Pediatric Asthma

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Asthma is a chronic respiratory disease. Although it can be worrisome and inconvenient, it is a manageable condition. With proper understanding, good medical care, and monitoring, you can keep asthma under control.

Asthma is different in children and adults for several reasons. For example, children can be harder to diagnose and may be unable to use some drugs that are available for adults. This module covers some of the special concerns of children with asthma and their parents.

  1. What is asthma?
  2. How does asthma in children differ from asthma in adults?
  3. When do you call a child who wheezes an asthmatic?
  4. How do you treat a child with asthma?
  5. Can children take oral steroids for their asthma? Inhaled?
  6. How can I get my child to use asthma medications appropriately?
  7. How can I tell how well my child's lungs are working?
  8. Do children grow out of asthma?
  9. How can I prepare my child for a new school year?
  10. Can my child take gym or sports at school?
  11. Can my child go to summer camp?
  12. How can I explain asthma to my child?
  13. Where can I find out more about pediatric asthma?

What is asthma?

Asthma, also known as reactive airway disease, is a chronic lung condition with:

  • Inflammation (swelling) of the airways
  • Increased sensitivity of the airways to a variety of things that make asthma worse
  • Obstruction of airflow

Inflammation. Inflammation of the lining of the airways is the most common feature of asthma. When they are stimulated, certain cells lining the airways release chemical substances (mediators) that lead to inflammation. This causes the airway lining to swell and narrow. The inflammation may last for weeks following an episode. Most people with asthma have some degree of inflammation all the time. Some long-term-control medications can help prevent and reduce inflammation.

Increased sensitivity. Another characteristic of asthma is increased sensitivity of the airways. When inflammation occurs in the airways, the airways become more sensitive. When the airways are more sensitive, you are more likely to have asthma symptoms when exposed to things that make asthma worse. When there is less inflammation, the airways are less sensitive and you are less likely to have asthma symptoms when exposed to things that make asthma worse.

Airway obstruction. In addition to inflammation, further airway obstruction occurs with asthma. Obstruction is caused by tightening of muscles that surround the airways. This is also called bronchospasm. Bronchospasm causes further narrowing of the inflamed airways. In some people with asthma, the mucous glands in the airways produce excessive, thick mucus, further obstructing the airways.

How does asthma in children differ from asthma in adults?

Both children and adults have airway inflammation and obstruction, as described above. However, asthma in children differs from asthma in adults for several other reasons. Children are not diagnosed with asthma until they have had several attacks, as described below. For many children who have asthma before age 3, there is a good chance it will go away in the next few years. This is particularly true for children who have no family history of allergy or asthma and who started wheezing because of an infection.

Diagnosing asthma is also more difficult in children, particularly those under the age of 5. In adults, it is fairly easy to perform a lung function test. This is not the case with young children, who can't easily be coaxed to blow into a spirometer, a device that measures lung capacity. Therefore, the physician often has to assume the diagnosis is asthma and treat it without really being sure. Also, an adult patient can tell the doctor if he is wheezing, waking up at night, and having difficulty breathing. Nighttime wheezing is a common symptom of asthma in both adults and children, and often precedes daytime symptoms. With a young child, someone else has to observe the symptoms. If the child's symptoms aren't disturbing enough to wake a parent during the night, the parent is often unaware. This frequently leads to a delay in recognizing the symptoms and seeking care. Thus, children often aren't seen by a physician until later in the course of the problem—and their first visit may be to the emergency room.

A key part of managing chronic asthma is following patients to determine how they are doing and to adjust medications accordingly. Part of that monitoring is making objective measurements of the airflow in the lungs. This can be done using a spirometer in a doctor's office or at home with a peak flow meter. But most young children (again, under 5) can't effectively use these devices, which require patients to follow instructions and blow into a tube. This means it is impossible to keep measurements on lungs over time, which makes it harder to make decisions about medication use for a young child.

Young children do not have as many medication options as adults because many asthma medications have not been studied in young children. Also, young children can't always take medicines the same way adults can. Adults can use inhalers and nebulizers to take aerosol medications, while young children must use face masks. The exact dose has been calculated for children of different ages using various medication delivery systems, but all of these choices and issues make children's asthma more difficult to manage. Older children can handle inhalers; a good time to teach kids to use inhalers is when they start school.

A key difference between young children and adults is that side effects of medications in children are not well understood. While adults can describe when they are feeling different as a result of medication, this is not usually the case in children. Therefore, the side effects described for medications in young children are what adults report about the same medications (such as a headache or feeling jittery) or symptoms that adults can observe in children (such as shaking of the hands or tremor). Children may not eat, sleep, or play as usual with certain medications, but these symptoms are difficult to report or observe until they represent a marked divergence from normal behaviors.

All of these differences make treating young children with asthma a little more difficult than treating adults.

When do you call a child who wheezes an asthmatic?

There is no definite time for a physician to call a child who is having episodes of wheezing an asthmatic. In fact, physicians may choose many terms to describe a wheezing child, including bronchitis, wheezy bronchitis, reactive airways, and even pneumonia. Not making the accurate diagnosis delays appropriate therapy and often leads to nothing being done to prevent the next attack. No one wants to put a label associated with a chronic illness like asthma on a child before being sure of the diagnosis—usually not until the child has had several episodes of wheezing.

The following factors help in making the diagnosis:

  1. There is a family history of allergy and/or asthma
  2. The child has had a recurrence of the same symptoms in a fairly short period
  3. The child has atopic dermatitis (eczema) already

How do you treat a child with asthma?

One important step in getting children to use their medications for asthma correctly is to explain what each one does.

Controller medications need to be taken every day, even if there are no symptoms that day. These medications prevent asthma from getting to be a problem when it is out of control. It is best to associate taking these medications with a consistent event that occurs every day, such as waking up in the morning or getting ready to go to sleep. For medications that require administration more than two times a day, it might be a good idea to tie taking the medications to meals.

Taking medications should not be viewed as a punishment but as an important way to keep from having problems. Positive reinforcement is the best way for some children to remember to take their medications.

Medications that serve to relieve symptoms (relievers) need to be identified as being different. They are used when your child is experiencing more problems, such as wheezing or difficulty breathing. When these symptoms occur, it is frightening for children, and they may not take the medications correctly. You can prepare for this by practicing when your child is not having an attack.

Can children take oral steroids for their asthma? Inhaled?

Corticosteroids (steroids) are medicines that are used to treat many chronic diseases. Corticosteroids are very good at reducing inflammation (swelling) and mucus production in the airways of the lungs. They also help quick-relief medicines work better. The steroids (corticosteroids) used to treat chronic lung diseases are not the same as anabolic steroids, used illegally by some athletes for bodybuilding. Corticosteroids do not affect the liver or cause sterility.

The most common way steroids are prescribed for children is by inhalation. An inhaled steroid is typically prescribed as a long-term-control medicine. This means that it is used every day to maintain control of your child's asthma and prevent symptoms. An inhaled steroid prevents and reduces swelling inside the airways, making them less sensitive. It may also decrease mucus production. An inhaled steroid will not provide quick relief for asthma symptoms.

Your healthcare provider usually will recommend a starting dose to control symptoms but may adjust the dosage of the inhaled steroid based on your child's symptoms, how often the child uses quick-relief medicine to control symptoms, and peak flow measurements. Children with asthma may still need a short burst of oral steroids when they have more severe symptoms.

The most common side effects of inhaled steroids are thrush (a yeast infection of the mouth or throat that causes a white discoloration of the tongue), cough, and hoarseness. Your child should rinse his mouth (and spit out the water) after inhaling the medicine and use a metered-dose inhaler with a spacer to reduce the risk of thrush. When a dose is prescribed that is higher than the normal dose listed in the package insert, or even the normal dose, some systemic side effects may occur. These can include reddening of the cheeks, irritability, and sleep problems. Prolonged use of a higher dose can affect a child's growth. This is the most important side effect in children, and children on inhaled steroids should be followed closely by a physician to check for this side effect. Keep in mind, however, that an inhaled steroid has much less potential for side effects than steroid pills or syrups.

Steroid pills and syrups are very effective at reducing swelling and mucus production in the airways. They also help other quick-relief medication work better. They are often necessary for treating more severe episodes of lung disease.

Many children with asthma periodically require a short-term burst of steroid pills or syrups to decrease the severity of acute attacks and prevent an emergency room visit or hospitalization. A burst may last two to seven days and does not necessarily require a gradually decreasing dosage (this is normally required after people take steroids for more than seven days). Your child may experience a few mild side effects, such as increased appetite, fluid retention, moodiness, sleep disturbances, and stomach upset. These side effects are temporary and typically disappear after the medicine is stopped. Frequent bursts of oral steroids can dramatically slow growth in children. Taking frequent bursts of steroids usually means a child's asthma is out of control and requires significantly more attention to determine the cause and address it.

Some children need extra calcium and vitamin D because of long-term steroid therapy.

How can I get my child to use asthma medications appropriately?

One important step in getting children to use their medications for asthma correctly is to explain what each one does.

Controller medications need to be taken every day, even if there are no symptoms that day. These medications prevent asthma from getting to be a problem when it is out of control. It is best to associate taking these medications with a consistent event that occurs every day, such as waking up in the morning or getting ready to go to sleep. For medications that require administration more than two times a day, it might be a good idea to tie taking the medications to meals.

Taking medications should not be viewed as a punishment but as an important way to keep from having problems. Positive reinforcement is the best way for some children to remember to take their medications.

Medications that serve to relieve symptoms (relievers) need to be identified as being different. They are used when your child is experiencing more problems, such as wheezing or difficulty breathing. When these symptoms occur, it is frightening for children, and they may not take the medications correctly. You can prepare for this by practicing when your child is not having an attack.

How can I tell how well my child's lungs are working?

A peak flow meter is a small, easy-to-use instrument that measures peak expiratory flow, a gauge of how fast your child can blow out air after breathing all the way in. It reveals how well your child's lungs are working. This number is very useful for you and your doctors.

Sometimes peak flow numbers will decrease hours, or even a day or two, before other asthma symptoms become evident. When you monitor peak flow numbers on a daily (or regular) basis, you can identify this drop and take steps to prevent an asthma episode. The peak flow numbers, along with watching for asthma symptoms, can be used to make decisions about asthma treatment.

You and your doctor may find it easier to develop an asthma management plan for your child if you record peak flows routinely. Also, it is important to talk with your doctor about the steps you should take when the peak flow number drops.

Children who require medication for asthma on a daily or near-daily basis are good candidates for using a peak flow meter. Children over 5 years of age are usually able to give accurate readings on a peak flow meter.

Do children grow out of asthma?

One of the most common questions asked is whether a child will grow out of asthma. This is not an easy question to answer specifically for an individual child. Many children do, in fact, outgrow asthma. These are usually children who developed their asthma as a result of an infection, do not have allergies, and do not have anyone with allergies or asthma in the immediate family. These children's symptoms usually go away before they are about 6 years old. There are other children who do come from an allergic family and usually see their symptoms go away as they go through puberty, only to return later in life. There are no good tests that can predict which children will grow out of asthma and which will continue having symptoms as they grow older.

How can I prepare my child for a new school year?

Allergy and asthma symptoms often increase soon after school starts. Close contact with other children in enclosed spaces exposes children with asthma to respiratory viruses and animal dander that children with pets carry from home. Weed pollens are often at peak levels during the early weeks of school. Make sure your child's allergy and asthma prescriptions are filled so you can be ready to treat the very first signs of worsening symptoms.

Below are several tips to help parents of children with asthma prepare for the new school year.

Asthma Action Plan
Ask your doctor for a written asthma action plan for the school. A sample version of this form is available here for web viewing or available here for easy printing. This plan should include what medicine to use to treat asthma symptoms and changes in peak flow zones, what medication to use as a treatment before exercise, emergency telephone numbers, and a list of things that make your child's asthma worse. Schools have varying policies about allowing children to bring medications to school. Contact your child's school, and find out its policy. Many school districts require a doctor to fill out a form listing medications a child should be allowed to have at school. If those forms are needed, get them and make sure your doctor fills them out.

Getting Ready for Fall
When school starts, weed pollens and cooler weather may bring about a change in your child's condition. Being prepared for these changes can make a big difference in keeping your child's asthma well controlled.

Dealing With School Stress
The first weeks of school can be a stressful time, which can exacerbate existing allergies and asthma. Parents can help their children cope with the stresses of a new school year. Give your children opportunities to talk and bring up issues that are on their mind. Often routine activities, such as sharing a meal, washing the dishes, or driving to school, provide the best opportunities for conversation. Don't worry if you don't have an answer right away; listening is the most important thing.

Meet With School Staff
Plan a meeting with school staff before or in the beginning weeks of the school year. It is helpful to have the school nurse, health aide, teacher, and physical education teacher at the meeting. Your child also can be involved in the meeting. Take the written asthma action plan to the meeting. Review the action plan, use of the peak flow meter, medicines, and things that make your child's asthma worse.

Special School Supplies
Keep a peak flow meter, spacer, and rescue medicine at school for your child. Make sure the rescue medicine has not passed its expiration date. Take these items home at the end of each school year.

Field Trips
Asthma should not keep your child from participating in an off-site field trip. Be prepared to take medicines along to use for flare-ups.

Keep in Touch
Continue talking on a regular basis with your child and school staff about managing asthma at school, even if everything is fine. Talk with the school staff if your child misses school and assignments.

When to Stay Home
Talk with your child's doctor about when it is OK to stay home from school because of asthma or illness. Mild asthma symptoms can usually be handled at school, but there are a number of factors (what triggered the asthma, the stability of peak flows, fever, how much medicine your child is taking, etc.) to consider when deciding whether to keep your child at home.

Asthma Action Plan

NAME OF STUDENT_______________________ DATE____________

School-Age Children and Asthma
Asthma is the most common pediatric lung disorder. It affects as many as 5 percent of children under the age of 15 years. There are almost 5 million children in the United States with asthma. Children with asthma have swollen, sensitive airways that lead to episodes of breathing difficulty. Although there is no known cure for asthma, it can be controlled effectively. When asthma is under good control, the inflammation and obstruction in the airways will be decreased. Because children spend most of their day at school, it is important that school professionals understand asthma and asthma management. This handout introduces asthma management concepts and gives school professionals detailed information about this student's asthma management program. Managing asthma makes it possible for children to participate in school to the level of their ability.

What Makes Asthma Worse
Asthma triggers are the things that make asthma worse immediately or slowly over time. Every child with asthma has different asthma triggers. Things that make asthma worse should be avoided or controlled in the school environment. Things that can make asthma worse include irritants (e.g., smoke and fumes), allergens (e.g., furry animals, grasses, and trees), exercise, infections, changes in the weather, and emotions.

Comments:

Asthma Symptoms
Early warning signs and asthma symptoms are indicators that a child's asthma may be getting worse. Monitoring asthma signs and symptoms is very important in managing asthma at school. Signs and symptoms are things that children feel or that you may notice when asthma is getting worse. Common symptoms to watch for include wheezing, coughing, shortness of breath, and chest tightness.

Comments:

Peak Flow Monitoring
In addition to watching for asthma symptoms, children with asthma can monitor their breathing at school by using a peak flow meter. A peak flow meter measures the flow of air in a forced exhalation in liters per minute. Peak flow monitoring can help identify the start of an asthma episode, often before the child is having symptoms. Peak flow zones divide the peak flow meter into the colors of a traffic light and can help children and school professionals make decisions about asthma management.

  • Personal Best _________________________
  • Green Zone (All Clear) Above _________________________
  • Yellow Zone (Caution) ___________ to ____________
  • Red Zone (Medical Alert) Below _________________________

Asthma Medications
Asthma medications are divided into two groups: long-term-control and quick-relief medications. Some quick-relief medications (e.g., Proventil, Ventolin, Maxaire) work quickly to relax the muscles around the airways. These are used to treat asthma symptoms. Long-term-control medications are used daily to maintain control of asthma and prevent asthma symptoms. Long-term-control medications may be inhaled (e.g., Flovent, Pulmicort, QVar) or taken as a pill (e.g., Singulair). Most children use a combination of long-term-control and quick-relief medications to manage their asthma. Many children uses spacers or holding chambers, devices that attach to the inhaler to increase the amount of medication that is delivered to the airways.

Name of Medication Dose When to Use
     
     
     
     

Can my child take gym or sports at school?

Exercise is a common trigger for asthma symptoms. But children with asthma can participate in gym and sports activities at school. To do so, however, it is important to discuss the level of activity with your child's physician and have a written plan for preventing problems. For some children, it is a good idea to use an inhaler before activity to prevent difficulties. It is also important to have a plan for what to do if your child has a problem after activity. Don't hesitate to call or send a note to the physical education teacher.

The following suggestions may help your child participate:

Make sure your child has a pretreatment, such as albuterol, for gym class or other physical activities, especially outdoors in cold weather.

During warm weather, when pollen is still in the air, outdoor exercise can exacerbate both asthma and allergies. Pretreatment with antihistamines and intranasal steroids can greatly reduce those symptoms.

Sports or activities with bursts of movement are least likely to cause asthma symptoms. Activities followed by brief rest periods can allow the child to regain control of breathing. Activities such as baseball, softball, volleyball, tennis, downhill skiing, golf, and some track and field events all have brief rest periods.

Sports that require continuous activity, like swimming, cycling, distance running, and soccer, also can be enjoyed by people with exercise-induced asthma. Participation in any sport often requires use of a treatment before exercise and close monitoring. Along with appropriate treatment and close monitoring, good warm-up and cool-down periods are often helpful.

Can my child go to summer camp?

For many people, fond memories of summer camp last into adulthood. Specific camps for children with asthma are available. The American Lung Association is a good resource for information about asthma camps in different parts of the country. But with careful planning, children with asthma can attend camps that aren't designed specifically for them, too.

Parents often have a checklist of things to prepare for their children's going to camp. This asthma checklist can help parents, children with asthma, and camp staff work together to provide a safe camp experience for children with asthma.

  • Find out who is responsible for medical care at the camp. Is there a physician or nurse on site? Who is the medically trained person who will be administering medications? If your child is going to an overnight camp, is a medically trained person there 24 hours a day?
  • Plan a meeting with the person responsible for medical care and your child's counselor on or before the first day of camp.
  • Your child can be involved in the meeting. Topics to discuss include:
  • What makes your child's asthma worse, especially in the camp setting
  • Asthma symptoms, including the child's awareness of the symptoms
  • Peak flow use (when appropriate), including technique and the use of peak flow zones
  • Actions to take when asthma symptoms occur or peak flows are in the yellow or red zones
  • Use of a metered-dose inhaler and spacer at camp, including the correct technique
  • Whether the healthcare provider and the parent recommend that the child keep the metered-dose inhaler and spacer with him or her. If not, the metered-dose inhaler and spacer should be quickly accessible when asthma symptoms occur.
  • Compile a written asthma action plan to support what you discuss at the meeting. Talk with your child's healthcare provider before camp about the written plan. The asthma action plan should include what medication to take daily, what medication to use to treat asthma symptoms and decreases in peak flow zones, what medication to use as a treatment before exercise, emergency telephone numbers, and what makes the child's asthma worse.
  • Provide the necessary equipment for the stay at camp. This often includes enough medications for the child's stay at camp, a spacer, a peak flow meter, and possibly a nebulizer.
  • Ask where the medication is kept at camp. Make sure the quick-relief inhaler will be available when needed.
  • Talk with the medically trained person during the camp stay to see how the asthma action plan is working.

How can I explain asthma to my child?

How you explain asthma to a child depends on factors such as the age and maturity of the child and the severity of the disease. It is important to discuss what happens in the airways, both during an attack and when asthma is under control. Also, your child should understand how medications are used in asthma to control the problem and during attacks. It is also important to let your child know that many children have asthma and they lead normal lives every day.

You and your child can learn more about asthma together with the help of the Asthma Wizard, a magician who explains asthma symptoms, peak flow meters, and other concepts. The Asthma Wizard is on the National Jewish Medical and Research Center website.

Where can I find out more about pediatric asthma?

More information on pediatric asthma is available at these websites recommended by the U.S. News & World Report Library:

The Asthma Wizard
Brought to you by the National Jewish Medical and Research Center, the Wizard "is an expert about asthma, and he's here to teach kids like you everything he knows."

Asthma in Children (National Library of Medicine)
Latest news, treatment options, disease management, clinical trials, and related issues

Asthma and Children (American Lung Association)
Early warning signs that your child may have asthma, tips on controlling your child's asthma, an overview of asthma medication for children, and more

Children With Allergies and Asthma (American Academy of Pediatrics)
Includes handouts developed by the AAP Section on Allergy and Immunology Pediatric Asthma and links to additional websites with pediatric allergy information

The Consortium on Children's Asthma Camps
Founded in 1988, the consortium provides a list of camps throughout the United States and includes a pre-camp guide for parents of children going to asthma camps.

"Just for Kids" (AAAAI)
Developed by the American Academy of Allergy, Asthma, & Immunology especially for children, this section includes puzzles and games developed to help them learn to manage their asthma.

Last reviewed on 10/14/09

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