Asthma in children

What is it?

Asthma is a chronic lung disease that affects the airways, the tubes that carry air to and from the lungs (MedlinePlus). In it the airways may become inflamed and sometimes narrow, making it hard to breathe air out (NHLBI). During an attack the muscles around the airways tighten and their lining swells, so less air passes, and mucus blocks these passages (MedlinePlus, CDC). This page focuses on children; for general information see the asthma page.

According to MedlinePlus, “asthma often starts in childhood, usually before age 5” and is “the most common chronic disease of childhood”; it can cause missed school and hospital admission. The CDC estimates that in the United States, in a class of 30 children about 3 are likely to have asthma, and counts it among the leading causes of school absence.

The NHS says asthma cannot currently be cured, but with good treatment symptoms should not cause problems, and asthma in young children sometimes disappears by adolescence or adulthood. MedlinePlus says most children affected live normal lives with appropriate treatment.

Causes

The exact cause is unknown, and both genetic predisposition and environmental factors play a part (MedlinePlus, NHLBI). The NHLBI states that asthma may occur when the body's defences react strongly to a new substance in the lungs, and that “asthma is usually a type of allergic reaction”, and MedlinePlus stresses that allergy plays a big role in childhood asthma.

Triggers are things that set off or worsen symptoms (NHLBI). Among the most common (MedlinePlus, CDC, NHLBI): dust mites, mould, pet dander, pollen, cockroaches and pest droppings, tobacco smoke including second-hand smoke, air pollution (from factories, cars and wildfire smoke), cold or dry air and weather changes, viral infections such as colds, influenza and respiratory syncytial virus (RSV), exercise, strong emotions, some medicines such as aspirin, chemicals and cleaning and disinfecting products, and acid reflux.

Triggers at home and at school: at home MedlinePlus lists smoking, dust, pets and damp or mouldy rooms, and during activity and play cold or dry air and smoky or polluted air. The CDC urges schools to provide a healthy environment that reduces asthma triggers.

Risk factors

According to MedlinePlus and the NHLBI: exposure to tobacco smoke (including in infancy and early childhood), a family history of asthma especially in the mother, allergy, repeated viral respiratory infections, and obesity. In childhood boys are affected more than girls, while in adolescence it becomes more common in girls (MedlinePlus). US sources mention differences between ethnic groups in rates of illness and death.

The NHLBI says about 4 in 10 children who breathe with a wheeze when they have a cold or respiratory infection are later diagnosed with asthma.

Symptoms

Main symptoms (MedlinePlus, NHS, CDC): wheezing (a whistling sound heard mostly when breathing out), cough especially at night or in the early morning (a night-time cough may be the only sign), shortness of breath or fast breathing or panting, difficulty breathing out, and tightness or heaviness in the chest. Symptoms may come and go, or appear only on exposure to a trigger (MedlinePlus, NHS).

Signs specific to children (NHLBI, MedlinePlus): coughing during sleep or waking often, avoiding strenuous activities, tiring quickly and asking to be carried, dark circles under the eyes, and irritability and quick temper. Signs of poor control include increased night-time cough, eating less, tiredness and mood changes (NHLBI).

When breathing is difficult, the skin of the chest and neck may pull inward with each breath (MedlinePlus). Signs of a severe attack include severe coughing, serious difficulty breathing, and marked pallor or blue discolouration of the face, lips or nails (MedlinePlus). MedlinePlus lists early signs that may come before an attack, such as nervousness and irritability.

How is it diagnosed?

The care provider asks about symptoms and their pattern (especially night-time cough and breathing problems with exertion) and about family history of asthma and allergy, and listens to the chest (CDC, NHS). MedlinePlus notes that lung sounds are often normal when the child is not having an attack.

The difference in young children: the NHLBI says that “it is hard to tell whether a child under 6 has asthma or another condition affecting breathing”, because most asthma tests do not work well in young children and they cannot usually do spirometry. The doctor therefore relies on history and symptoms, may ask parents to record the child's breathing sound on a phone to confirm wheezing, and may try asthma medicines for several months to see the response (NHLBI, MedlinePlus). The NHS says diagnosis may take time because symptoms change and breathing problems can have different causes.

Possible tests in those able to do them (NHLBI, MedlinePlus, NHS): spirometry to see how much air is breathed out and how fast, a peak flow test with a portable device that may be used at home for a few weeks, a bronchodilator response test, a fractional exhaled nitric oxide (FeNO) test, challenge tests, skin or blood allergy tests, and sometimes a chest X-ray.

Treatment

The treatment categories usually used are listed here; this is not a prescription. The doctor chooses the plan according to each person's condition; do not change any medicine or dose without a specialist.

There is no cure for asthma, but treatment and an asthma action plan help control it, and the plan includes monitoring, avoiding triggers and using medicines (NHLBI). The doctor determines each child's medicines, as not everyone affected takes the same medicine (CDC), and treatment may be adjusted until symptoms are controlled (NHLBI).

Two types of medicine (MedlinePlus, NHLBI): quick-acting (reliever) medicines that work fast during coughing, wheezing or an attack, including inhaled short-acting bronchodilators and short-acting anticholinergics, and sometimes oral corticosteroids to reduce swelling; and long-term control medicines the child takes daily to prevent symptoms by reducing airway inflammation and preventing narrowing, including inhaled steroids (usually the first choice according to MedlinePlus), long-acting bronchodilators, leukotriene modifiers, cromolyn, biologic medicines that may help in hard-to-control asthma, and allergy shots (NHLBI). Only the doctor decides the type, amount and timing.

Inhaler with a spacer: MedlinePlus says children who use an inhaler should use a spacer so the medicines reach the lungs well, and that “almost all children can use one”; young children can use a nebuliser instead. Steps for use in words (MedlinePlus): shake the inhaler well and attach the spacer, breathe out gently, place the end of the spacer in the mouth and close the lips around it, press the inhaler into the spacer while breathing in slowly and deeply through the mouth, then hold the breath briefly if possible and breathe out slowly. After use, rinse the mouth with water and spit without swallowing, and watch the inhaler's counter so it can be replaced before it runs out. The CDC advises knowing well how to use the inhaler, and the doctor determines the number of puffs and their timing.

In a severe attack the child may need hospital, and emergency treatment may include a nebuliser, oxygen, intravenous medicines or a ventilator (MedlinePlus, NHLBI). Parents should not start or stop a medicine or change how it is given without the doctor.

Follow-up

The asthma action plan is a written treatment plan made by the care provider with the family, and according to the NHLBI it includes: how to recognise the triggers to avoid, how to recognise an attack and what to do, which medicines to take and when, when to call the doctor or go to the emergency department, and whom to call in an emergency. MedlinePlus adds monitoring symptoms and measuring peak flow. The CDC says everyone with asthma needs their own action plan made with their care provider.

When to see the doctor (MedlinePlus, NHS): after any emergency visit, when peak flow readings fall, when symptoms become more frequent and severe despite following the plan, and if the child needs the reliever inhaler more than usual or symptoms wake them at night or stop them doing their usual activity. The NHS advises seeing the doctor within two days after any attack even if the child has recovered.

After leaving hospital, wheezing and coughing may continue for up to 5 days, and sleeping and eating may take up to a week to return to normal (MedlinePlus).

Complications

MedlinePlus says poor asthma control can lead to missed school and long-term lung problems, and that asthma is “in rare cases” life-threatening. The NHS describes an asthma attack as severe symptoms with difficulty breathing that can be life-threatening. The CDC states that more vulnerable groups in the United States have higher rates of emergency visits, hospital admissions and deaths.

Prevention

“Getting rid of tobacco smoke in the home is the most important thing a family can do to help a child with asthma” (MedlinePlus), and no one should smoke in the home. Other steps (MedlinePlus): keep pets out of the child's bedroom, avoid open indoor fireplaces, keep the home clean, and use fragrance-free cleaning products.

Reducing triggers at home according to the CDC: for dust mites, allergen-proof covers for bedding, washing bedding weekly, vacuuming with a HEPA-filter vacuum and keeping humidity between 30% and 50%; for pests, removing food residue, storing food in sealed containers, sealing cracks and avoiding insect sprays; for mould, drying anything that gets wet within 24 to 48 hours, fixing leaks and keeping humidity below 50%.

To limit infection: wash hands and clean frequently touched surfaces, avoid disinfectants that may trigger an attack, and have someone without asthma do the cleaning and disinfecting (CDC).

Living with it

At school (MedlinePlus): the asthma action plan should be at school, a copy given to the teacher, school nurse and school administration, and the child should be able to take asthma medicines at school when needed. The NHLBI advises giving copies of the plan to the school and to those who care for the child.

The CDC urges schools to coordinate with students' doctors, make sure students take their medicines and learn to use them at the right time, educate students, staff and families, reduce triggers at school, and provide physical education and safe, enjoyable activities for students with asthma.

Everyone who looks after the child, including teachers and babysitters, must know the danger signs and call the ambulance when they appear (MedlinePlus). The CDC says strong emotions can trigger an asthma attack, so managing stress helps.

Common questions