August 27, 2008

Childhood Asthma

By Cydulka, Rita K

Asthma is a chronic inflammatory disorder of the airways that affects almost 10% of children, making it the most common chronic disease of childhood. Last year, children with asthma missed an estimated 12.8 million school days due to their disease. If not well controlled, asthma may limit a child's activity and sense of well being, and place a significant burden on the family. Although the death rate from asthma has declined, following a rise from the 1980s until the mid-1990s, poorly controlled asthma still accounts for more hospitalizations in children than any other disease. Asthma may be diagnosed at any age, although doctors are frequently reluctant to label very young children with a chronic disease like asthma, as there are many causes of wheezing in infants and toddlers. As children reach school age, symptoms and triggers become more identifiable and predictable, thereby making an asthma diagnosis easier.

Asthma symptoms include shortness of breath, cough, wheezing, and chest pain or tightness, and they may vary from person to person. A variety of situations, such as allergen exposure (e.g., pollen, dust mites, animal dander, house dust, cockroach droppings or mold, etc.), infections (colds, upper respiratory illnesses, etc), exercise, changes in the weather, and exposure to airway irritants (e.g., cold air, chemicals, tobacco smoke) can trigger symptoms. Severity of asthma is variable, as well. While some children have occasional mild symptoms, others may have daily severe symptoms.

Three-quarters of a million children come to the emergency department every year for treatment of asthma. Rest assured that if your child needs emergency care, emergency physicians are well trained to treat your child's asthma emergencies. Although emergency physicians want your child to lead a fully active, energetic life without ever having to visit the emergency department, we will be there to get him back in action as quickly as possible. Now that spring is here, this is an ideal time to put together an asthma management plan so that you and your child can practice it and make adjustments with your doctor before the real trouble starts with the fall allergy and winter flu seasons. A good plan, organized with your child's doctor and written before an emergency, may help your child stay out of the hospital altogether.

If you are not sure if your child has asthma, but he has asthma symptoms (coughing, wheezing, shortness of breath), talk to your doctor. After a child has been diagnosed with asthma, you and your child should meet with your doctor to develop a plan for monitoring asthma symptoms (usually a peak flow meter), recognizing problems, adjusting medications and adding special medications, such as corticosteroid pills or liquid, when trouble develops.

Since asthma is a chronic disease, many children will need lifelong medications. There are two main types of medications for asthma: controller medications and rescue medications. Controller medications decrease airway inflammation in an ongoing basis and rescue medications quickly and briefly open up the airways. Types of controller medications that you may have heard of are inhaled corticosteroids and leukotriene modifiers. Rescue medications tend to be inhaled, short-acting, beta-agonist drugs, most commonly prescribed as albuterol and levalbuterol in the U.S.

Children with occasional asthma attacks will only need to use rescue medications when they get an attack. On the other hand, children whose ability to participate in their normal daily activities or desired activities are disrupted by their symptoms, those who require frequent use of rescue inhalers, and those with frequent nighttime symptoms will likely benefit from two types of medication: controller medications/inhalers that they use daily to prevent asthma attacks and rescue medications/inhalers that they use to relieve symptoms. Consistent use of controller medications can prevent many asthma attacks and help children lead normal, physically active lives. How and when medications are used may vary from season to season, depending on what an individual child's triggers are. The medication plan developed with your child's doctor should fit in with both your and your child's lifestyle. Control of this disease requires active participation and partnership among you, your child and your child's doctor.

Although pre-teens and teens are more independent than younger children in many areas, they need close parental monitoring for signs that their asthma symptoms are worsening, as children this age may test their independence and be less compliant with medications than desired. That children aged 11-17 have the lowest rate of emergency department visits but the highest rate of death from asthma highlights this important point.

Whether or not your child needs daily medication or occasional medication, all children with asthma should carry a rescue inhaler with them or have one readily available to them at school. It is important that when children develop symptoms, they and their caregivers or teachers know how to administer the medication and do so quickly. In addition, do what you can to limit your child's exposure to his or her asthma triggers.

For example, if your child is allergic to furry animals, minimize his or her exposure to them at friends' houses and in the classroom at school. If cold air is a trigger, arrange for your child to exercise indoors during the winter instead of outdoors. If dust is a trigger, replace carpeting with wood, tile or vinyl floor coverings. Also, be sure to get your child a flu shot as soon as it is available in the fall. A recent study by the Centers for Disease Control and Prevention showed that only 30 percent of children with asthma get the flu shot, even though flu can be fatal for people with asthma.

Even with the best planning, some children will have asthma attacks that require immediate attention from an emergency physician at the emergency department. The following conditions should prompt a call for emergency help (911 in most areas):

* Symptoms do not improve quickly after the use of rescue inhalers

* The child strains to breathe or cannot complete a sentence without pausing for breath

* The child's lips or fingernails turn blue

Treatment of this kind of asthma emergency is best handled by an emergency physician at a hospital, rather than by parents at home, as medications, oxygen, and any equipment needed are readily available.

In summary, asthma is the most common chronic disease of childhood. With proper planning and care, children with asthma can attend school daily, participate in any activity they choose, and avoid visiting the emergency department altogether.

By Rita K. Cydulka, MD, MS

Rita K. Cydulka, MD, MS, is associate professor and vice chair of emergency medicine at MetroHealth Medical Center and Case Western Reserve University in Cleveland, OH. She is a member of the steering committee of the NIH's National Asthma Education and Prevention Program.

Copyright Pediatrics for Parents, Inc. May 2008

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