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Definition
Asthma in children is an obstructive respiratory condition characterized by recurring attacks of wheezing, shortness of breath, prolonged expiration, and an irritated cough that is a common, chronic illness in childhood. Onset usually occurs between 3 and 8 years of age.
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Description
Asthma is the most common chronic childhood disease. It causes more hospital admissions and visits to the emergency department and is responsible for more school absenteeism than any other chronic disease of childhood.
It is a disorder characterized by both inflammation and bronchospasm (airway narrowing).
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Causes and Risk Factors
There is a strong hereditary factor associated with the disease. Patients and their family may have a history of asthma, atopic dermatitis (eczema, an itchy skin rash), and allergic rhinitis (hay fever).
Stimuli (triggers) that can worsen asthma include air irritants such as smog, smoke, fragrances, pollen, animal dander, and dust. In addition, the lungs of asthmatics are sensitive to rapid environmental changes in temperature and humidity. Children with this condition often have exaggerated reactions to viral respiratory illnesses.
Many asthmatics are sensitive to strenuous exercise and even to cold weather. Medications, such as aspirin, may trigger wheezing episodes in some children. Although not the cause of asthma, emotional distress such as anxiety, fear, or anger can trigger an asthmatic attack. Food allergy can also be a precipitant.
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Symptoms
Parents may notice their child has less stamina during active playtime than his or her peers. Or the child may limit his or her activity to prevent coughing or wheezing. The child may have heavy breathing, shortness of breath, and wheezing at rest or with exercise.
If accompanied by infection, the child may have a fever, runny nose, and cough and be irritable.
More subtle signs of asthma, such as chest tightness, may be overlooked or not identified by a child. In severe cases, the patient may have bluish skin around the lips and fingers.
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Diagnosis
The physician relies heavily on the observations of the parent for diagnostic clues. Recurrent or constant coughing spells, sometimes at night, may be the only sign of an asthmatic state.
Diagnosis is made by the medical history, including family history and symptoms, physical examination, and measurements of expiratory function with a peak flow meter.
A chest X-ray and more elaborate pulmonary function tests may be necessary. If the child has a fever and a productive cough, blood tests and a sputum sample may be taken.
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Treatment
Doctors advise patients of asthmatic children whose attacks are allergy-related to help the child avoid the allergens wherever possible, or more rigorous dust-control measures must be instituted.
Children and their parents need to understand how to use a peak flow meter and to understand the symptoms and signs of an asthma exacerbation.
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Daily Management
Choice of medications, and methods of dispensing them, differ with each child and with the severity and frequency of symptoms. A physician will help determine the optimal treatment plan for your child.
Treatment of asthma requires control of both inflammation and bronchospasm (narrowed airways).
Long-term control medications are taken daily to maintain control of persistent asthma. They primarily serve to control airway inflammation.
Quick-relief medications are taken to achieve prompt reversal of an acute asthma "attack" by relaxing bronchial smooth muscle.
Many asthma medications can be administered by inhalation. Metered-dose inhalers (MDIs) are the most widely used method and can be used with a spacer in children.
Nebulizer therapy is reserved for patients who are unable to use MDIs because of difficulties with coordination, including small children.
Long-Term Control Medications
Corticosteroids: Steroids, more correctly called corticosteroids, can change the course of asthma for the better. Corticosteroids are drugs used to treat many disorders and come in three forms for use in asthma: inhaled, oral, and injectable.
Inhaled forms are used for everyday management and are generally used daily. Dosages for inhaled corticosteroids vary depending on the specific medication and delivery device.
Oral tablets or pills (e.g., prednisone) are used to treat more severe asthma. Injectable forms are used to treat asthma in emergencies.
Long-term bronchodilators: Cromolyn sodium and nedocromil are long-term control medications that can be used to prevent asthma symptoms and improve airway function.
Desensitization: Immunotherapy for specific allergens may be a consideration in certain asthma patients.
Quick-relief Medications
Beta-adrenergic agents: Short-acting, inhaled bronchodilators are the most effective treatment during asthma exacerbations. These medications relax airway smooth muscle and allow for easier airflow. One example is albuterol (Proventil, Ventolin).
One or two inhalations of a short-acting inhaled beta adrenergic agonist from an MDI is usually adequate for mild to moderate symptoms. Severe exacerbations may require inhalations every few hours. Nebulizer therapy may be more effective for some patients.
Increased use or lack of effect may indicate need for stronger long-term control therapy.
Corticosteroids: These are one of the important forms of treatment for patients with severe asthma. These medications may be given via the intravenous route in critically ill patients, for example in the emergency room.
Antibiotics: If a child has a bacterial respiratory infection (fever, productive cough) during an asthma exacerbation, antibiotics will be given.
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Asthma Attack
An acute asthmatic attack is a medical emergency and requires immediate relief of bronchial obstruction with bronchodilating drugs, reduction of mucosal edema, and removal of excess bronchial secretions.
The major drugs used to relieve bronchospasm are a beta-adrenergic agent (nebulized albuterol), oral corticosteroids (prednisone), and antibiotics for cases in which infection is the triggering mechanism.
Management also includes intravenous fluids and humidified oxygen. In some cases, an asthma attack does not respond to these measures and hospitalization is required.
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Prevention
Allergic responses to perennial environmental allergens, such as dust, mold, or indoor pets, can worsen asthma and can be unrecognized because of the mistaken idea that children cannot develop allergy until they are several years old. It is essential that the child be protected from irritants, most importantly tobacco smoke. Chronic irritation of the airway of an asthmatic child exposed to secondary smoke may make asthma difficult to control.
Periodic assessments and ongoing monitoring of asthma are essential to determine if therapy is adequate. Children and their parents need to understand how to use a peak flow meter and to understand the symptoms and signs of an asthma exacerbation. Regular follow-up visits (at least every 3 to 6 months) are important to maintain asthma control and to reassess medication requirements.
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Questions to Ask Your Doctor
What is the probable cause of the asthma attacks?
Can you identify the "triggers" involved?
Is there evidence of a respiratory infection?
What is a peak flow meter and how does my child use it? How often?
What is an MDI (inhaler)? What is a spacer?
Is the child using the MDI (inhaler) correctly?
Do you suggest a daily steroid inhaler? Or daily cromolyn?
Do you recommend use of a bronchodilator? When?
What further treatment do you recommend?
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