how well treatment is working
• Identify the signs of an asthma attack and know what to do when one occurs
• Know when to call a doctor or seek emergency help

Depending on his or her age, your child may use a hand-held device to measure how well he or she can breathe (peak flow meter). Using a written asthma action plan can help you and your child remember what to do when peak flow measurements reach a certain level. The action plan may use peak flow measurements and symptoms to categorize your child’s asthma into zones, such as the green zone, yellow zone and red zone. These zones correspond to well-controlled symptoms, somewhat-controlled symptoms and poorly controlled symptoms. This makes tracking your child’s asthma easier.

Your child’s symptoms and triggers are likely to change over time. You’ll need to carefully observe symptoms and work with the doctor to adjust medications as needed. If your child’s symptoms are completely controlled for a period of time, your child’s doctor may recommend lowering doses or taking your child off a medication (stepping down treatment). If your child’s asthma isn’t as well controlled, the doctor may want to increase, change or add medications (stepping up treatment).

Taking steps to reduce your child’s exposure to his or her asthma triggers will lessen the possibility of asthma attacks. Steps to help avoid triggers vary depending on what triggers your child’s asthma. Here are some things that may help:

• Maintain low humidity at home. If you live in a damp climate, talk to your child’s doctor about using a device to keep the air drier (dehumidifier).
• Keep indoor air clean. Have a heating and air conditioning professional check your air conditioning system every year. Change the filters in your furnace and air conditioner according to the manufacturer’s instructions. Also consider installing a small-particle filter in your ventilation system.
• Reduce pet dander. If your child is allergic to dander, it’s best to avoid pets with fur or feathers. Regularly bathing or grooming your pets also may reduce the amount of dander in your surroundings.
• Use your air conditioner. Air conditioning helps reduce the amount of airborne pollen from trees, grasses and weeds that finds its way indoors. Air conditioning also lowers indoor humidity and can reduce your child’s exposure to dust mites. If you don’t have air conditioning, try to keep your windows closed during pollen season.
• Keep dust to a minimum. Reduce dust that may aggravate nighttime symptoms by replacing certain items in your bedroom. For example, encase pillows, mattresses and box springs in dust-proof covers. Consider removing carpeting and installing hard flooring, particularly in your child’s bedroom. Use washable curtains and blinds.
• Clean regularly. Clean your home at least once a week to remove dust and allergens.
• Reduce your child’s exposure to cold air. If your child’s asthma is worsened by cold, dry air, wearing a face mask outside can help.

Help your child stay healthy

Staying active and treating other conditions linked to asthma will help keep your child’s asthma under control.

• Make treatment a regular part of life. If your child has to take daily medication, don’t make a big deal out of it — it should be as routine as eating breakfast or brushing teeth.
• Make sure your child gets exercise. Don’t let asthma sideline your child. Regular exercise reduces symptoms and is important for your child’s overall health. With asthma under control, there should be no limit to your child’s physical activity level.
• Help your child maintain a healthy weight. Being overweight can worsen asthma symptoms, and it puts your child at risk of other health problems.
• Keep heartburn under control. Acid reflux or severe heartburn (gastroesophageal reflux disease, or GERD) may worsen your child’s asthma symptoms. He or she may need over-the-counter or prescription medications to control acid reflux.

While some alternative remedies are used for asthma, in most cases more research is needed to see how well they work and to measure the extent of possible side effects. Alternative treatments that may help with asthma include:

• Breathing techniques. These include structured breathing programs, such as the Buteyko breathing technique, the Papworth method and yoga breathing exercises (pranayama).
• Acupuncture. This technique has roots in traditional Chinese medicine. It involves placing very thin needles at strategic points on your child’s body. Acupuncture requires holding still for up to a few minutes, which can be hard for young children. It’s safe and generally painless.
• Relaxation techniques. Techniques such as meditation, biofeedback, hypnosis and progressive muscle relaxation may help with asthma by reducing tension and stress.
• Homeopathy. Homeopathy aims to stimulate the body’s self-healing response by using very small doses of substances that cause symptoms. In the case of asthma, homeopathic remedies are made from substances that trigger an asthmatic reaction, such as pollen or weeds. There’s still not enough evidence to determine whether homeopathy helps treat asthma caused by allergies or not.
• Herbal remedies and supplements. A number of herbal remedies have been tried for asthma, such as butterbur, ginkgo and dried ivy. Studies are unclear about the benefit of these and other herbal treatments for asthma. Herbs and supplements can have side effects and some may interact with other medications your child is taking. Talk to your child’s doctor before trying any herbs or supplements.

It can be stressful to help your child manage his or her asthma. Keep these tips in mind to make life as normal as possible:

• Use a written asthma action plan. Work with your child’s doctor to develop your child’s action plan, and give a copy of it to all of your child’s caregivers, such as child care providers, teachers, coaches, and the parents of your child’s friends. Following a written plan can help you and your child identify symptoms early, providing important information on how to treat your child’s asthma from day to day and how to deal with an asthma attack.
• Be encouraging. Focus attention on the things your child can do, not on the things he or she can’t. Involve teachers, school nurses, coaches, relatives and friends in helping your child manage asthma. Encourage normal play and activity. Don’t limit your child’s activities out of fear of an asthma attack — work with your child’s doctor to control exercise-induced symptoms.
• Be calm and in control when facing asthma symptoms.Don’t get rattled if you see asthma symptoms getting worse. Focus on your child’s asthma action plan and involve your child in each step so that he or she understands what’s happening.
• Talk to other parents of children with asthma. Chat rooms and message boards on the Internet or a local support group can connect you with parents facing similar challenges and let you know that you and your child are not alone in dealing with asthma.
• Help your child connect with others who have asthma.Send your child to “asthma camp” or find other organized activities for children with asthma. This can help your child feel less isolated and help him or her gain a better understanding of asthma and its treatment.

Careful planning and steering clear of asthma triggers are the best ways to prevent asthma attacks.

• Limit exposure to asthma triggers. Be proactive in helping your child avoid the allergens and irritants that trigger asthma symptoms.
• Don’t allow smoking around your child. Exposure to tobacco smoke during infancy is a strong risk factor for childhood asthma, as well as a common trigger of asthma attacks.
• Encourage your child to be active. As long as your child’s asthma is well controlled, regular physical activity can condition the lungs to work more efficiently.
• See the doctor when necessary. Check in on a regular basis. Don’t ignore signs that your child’s asthma may not be under control, such as needing to use a quick-relief inhaler too often. Asthma changes over time. Consulting your child’s doctor can help you make any needed treatment adjustments to keep symptoms under control.

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