Out of Breath

Reading Time: 7 minutesIt’s estimated that almost one-third of pre-school aged children have experienced repeated attacks of asthma-like symptoms. We know that, globally, chronic asthma affects about 12 per cent of all children younger than 18 years.

For many parents, learning that their child has a “chronic” illness can be extremely frightening. However, the term chronic simply means a condition is long-lasting and recurring – the majority of children recover and out-grow asthma as their lungs mature with age. In addition, there are now many drugs and strategies available to control asthma effectively.

What is asthma?

Asthma is a condition that affects the small airways leading to the lungs. During an asthmatic attack, the lining of the airways becomes inflamed and produces lots of thick mucus. The muscles tighten along the airway wall, and the airways become narrower, making it difficult for air to pass through.Blausen_0620_Lungs_NormalvsInflamedAirway

Most people with asthma only experience attacks – also called flare-ups, episodes, or exacerbation – periodically. The most recognisable symptoms are:

Coughing: Usually dry and hacking, coughing is most noticeable during the night or in the early hours of the morning, and can also be triggered by exercise.

Wheezing: This is a high-pitched breathing sound, which is produced when air is forced through a narrowed airway.

Shortness of breath: Children with asthma will generally breathe faster and shallower; sometimes you will be able to see your child’s chest wall sucking in and tummy bulging out.

Chest tightness: Older children might be able to tell you that they sometimes feel tightness or pressure in their chest.

Although asthma sufferers do not experience these symptoms all the time, there are some common patterns, particularly for children:

Intermittent attacks: Children can be completely well most of the time and only have individual attacks when they’re exposed to their particular triggers.

Chronic symptoms with intermittent flare-ups: This usually happens when children with poorly controlled asthma have ongoing symptoms of coughing and intermittent flare-ups.

Morning “dipping”: Symptoms can commonly worsen early in the morning and improve as the day passes.

A cold that lingers: Symptoms might be triggered by a cold and then not settle for several weeks.

Seasonal attacks: Symptoms can worsen during the winter, when the air is cold and dry and respiratory viruses are more active. These usually resolve in warmer, more humid weather.

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Common triggers

Asthma is usually triggered by specific irritants like dust, cigarette smoke or even exercise. People who have asthma are overly sensitive or hyper-reactive to a particular trigger and the source can vary from person to person, and with seasons or time. With proper management, the most common triggers can be avoided to reduce the likelihood of an attack.

The environment itself, including seasonal changes, pollution or mould, can trigger asthma. Many children are sensitive to pollens and plant materials, particularly in the spring and summer. The growth of mould during the rainy season can also make children susceptible to asthma. For these kids, it’s best to avoid outdoor activities when the level of air pollution is high. Close windows and use air-conditioning when appropriate.

For some kids, exercise is a trigger. However, exercise should not be restricted as it strengthens heart function and lung capacity, and may decrease sensitivity to other asthma triggers. These kids should use a short-acting inhaled bronchodilator a few minutes before beginning exercise, then start exercising slowly, ensuring that they’re sufficiently warmed up. Short bursts of exercise are better tolerated than prolonged ones. Since cold or dry air can cause narrowing of airways in sensitive children, they should avoid exercising in extremely cold or dry weather. Some exercises, like swimming, are less likely to induce asthma symptoms.

Studies have found that allergies that cause a blocked nose, when well controlled, can actually decrease asthmatic attacks. Respiratory infections can cause airway inflammation, which can trigger asthma. Head and chest colds are common triggers in young children. To cope with this, affected kids should get the seasonal flu shot annually, as well as the pneumonia vaccine. To reduce infections, teach your children good hand-washing habits and consider having them wear a face mask to minimise contact with infected people. Use nasal sprays as prescribed by your doctor for controlling nasal symptoms.

There are several indoor allergens that can trigger asthma attacks.

Tobacco smoke is a pollutant that can trigger asthmatic attacks. Exposure to tobacco smoke during pregnancy affects the development of babies’ lungs, making them more prone to developing asthma later in life. Exposure during childhood also significantly increases the risk of developing asthma.

Mould is a fungus that thrives in damp areas and can trigger asthma attacks. To minimise the mould in your home, control humidity by removing standing water in plants. Remove old books, newspapers, clothing and bedding, and regularly clean sinks, bathtubs, tiles and even walls to avoid mould build-ups. Control humidity by opening windows in dry weather and using air-conditioning in humid seasons.

Dust mites, tiny insects that inhabit bedding, sofas and carpets, can trigger attacks. To combat them in your home, use special covers on pillows and mattresses designed to reduce mites, use washable blinds instead of curtains, and wash soft stuffed toys regularly.

Animal dander, the dead skin cells, hair and fur shed by animals, is a trigger for some kids. While we would never recommend abandoning your pets, if your child is allergic to pets, removing the trigger is the most effective way to control asthma. If you’re determined to have pets in the house, limit the allergens by controlling the areas your pet can access in the house. Regularly clean carpets and fabric-covered furniture, and use a vacuum cleaner with a HEPA filter.

Cockroach droppings have been shown to trigger asthma. To eliminate cockroaches, use poison to control their population. To avoid inviting them back into your home, clean out the bin regularly and don’t leave open food around the house.

Paint, perfume, detergents, heaters, gas stoves and deodorisers can all trigger asthma in some kids. If you find that your child’s symptoms seem to be triggered by any of these, try to limit their use inside the house.

Recently there has been a surge in advertisements for air purifiers and filters for indoor allergen control. These devices are expensive and, so far, few have been scientifically proven to significantly improve asthma or allergic symptoms. However, vacuum cleaners with a HEPA filtration system have been shown to decrease allergen levels, especially cat and dog dander, and may decrease asthma and allergic rhinitis symptoms.

Diagnosis

Children of asthmatic parents are more likely to have asthma, and a significant percentage of babies with eczema have shown an increased risk of developing asthma or allergic rhinitis later in childhood. A doctor will review a child’s symptoms and medical history and perform pulmonary function tests before diagnosing asthma.

The most accurate method is “spirometry”. For this test, the patient takes a very deep breath and then forcefully blows into a tube, which measures the volume and speed of the air. The results can show if there is any airway blockage or narrowing. Then the same test is repeated after the patient has taken an inhaled bronchodilator – a medication that opens up the airway and relieves the obstruction.

A similar test called a “peak flow rate measurement” is another useful way of monitoring asthma control in a clinic or home setting.

Diagnosing asthma in infants and young children – especially those under six years – is a big challenge because they have difficulty following the instructions of the spirometry test accurately. In addition, they have smaller airways which are more prone to narrowing, especially during respiratory tract infections, such as colds. For young children suspected of having asthma, a careful review of their medical history, family history and allergic history with continual monitoring of symptoms is the most effective way to reach an accurate diagnosis. Doctors will sometimes recommend a trial of asthmatic medication for confirmation.

Testing for allergies, such as a skin prick or blood test, can provide additional information about possible sensitivities and asthma triggers. For example, if a child frequently develops symptoms at home, indoor allergens may be involved, and testing can help figure that out.

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Treatment

By controlling their asthma, children are able to lead a better quality of life. Today, there are many options to control asthma and your doctor will regularly monitor the response to each one.

Short-acting bronchodilators, such as salbutamol (brand name Ventolin), quickly relax the muscle in the wall of the small airways and reduce any constriction. They can be in the form of inhaled puffs, oral syrup, tablets or injection, depending on the severity of symptoms. Most asthma sufferers keep them close at hand because of the fast relief they offer. In addition, they are useful before exercise for exercise-induced asthma.

Steroids, such as budesonide, fluticasone and prednisolone, reduce inflammation and, therefore, airway swelling. They also stop the airway from being hyper-reactive to triggers. Because of the slow response time, regular treatment is best to keep the inflammation under control.

For severe asthmatic attacks, oral or injected steroids might be used for a short period of time. Once the symptoms are under control, an inhaled steroid may become the main treatment. Many parents are concerned about giving their children steroids, mainly because there have been concerns of an adverse effect on growth. However, studies have reassured us that an inhaled steroid and short-term systemic steroid treatment have excellent safety profiles and have minimal effect on growth. Asthma itself, if poorly controlled, can significantly compromise a child’s growth, as the child needs to use extra energy to fight for air from bronchoconstriction. In addition, the child will be more prone to infection.

Both inhaled short-acting bronchodilators and steroids can be given through a metered-dose inhaler or nebuliser. So what are the differences between them and when should they be used? A nebuliser uses compressed air to evaporate the liquid form of medication into aerosol form. It can be inhaled through a mouthpiece or a mask. Nebulisers are preferred to inhalers when children are unable to use the handheld device correctly.

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Metered-dose inhalers deliver the fine powder medications mixed with air that is breathed into the lungs through a spacer or face mask. So, to be effective, a child must be able to follow the instructions of breathing through the spacer or face mask correctly. Discuss both options with your doctor so you can choose the one that will give your child the most effective results from the medication.

Leukotriene modifiers such as montelukast (brand name Singulair) can be an alternative to inhaled steroids for children with milder symptoms, or in addition to inhaled steroids for better control of severe symptoms. They are available in chewable tablets and in granules that can be mixed with food or beverages.

Long-acting bronchodilators, such as seretide, cannot be used alone, but rather in combination with an inhaled steroid for difficult-to-control asthma. They are not recommended for long-term use, and users will be instructed to taper off these medications once the asthma is under control.

Asthma is a common condition that affects children. But with an increased understanding of the disease, doctors are more able than ever before to offer treatment plans that can effectively alleviate symptoms and allow your asthmatic child to lead a full and active life.

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Dr Angela Lau
Dr Angela Lau received her medical training at the University of Hong Kong. She has more than 15 years’ experience in both public and private sectors before setting up her own clinic, Little Angel Paediatric Clinic. She also provides emergency services in the hospitals and special care baby units. Being a mum of two children, her motto is to provide care not only to her patients but supportive care to their families.

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