| Asthma (also called reactive airway disease) is a common problem in infants and children, affecting about 5-10% of children (about 5 million children under the age of 18 years of age). The most common symptoms include recurring episodes of coughing, wheezing and difficulty breathing, although some children just have coughing and don't wheeze with each episode. There is no cure for asthma, but with the right management, your Pediatrician can help to get your child's asthma under control, minimize symptoms, avoid missed days from school, and avoid visits to the emergency room or hospitalizations. With good control, your child's asthma should not limit his activities or slow him down and he should be able to participate in physical activities and sports and keep up with the other children.
Although it is not known what causes asthma, children with asthma do seem to have very sensitive or hyperresponsive airways, and when they come in contact with certain triggers, such as smoke, dust, pet hairs, exercise etc, they react by tightening (bronchoconstriction) and becoming narrow, inflamed and producing mucus, which can lead to the air passages becoming smaller and limiting the amount of air that passes through them and into and out of the lungs. Although this narrowing may occur for a short time and reverse with a bronchodilator, it could also lead to a longer asthma attack or exacerbation.
This condition does seem to run in certain families and is more common in kids that also have allergic rhinitis or eczema. It is also more common in children that are exposed to second hand smoke, air pollution, dust mites, mold and pets. If you have a strong family history of allergies or asthma in your family, then minimizing your children's exposure to these common triggers my prevent them from developing asthma.
Asthma is diagnosed in children who have recurrent episodes of wheezing, coughing, difficulty breathing, especially if these symptoms worsen at night or after being exposed to certain triggers, and if they have evidence of airway obstruction that improves with a bronchodilator. Asthma can be difficult to diagnosis, especially in young children, who may have wheezing and coughing as part of a viral illness, such as bronchiolitis. And the testing commonly used to detect asthma in children, the peak flow meter, can not usually be used in children under 5-6 years old (although pulmonary function tests may be performed by a Pediatric Pulmonologist in younger children).
Asthma is increasing in developed countries such as the United States. It is also probably underdiagnosed and undertreated. Children with asthma may often be misdiagnosed as having a cold, bronchitis, or pneumonia. Asthma should be suspected in children that have a persistent cough that is not improving with standard therapies, even if they are not wheezing (cough varient asthma), or recurrent episodes of wheezing and coughing that do not quickly improve in 7-10 days.
The severity of untreated asthma can vary from having mild and infrequent symptoms to having severe daily symptoms that interfere with daily activities. Asthma can usually be classified into one of the four following steps:
- Step 1: Intermittent - asthma symptoms less than once each week (nighttime symptoms less than twice a month), peak flows within 80% of predicted, and with brief and mild attacks or exacerbations. This class of asthma can usually be treated with short acting bronchodilators as needed.
- Step 2: Mild Persistent - asthma symptoms more than once a week, but not everyday, peak flows within 80% of predicted and with attacks or exacerbations that may interfere with regular activities. Children with mild persistent asthma should be treated with a daily controller or anti-inflammatory medication.
- Step 3: Moderate Persistent - asthma symptoms daily, requiring daily use of a short acting bronchodilator medicine and with attacks or exacerbations that do interfere with regular activities and sleep, peak flows within 60-80% of predicted. Children with moderate persistent asthma should be treated with a daily controller or anti-inflammatory medication and a long acting bronchodilator medication.
- Step 4: Severe Persistent - asthma symptoms continuously, requiring regular use of a short acting bronchodilator medicine and with frequent attacks or exacerbations that limit activities and interfere with sleep, peak flows less than 60% of predicted. Children with moderate persistent asthma should be treated with multiple daily controller or anti-inflammatory medication, including high doses of an inhaled steroid, a long acting bronchodilator medication, and possibly long term oral steroids. Most children with severe persistent asthma should be treated by a Pediatric Pulmonologist.
Among the techniques that will help get your child's asthma under good control, include:
- Aggressively identifying and treating asthma attacks with a bronchodilator medicine and sometimes an oral steroid. Your Pediatrician should prepare an asthma action plan so that you know what to do when your child begins to have symptoms.
- Be prepared by always having your child's quick relief asthma medications handy, especially on trips, etc. Call in advance for refills so that you never run out.
- Let your Pediatrician know if you are needing to use your quick relief bronchodilator medicine more than once or twice a week.
- Identifying and avoiding triggers. Keeping a daily symptom diary can be helpful in identifying triggers.
- Monitoring peak flows in older children, which can help predict an asthma attack and help you and your Pediatrician determine how well your child's asthma is under control.
- For children with persistent asthma symptoms, using anti-inflammatory medicines to help prevent asthma attacks, such as steroid inhalers, long acting bronchodilators, and anti-leukotriene medications.
- Review your treatment plan with your Pediatrician every 3-6 months. Don't change or stop medications unless instructed to do so by your Pediatrician, even if your child's asthma seems to be under good control.
- Treating allergies if present, since uncontrolled allergies can worsen your child's asthma.
- Learn to identify the signs and symptoms of a severe asthma attack which can require immediate medical attention, including breathing rapidly or being short of breath, having retractions, talking in short words or phrases (instead of regular complete sentences), being irritable or agitated, wheezing loudly, chest tightness, color changes (pale or blue), nasal flaring (nostrils open wider), grunting, having a peak flow below 50% of his usual or best, and/or having a persistent cough.
- Learn to predict when your child is going to have an asthma attack and begin his medications early. You can learn to predict attacks by watching for warning signs, including a drop in peak flows, worsening allergies, runny nose, cough, exposure to a known trigger, etc. Keeping a daily symptom diary can be helpful in identifying warning signs of an asthma attack.
- Be especially vigilant if your child is at high risk, with a history of poorly or difficult to control asthma, previous severe attacks (which may include hospitalizations and/or stays in an intensive care unit and which may have required intubation and assisted ventilation with a breathing machine), or a history of having asthma attacks that quickly worsen.
- Bring all medications, spacers, peak flow meter, symptom diary and your record of peak flows to each office visit.
- Avoid using over the counter asthma medications.
- Get your child a flu shot each year.
Asthma is a chronic disease, but many children do outgrow it as they get older, although some continue to have problems as teens and adults. With the proper management, your child should be able to run and play without any limitations.
If your child is not improving with his current medication regimen, then he may need a step up in his therapy, which can include increasing the amount of anti-inflammatory medications he is on. Also, be sure that he does not have uncontrolled allergies or gastroesophageal reflux, both of which can make asthma symptoms worse.
An important thing to keep in mind, especially if your child has been diagnosed with asthma and is not improving with standard treatments, is that not all wheezing in children is from asthma. Other things that can cause wheezing include:
- Bronchiolitis - a viral infection of the lungs.
- Foreign body inhalation - such as a button or peanut, etc which can get lodged in the airways or lung. Children who have wheezing or difficulty breathing that is due to a foreign body usually have a coughing or choking attack or fit before they began wheezing. They may also have wheezing on just one side of their chest.
- Other causes of obstruction of the large airways that can cause wheezing include vascular rings, laryngotracheomalacia, laryngeal webs, tracheostenosis or bronchostenosis.
- Cystic fibrosis
- Bronchopulmonary dysplasia in premature infants
- Gastroesophageal reflux
Another reason for your child's asthma to not be getting better despite being on a good medical regimen is noncompliance. The medications can't help if your child isn't taking them appropriately.
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