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Asthma Prevention Tips

Asthma in Children
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.

Last Updated - 25th October 2005

Possible Causes of Asthma

• 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 variant 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:

• 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 exacerbation. This class of asthma can usually be treated with short acting bronchodilators as needed.
• Mild Persistent - asthma symptoms more than once a week, but not everyday, peak flows within 80% of predicted and with attacks or exacerbation that may interfere with regular activities. Children with mild persistent asthma should be treated with a daily controller or anti-inflammatory medication.
• Moderate Persistent - asthma symptoms daily, requiring daily use of a short acting bronchodilator medicine and with attacks or exacerbation 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.
• Severe Persistent - asthma symptoms continuously, requiring regular use of a short acting bronchodilator medicine and with frequent attacks or exacerbation 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.

Diagnosis

• Up to 80% of children with asthma develop symptoms before age five. The child's physician must rely heavily on parents' observations to make a proper diagnosis.
• To make a diagnosis of asthma your child's physician will want to know about the following:
  • Does your child cough, wheeze (a whistling sound when breathing), have chest tightness or shortness of breath?
  • Do colds go right to your child's chest and last much longer than other siblings?
  • Does your child cough or wheeze with exercise, play and laughter or during temper tantrums?
  • Is there a family history of asthma or allergies?
  • What triggers your child's symptoms - colds, allergens (like the family pet) or exercise?
  • How often are the symptoms and how bad?
  • Is your child missing school?
  • Is coughing or wheezing keeping you and your child up at night?
  • If your child is old enough (usually older than 5-6), he or she may do a Pulmonary Function Test. The results will tell the physician about how the child's lungs actually work. This test helps not only in the diagnosis but will help the doctor follow the response to medication.

For children, asthma symptoms can interfere with many school and extracurricular activities. Parents may notice their child has less stamina during play than his or her peers, or they may notice the child trying to limit or avoid physical activities to prevent coughing or wheezing. More subtle signs of asthma, such as chest tightness, are often not identified as such by children. Sometimes they will complain that their "chest hurts" or that they cannot "catch their breath." Often, recurrent or constant coughing spells may be the only observable symptom.

The two most common triggers of asthma in children are colds and allergens (substances that trigger allergies). In fact, most kids with asthma are allergic and should have an allergy evaluation as part of their care. Common allergens include dust mite, animal dander, cockroach, pollen and molds. We cannot do a lot about viral illnesses but there are ways to limit allergen exposure in the home environment if you know what you need to avoid.

Asthma medications include rescue medication or quick relievers to treat symptoms (ie albuterol) and long-term controller medicines to control the inflammation that causes asthma. If a child has symptoms more than twice a week or wakes more than twice a month at night, they should be on long-term controller therapy. For more information on asthma medications, please see the Tip brochure in this series.

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 incubation 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 reflex, 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.
  

Important Reminders

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  Always call your pediatrician to refill your medications before you run out and always have your medicines available in case of an acute attack.
• Call your pediatrician if you are not improving or if you are getting worse on your current regimen and treatments.
• Do not stop taking your preventative medicines unless instructed to do so by your pediatrician.
• Follow-up appointments are usually every two to three months, or sooner depending on the severity of your child's symptoms.
• With the right treatments, your child's asthma should not limit his activities.
  

Asthma Prevention

Acute attacks can be triggered by many things, including irritants (smoke or strong odors), allergens (dust mites, molds, etc.), exercise (especially in kids with exercise induced symptoms), upper respiratory infections, and changes in the weather. The best treatments are to avoid the things that trigger your child's attacks (keep a diary), follow the environmental controls described below, use any preventative treatments that have been prescribed for your child everyday, and get a flu shot each year.
Uncontrolled medical problems, including allergic rhinitis and gastroesophageal reflux can also make asthma worse, and should be treated if also present.

You may also be able to prevent asthma attacks if you can 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.

Environmental Controls

These steps are aimed at controlling the most common allergens that can trigger an acute attack.

• Get rid of dust collectors, including heavy drapes, carpeting, & stuffed animals.
• Control cockroaches with insect sprays and roach traps, as cockroach allergens are a very common asthma and allergy trigger.
• Use an airtight, allergy-proof plastic cover on all mattresses and pillows.
• Wash all bedding and stuffed animals in hot water every 7-14 days.
• If you must keep pets in the house, at least keep them out of your child's bedroom and choose pets without fur or feathers (such as fish).
• Avoid exposing your child to molds by keeping them away from damp basements, water-damaged areas of the house, wet leaves or garden debris.
• Keep indoor humidity low (less than 50%), since dust mites and mold increase in high humidity.
• Provide a smoke-free environment for your child (it is not enough to smoke outside).
• Vacuum frequently, but only when your child is not at home.
• Avoid the use of ceiling fans.
• Cover air vents with filters.
• Avoid allowing strong odors and sprays in the home. Do not allow your child to stay at home if it is being painted, avoid using strong perfumes, or room deodorizers and household cleaning products that have a strong odor.
• For seasonal problems, keep windows closed in the car and home to avoid exposure to pollens and use air conditioning instead. Stay indoors during the midday and afternoon when pollen counts are at their highest.
• Avoid being outside on days when pollution or ozone counts are high.
• Consider using a HEPA filter to control airborne allergens.
• Take any allergy medication that have been prescribed on a daily basis, since uncontrolled allergies can make your symptoms worse.
  

Asthma Treatments

• The medications that are used to control asthma include bronchodilators and anti-inflammatories (including steroids). Do not use over the counter medicines to control your wheezing.
• The goals of treating children with asthma include reducing (or preferably eliminating) symptoms, limiting how often and how severe his asthma attacks (or exacerbation) are, and allowing him to participate in normal activities, including sports and other physical activities.
• Most Pediatricians practice a step wise approach to treating asthma, with a step up in the amount of medications for uncontrolled asthma and a step down in the amount of medications for well controlled asthma.
• For acute asthma attacks or exacerbation, your child may also need to be on a short course of an oral steroid medication, such as Prelone or Prednisone.
• A common reason for not getting better despite being on a good medical regimen is noncompliance. The medications can't help if your child isn't taking them appropriately.
• If your child is having frequent symptoms, frequent asthma attacks or he has a limitation in his physical activities, then you should see your Pediatrician or Pediatric Lung Specialist (Pulmonologist) to reevaluate his treatment plan and possibly change or increase the amount of daily medication he is taking.
• Your child may also need treatment for other medical problems, including allergic rhinitis and gastroesophageal reflux, both of which can make asthma worse.

Answers to commonly asked questions

• Will my child outgrow his/her asthma?
  The challenge to the physician who cares for children and the parent is to identify the child who wheezes early in life and will outgrow their asthma, vs. the child who will continue to have persistent wheezing. Some babies who wheeze with viral respiratory illnesses will stop wheezing as they grow and their airways get bigger. If a child has atopic dermatitis(eczema), there is smoking in the home or if the mom has asthma, there is a greater chance that the child will have persistent wheezing. Some children have asthma symptoms that improve during adolescence, while others worsen. Often, symptoms in young children seem to resolve, but their asthma may flare up later in life.
• Can asthma be cured?
  Currently there is no cure for asthma. However, for most children, asthma can be controlled with appropriate management and treatment. While asthma is a chronic illness, it should not be a progressively debilitating disease - a child with asthma can have normal or near-normal lung function with appropriate management and medications.
• Should my child exercise?
  Parents may have the urge to restrict their asthmatic child's physical activity to prevent wheezing. But once a child is taking proper medications, aerobic exercise needs to become part of his or her daily activities, because it improves airway function. Children must be encouraged to participate in normal activities as much as possible. It is also very possible for a child with asthma to excel in athletics - several Olympic athletes have asthma.

Asthma at school

• The child, family, physician and school personnel must work together to prevent and/or control asthma symptoms at school. Many children with asthma are embarrassed about their need for medication. In some cases, children may have difficulty because they are required to go to another part of the school building, such as a nurse's office, to take their medication. School officials and parents must create a supportive environment. With the approval of physicians and parents, school-age children with asthma should be allowed to carry metered dose inhalers with them at all times and use them as appropriate. Many states have now passed laws to allow responsible children to keep their inhaler in their book bag.
• To ensure optimal care at school, parents can also take the following proactive steps:
  • Meet with teachers, the school nurse, coach and perhaps the principal at the beginning of the school year.
  • Have your child's doctor provide a written asthma plan for school such as the Asthma School Action Plan.
  • Encourage local educational programs to improve education for schools about asthma.
  • For children with asthma to function normally, school personnel, families and health care providers must effectively communicate and work together to encourage them to fully participate in activities with their peers. This team effort will help create a positive, healthy and safe environment for the child - both in and out of school - and ensure the best asthma care possible.

General Tips

• Avoid smoke of all kinds. Avoid places where others are smoking and stay away from wood-burning stoves.
• Avoid irritants in the air. Stay indoors when the air pollution or pollen count is high.
• Avoid strong odors, fumes and perfume.
• Control cockroaches. Use poison bait and traps. Avoid chemical sprays, which can trigger an asthma attack.
• Avoid breathing cold air. In the cold weather, breathe through your nose and cover your nose and mouth with a scarf or a cold weather mask.
• Practice relaxation exercises as stress may be a factor in triggering asthma attacks.
• Reduce your risk of colds and flu by washing your hands often and getting a flu shot each year.
• If you use a humidifier, clean it thoroughly once a week.
• Build up the strength of your lungs and airways by getting regular exercise.
• Swimming or water aerobics are good exercise because you are less likely to have an asthma attack when you breathe moist air.

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