Childhood Asthma:

Asthma is by far the most common chronic disease of childhood. It is responsible for more missed days of school and more hospitalizations than any other childhood illness. Pediatrician and "Today" show contributor Dr. Mark Widome says we should be doing a much better job in recognizing and successfully managing childhood asthma.

He advises parents when to suspect the diagnosis, and urges them to have high expectations if asthma is diagnosed.

Effective treatment of asthma should relieve children of their symptoms, allow them to attend school every day and permit them to fully participate in sports and other strenuous activity.

When I first learned about childhood asthma as a pediatric resident, I was taught that it was a disease of the lung in which the small airways were very sensitive. If provoked by irritants, the muscles in the walls of these airways would constrict, causing narrowing and restricting air flow. This resulted in coughing, wheezing, increased effort to breathe and shortness of breath.

While that is all still true, physicians now have a better understanding of what asthma is all about. The story is more complicated. It is now known that the airways of most children with asthma are chronically inflamed, and that it is as a result of this chronic inflammation that the airways are overly sensitive — or hyperreactive — to irritants or triggers. Some triggers are allergic and some are non-allergic. This underlying inflammation also is responsible for mucous production and cough, which are regular features of asthma attacks.

Thus, three central concepts that I try to convey to asthma patients and their parents are the concepts of inflammation, hyperreactivity and triggers. Understanding these three features of childhood asthma are important if families — parents and children — are to become competent and self-confident in managing their disease. The first of these, airway inflammation, has very practical implications. Medication plans used in asthma management are now aimed directly at controlling airway inflammation, with greatly improved results. This is highly encouraging for patients and physicians alike.

Another thing that has changed since I first learned about asthma is not so encouraging. Despite better treatments, asthma is now twice as common as it was 20 years ago. This is true both in the United States and in other developed countries around the world. Asthma increases have been most dramatic and troublesome in our inner cities, where the term "asthma epidemic" is not much of an exaggeration.

Today, there are about 5 million children and teens in the United States with asthma, about a third of them are under the age of 5. About 5 to 7 percent of children have the disease. The consequences to these children on the quality of their day-to-day lives is often substantial. Children miss about 10 million school days a year due to asthma, more school days than are missed for any other serious disease. By some estimates, children with asthma miss three times as much school as other children. Asthma is responsible for about 2 million visits to the doctor each year and another half-million visits to the emergency room. There are 160,000 annual hospitalizations a year, making asthma the most common hospital admitting diagnosis for school-age children. And tragically, dozens of children die every year from asthma, a health care failure by any measure, particularly in light of the medical advances of the past two decades. This situation urgently needs to be better understood, addressed, and reversed.

Asthma has no single cause. There is a strong inherited component. If one of a child’s parents has asthma, there is at least 1 chance in 3 that the child will have asthma. If both parents have asthma, the chances are even greater.

Environment also plays an important role in determining whether a child will develop asthma. Otherwise, the rapid increase in the numbers of cases over a single generation would be hard to explain. Yet, what those environmental factors are is open for debate. For example, while it is an attractive idea to blame asthma on air pollution, outdoor air quality has improved over the years as the rate of asthma has gone up. But indoor air quality is a separate issue. Homes are now more tightly insulated than they were 20 years ago, and indoor air quality may be suffering. Tobacco smoke is a widely recognized example of indoor air pollution that is known to be an important contributor to asthma. Living in a home with tobacco smoke approximately doubles a child’s chances of being hospitalized with asthma. And there may well be a variety of other less-well-understood factors in our homes that may have changed over the past several decades.

The environmental causes of asthma and the things that trigger symptoms in someone who already has asthma may or may not be the same. But, whichever the case, discovering the triggers for an individual child with asthma is a key to controlling the disease. While avoiding triggers is always desirable, it is not always possible. The most common asthma trigger in infants and toddlers is viral respiratory infections — common colds. While these colds cause only a runny nose, mild cough and fever in most children, in children with asthma, these same infections can lead to persistent cough, wheezing and difficulty breathing. Parents of such children should get advice early from their pediatricians and step up asthma treatments before breathing problems begin.

Most children who continue to have asthma and recurrent chest symptoms as they get older have allergies, and they often are members of families with allergies. Many children with asthma are allergic to household pets with fur or feathers such as cats, dogs and birds. Outdoor grasses and pollens can cause allergy and asthma in the warmer months of the year.

Less widely recognized are three relatively "invisible" household allergens. Indoor molds are a common culprit that often cause symptoms in humid weather and when children play in damp parts of the home. House dust is another common year-round trigger because of the dust mite, a small insect to which many children with asthma quickly become allergic. And in recent years, investigations have found that cockroaches are a common cause of allergy and have been believed to be responsible for 1 in 4 cases of asthma in children in the inner cities.

Many children with asthma develop symptoms after exercise, particularly when they exercise in cold, dry air. And again, tobacco smoke is almost always a trigger of asthma attacks in children with asthma.

Asthma is under-diagnosed because many of its symptoms can be easily ignored or explained away. It is only when parents and physicians take the time to look at the whole picture of a child’s signs and symptoms that the diagnosis of asthma becomes apparent. Parents should suspect asthma in the following situations:

Wheezing or shortness of breath in certain situations.
Whether it be hard play, mowing the grass, or playing with Grandma’s cat, if there are predictable situations in which your child’s breathing becomes noisy, rapid or labored, then questions about asthma should be at the top of your list.

An exercise cough.
Children should be able to play soccer or go sledding without coughing. If coughing often causes your child to stop playing, asthma is likely. Note that asthma frequently causes only a cough, without causing noisy breathing, wheezing or shortness of breath.

A persistent nighttime cough.
Pay particular attention to a cough that interferes with sleep night after night, especially if your child does not have a cold, or a cough that occurs early in the morning before your child wakes up.

Repeated episodes of "bronchitis" and/or pneumonia.
Any child may occasionally develop a coughing illness lasting longer than 10 days and "settling in the chest". But if your child has repeated chest infections — whether they be called "bronchitis", "bronchiolitis", or "pneumonia" — then it is likely that there is an underlying problem. Asthma is far and away the most likely possibility.

Any of these signs or symptoms should prompt a consultation with your child’s pediatrician. I urge parents to be forthright in raising the possibility of asthma with their child’s physician. This is particularly true if your child has had repeated symptoms and/or there are other members of the family who have allergies or asthma. Early diagnosis and aggressive treatment can prevent worsening symptoms, missed days of school, missed work days for parents and trips to the hospital.

Children’s asthma is treated in steps, depending on how severe the symptoms are. This is different for each child and can change as seasons change or as a child grows. When symptoms are not well controlled, therapy is "stepped up". When the child has done well for several months, the therapy can be "stepped down" so that you and your child’s doctor can find the smallest amount of medicine that works well. Two important elements of any management plan are prevention and treatment.

Recognizing that childhood asthma is too often under-diagnosed and under-treated, federal agencies and professional organizations, including the National Institutes of Health, the American Academy of Allergy and Immunology, the American Academy of Pediatrics, and others have developed programs and public education materials to help doctors and parents close the gap between actual asthma management and optimal asthma management. Recent recommendations from expert panels emphasize that asthma is a chronic disease, and like other chronic diseases, it requires good patient education, family participation in care, individualized management plans and careful follow-up. Published recommendations place a priority on preventing symptoms and maintaining a normal active lifestyle. Therefore parents should expect management of their child’s asthma to include:

Education that involves both the child and parent.
Parents and children need to be educated about all aspects of asthma in order to be full partners in its management. Your physician should take the time to explain the disease and the treatment to you and your child. There should be printed materials for you to read, and your child’s physician or a member of his/her staff should be available to answer your questions and concerns.

Specifically, parents and children need specific instructions on how to give inhaled medicines. Metered-dose inhalers can be tricky, and using them improperly will result in not getting enough medicine or in more side effects from the medicine. Inexpensive "spacer" devices that attach to inhalers make them easier to use, more effective, and in some cases, make it possible for younger children to use them.

An asthma management plan that has two parts.
Parents should have a home asthma plan that describes what medicines to give to prevent asthma symptoms (long-term medications) and what medicines to give to treat symptoms (rescue medicines). The plan should describe what to do if the medications are not working and give guidelines about when to call for advice or seek urgent care.

(School-age children who are capable of administering their own inhaled medicines should be allowed to carry their medicines to school and use them as recommended by their doctor and parents. Children often will avoid going to the nurse’s office to get medicine before gym class or at other times that they might need it. Not all schools have an "asthma-friendly" policy.)

The asthma-management plan should include instructions for how parents or children can monitor the disease at home. Keeping track of symptoms is important, but for many children a hand-held peak-flow meter is a useful device to detect whether the child is having airflow obstruction even if he or she is not wheezing. Most school-age children and even some preschoolers can use a peak-flow meter.

Access to advice by telephone to deal with problems.
The telephone is an important medical device. I would much prefer that parents call as often as necessary to get advice rather than have them either visit the office unnecessarily or remain at home while the cough and wheeze are worsening and an office visit is needed.

Continuity of care rather than just "crisis management".
Access to care is necessary for good asthma control or control of any other chronic medical condition. Children who have no regular doctor and who seek their medical care from different places at different times, and children who use the emergency room for regular care, will be at a disadvantage, and it will show in how often they are sick, how much school they miss and how often they are hospitalized. Unquestionably, one of the reasons so many children in the inner city are so often admitted to the hospital for asthma treatment is because they don’t have a regular doctor or clinic where they are known and where they can get good advice on how to prevent asthma attacks. Such a "medical home" should be available for all children.

Availability of an asthma specialist if required.
Your child’s pediatrician usually can manage your child’s asthma. Yet, sometimes children require an asthma specialist: either a pediatric allergist or pediatric pulmonologist. The advice of a specialist can be helpful when medicines are not working, when symptoms are very severe, when your pediatrician recommends allergy testing and when asthma is severe in infants or toddlers. Parents should not hesitate to ask for an appointment with an asthma specialist if their children’s asthma is not doing well.

Good asthma control depends on cooperation between pediatricians and parents — and eventually with the children themselves. While managing a child’s asthma may take effort and commitment, the rewards are great. With the best care, nearly all parents of children with asthma should expect:

To some parents, these may seem like high expectations. But asthma experts agrees that this is all possible for almost all children with asthma if they are getting good health care on a regular basis and following their doctor’s recommendations closely.