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Get Smart About Asthma

In healthy lungs, small muscles move air through a network of branching airways that are lined with a thin layer of mucus. When a child has asthma, these tiny tubes become inflamed, making them very sensitive to irritants, allergens, cold air, and respiratory infections. In response to a trigger, the airways produce more mucus and the muscles around them tighten -- causing a child to wheeze, cough, or become short of breath.

Although 80 percent of children with asthma are now thought to develop the disease before age 5, kids traditionally haven't been diagnosed until about ages 7 to 9. The most accurate way for a doctor to pinpoint the disease is with spirometry, a simple test in which a child blows into a tube attached to a machine that measures how forcefully she can push air out. However, doctors usually don't get reliable test results from kids under age 5. "Doctors must rely on a young child's symptoms and history to make a diagnosis," says Sheldon Spector, MD, clinical professor of medicine at the University of California, Los Angeles. If you're worried about your child's breathing, here are the key questions your pediatrician will ask.

  • Does he wheeze? Although one bout of wheezing could be due to bronchitis, pneumonia, or viral bronchiolitis, recurring wheezing usually means asthma. However, a lack of wheezing doesn't rule asthma out.
  • Does she have trouble keeping up with other kids? Kids with asthma typically cough or get short of breath after running around for just five or 10 minutes.
  • Does he cough all the time? An asthma cough is dry, worse at night, doesn't cause a fever, and seems to hang on forever. "In some cases, asthma makes children cough so hard that they vomit," says Christopher Randolph, MD, clinical professor of pediatrics at Yale University School of Medicine.
  • Does she have any allergies or eczema? These related conditions make a child more likely to develop asthma.
  • Do you or your spouse have asthma? A child's risk is higher if a parent has a history of breathing difficulties or allergies.

A third of parents have "strong concerns" about their kids' asthma medications, according to one study. "Any drug can cause side effects in some children, but most asthma medications are very safe," says Parents advisor William E. Berger, MD, clinical professor of pediatrics at the University of California-Irvine. "Children with asthma rarely go to the hospital for using medication, but they often go because they haven't used it." Here, a guide to often-confusing treatments.

  • Short-acting bronchodilators: Drugs like albuterol (Ventolin, Proventil) or levalbuterol (Xopenex) relax the muscles in the airways for up to four hours. If your child has only occasional symptoms, this may be all the treatment she needs, but if she uses her inhaler more than twice a week, she probably needs a long-term control plan.
  • Inhaled corticosteroids: Taking a preventive drug such as fluticasone (Flovent) or budesonide (Pulmicort) once or twice a day reduces inflammation and makes airways less sensitive to triggers. "Inhaled corticosteroids are very different -- and much safer -- than anabolic steroids," says Dr. Berger. Doctors usually start kids at a low dose.
  • Leukotriene modifiers: Drugs like montelukast (Singulair) interfere with chemicals in the body that constrict bronchial tubes. Leukotriene modifiers are sometimes less effective than inhaled corticosteroids; doctors may prescribe them as an alternative (especially if parents are wary of corticosteroid medications) or as an addition.
  • Long-acting bronchodilators: Medications like salmeterol and formoterol, which open up airways for up to 12 hours, are combined with inhaled corticosteroids in the medications Advair and Symbicort for kids with more severe asthma. Since a small number of asthmatics may get worse on these drugs, some doctors avoid them.

Asthma attacks can seem to come out of nowhere, but these environmental factors are often to blame.

Smoke

Secondhand tobacco smoke triggers attacks, makes them worse once they start, and is a key risk factor for developing asthma in the first place.

What to do: If you're a smoker, ask your doctor to help you quit. Don't let anyone else smoke in your home or car, and avoid burning wood in fireplaces or stoves.

Pollen

Asthma spikes in the fall, when plants like ragweed are pollinating, as well as in the spring, when most trees and grasses release pollen.

What to do: Stay indoors at midday and late afternoon, when pollen counts are highest, and keep windows closed. Check with your doctor to see if your child should boost his anti-inflammatory drug dose or start taking an antihistamine before allergy season begins.

Dust Mites

Allergenic debris from these tiny bugs can saturate bedding, clothes, and carpeting.

What to do: Encase mattresses and pillows in mite-proof covers; wash bedding weekly in hot water, and use the dryer on the hottest setting. Run air-conditioning or dehumidifiers to reduce humidity to 30 to 50 percent because mites thrive in moist air. Keep stuffed toys out of your child's bed or wash them weekly.

Pets

Dander (especially from cats) gets everywhere and is tough to remove.

What to do: Find another family to adopt your pet. If you can't part with it, keep the pet out of your child's bedroom and close the door. Remove carpeting or cloth furniture where possible, or keep the pet out of carpeted and furnished rooms. HEPA filters may also be helpful.

Mold

These spores are allergens that grow indoors year-round. Outdoor molds are worst in the fall and spring.

What to do: Mold thrives on moisture, so run a fan or open a window when you take a shower or bath, run a dehumidifier in the basement, and fix leaky pipes or faucets. Clean visible mold with nonchlorine bleach or a cleanser like Concrobium Mold Control.

Most children are treated by their pediatrician, but you should see an asthma specialist if:

  • Your child needs short-acting medicine to relieve symptoms more than twice a week.
  • Allergies seem to trigger his asthma symptoms.
  • She gets sick more often than other kids, or respiratory problems make her miss school more than twice a month.
  • He still coughs frequently, especially at night.
  • She has to sit out normal activities because she has shortness of breath or coughs a lot.
  • Low doses of preventive medication aren't enough to control his asthma.
  • She's ever been hospitalized for breathing difficulty.

It's a major problem: Most kids don't use their inhaler properly. And when the drug doesn't get into the lungs, it won't work. Here's how to correct what often goes wrong.

Mistake #1: Your child doesn't capture enough mist.

A standard metered-dose inhaler (MDI) shoots a mist of medication into the air that can be tough to breathe in at exactly the right moment. Attachable plastic spacers capture the medicated spray, but if a child doesn't start inhaling within one or two seconds, the spray sticks to the interior lining, says Dr. Berger, author of Asthma for Dummies.

Solution: Attach the inhaler to a spacer and make your best effort to have your child inhale as soon as you pump the inhaler. Some models, such as the AeroChamber, are available with a face mask. Use a spacer whenever your child uses her medication at home, and also leave one with the nurse at school.

Mistake #2: She's breathing incorrectly.

A child needs to inhale slowly and deeply from an MDI for several seconds and then hold her breath for up to 10 seconds so medicine penetrates into her airways. "Most children can't do it properly until age 4 or 5," says Dr. Berger.

Solution: Kids up to age 6 who lack the coordination to properly inhale the medicine with an MDI should use a nebulizer, which dispenses medication in a mist that they can breathe normally through a face mask or a mouthpiece. When your child is 5 or older, ask your doctor whether she's ready for an inhaler.

Mistake #3: You don't check your child's technique.

Being "old enough" still won't guarantee that he uses his inhaler correctly. For example, some younger children have trouble drawing in air forcefully enough to use a dry powder inhaler (DPI), which requires them to inhale quickly and forcefully. And using the new environmentally friendly HFA inhalers (traditional chlorofluorocarbon inhalers will be banned as of January) "feels" different, so kids often don't think they're getting enough medication.

Solution: Ask a nurse or doctor to give your child a refresher course on how to use his inhaler, and make sure he's using it properly before you leave the office. If your child uses a DPI, ask your doctor to check how forcefully he's breathing with a special training device that whistles when it's used properly.

Mistake #4: You try to stretch the medicine.

It's tempting to economize by trying to get the last bit of medicine out of an inhaler, but your child may not get the full dose when a canister is nearly empty.

Solution: Keep track of doses so you know when you're low. Some corticosteroid medicines like Flovent HFA, DPIs like Pulmicort Flexhaler, and rescue medicines like Ventolin HFA have a built-in dose counter. For others, estimate how many days the canister should last, and mark the date on your calendar. You can also stick a blank label on the inhaler and mark it every time your child takes a puff, or buy a separate electronic counter such as the Doser ($28; doser.com).

Kids often have asthma attacks on the soccer field or playground because they're breathing heavily, which can lead to constriction of the airways. However, it's still important for children with asthma to exercise. Exercise reduces symptoms in the long run because it improves physical fitness and can help prevent obesity, says Carlos A. Camargo, MD, DrPH, associate professor of medicine and epidemiology at Harvard Medical School. To keep active kids symptom-free, follow these rules.

Every day: Use a controller medication like inhaled corticosteroids to make lungs less reactive to heavy breathing, allergens, and irritants.

When joining a team or class: Check with teachers or coaches to make sure your child is allowed to carry his bronchodilator inhaler.

Before exercising: Have your child use his inhaler to relax airways 15 to 30 minutes ahead of a game, practice, or gym class. This step prevents 80 percent of exercise-induced asthma attacks.

In the cold: Chilly air can make asthma symptoms worse, so cover your child's mouth with a mask or a scarf.

Isabella started wheezing when she had croup at 18 months. Nobody thought it was asthma, but when she kept having respiratory illnesses, our pediatrician eventually referred us to a specialist. She diagnosed Isabella with asthma at age 3, but tests showed she's not allergic to common allergens like pets, dust mites, and mold. It's frustrating not knowing what triggers her asthma, and it's taken a lot of trial and error with medications to keep her symptoms under control. -- Beth C., mom to Isabella, 4, Rochester, New York

My husband and I both have asthma, and we used to joke that we'd name our first child Wheezy. Isaac was diagnosed at 18 months, when he got a cough that lasted for days. Within a year, he became allergic to pollen, mold, grasses, and peanuts. Alex was diagnosed at 5 months, when the odor of chlorine at a pool triggered a serious coughing fit. Fortunately, they've never been hospitalized -- we all take our medicines together every day without fail. -- Trish V.T., mom to Isaac, 11, and Alex, 7, Austin, Texas

Maggie was constantly sick during the first two years of her life. But we really noticed her breathing problems when she and her sister would run to see friends down the street; Maggie would always be coughing by the time she reached our neighbor's house. When she started on Singulair, along with an inhaled corticosteroid, she stopped getting sick all the time -- but she's still had scary episodes. Once, during gymnastics, she sat down and said, "I can't breathe." I always worry she'll have an asthma attack at preschool or Sunday school, when I'm not there, and nobody will realize it. -- Jennifer D., mom to Maggie, 3, Roseville, California

Originally published in the September 2008 issue of Parents magazine.

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