When Amy Hendricks took her daughter Olivia to the doctor because of a bad cough and funny-sounding breathing, she expected to hear that her 1-year-old probably had a cold. "But after the pediatrician said she might have asthma, I burst into tears," says Hendricks, of Chambersburg, Pennsylvania. "It's awful to see your child in distress and then hear that she could have breathing problems for the rest of her life."
Olivia -- now age 5 and requiring treatment only for the occasional episode -- has plenty of company: Almost 5 million American children live with asthma, which accounts for almost 3 million doctor visits and 200,000 hospitalizations every year, according to the American Academy of Allergy, Asthma & Immunology. With asthma, the smooth, sensitive muscles surrounding the bronchial airways become inflamed easily. Set off by a trigger -- say, a virus, smoke, or exercise -- the muscles swell, causing a cascade of unhappy events. Inflammation makes the muscles spasm, tightening the airways, while the bronchial tubes' protective lining produces mucus. The result is tight, clogged airways that lead to coughing, wheezing, and breathing problems.
More and more children are living with these so-called twitchy lungs. Asthma cases in kids climbed an average of 4.3 percent a year between 1980 and 1996, and the condition is considered to be the most common serious, chronic childhood condition, according to the Centers for Disease Control and Prevention. Why is asthma, like other allergic diseases, on the rise? No one knows for sure, but theories abound -- notably, the hygiene hypothesis: With fewer germs to fight in today's sanitary environments, the body's hypervigilant but misguided immune system instead attacks harmless substances, such as dust and pollen.
But some experts wonder whether living in more hygienic conditions explains today's rash of cases. "We've been living cleaner for 50 years, and the asthma increase occurred very quickly and recently," says pulmonologist Chris Harris, MD, assistant professor of pediatrics at Vanderbilt Children's Hospital, in Nashville. "Likewise, though some theorize that pollution plays a role, our air is cleaner than it was 20 or 30 years ago." Also, he adds, increased awareness and recognition of asthma may explain why more kids are diagnosed nowadays.
But will your child be among them? If a parent has asthma, a child's risk might be as high as 20 to 25 percent, says Andy Liu, MD, associate professor of pediatrics at National Jewish Medical and Research Center, in Denver. "Allergies and eczema in early childhood also increase asthma risk, especially in babies and toddlers with recurrent coughing or wheezing," adds Dr. Liu.
Researchers are uncovering other possible links to asthma, including taking antibiotics before age 1 and living near a major road. Even having a high birth weight (generally, more than 8.8 pounds) raises the risk by 20 percent, say University of California at San Francisco researchers in a recent review of 12 studies. And the increased risk for overweight school-age kids is even higher: 50 percent. The researchers speculate that there may be a dietary connection -- perhaps overweight kids eat fewer foods, such as fish, with anti-inflammatory fats -- or that excess pounds place extra pressure on airways. "We can't yet say that high weight actually causes asthma, but the two seem to be linked," says the study's lead author, Valerie Flaherman, MD, a senior pediatrics fellow at UCSF.
The rate is rising, and there are many possible causes -- yet asthma is not the only reason for wheezing. "Some kids are transient wheezers -- they'll wheeze until age 2 or 3 and then stop," says Omaha osteopathic physician and allergist James M. Tracy, DO, president of the Nebraska Allergy Society. Otherwise healthy young children may be prone to occasional wheezing or coughing, often set off by illness or a condition such as gastro-esophageal reflux (recurrent spitting up), but two-thirds eventually outgrow it. Until then, their wheezing could be treated the same way as an asthma attack, with a "rescue medication" such as albuterol (sold under the brand names Proventil and Ventolin), a bronchodilator that quickly relaxes the airway muscles. These drugs can cause restlessness, irritability, and nervousness. Xopenex, a new drug (levalbuterol), may cause fewer side effects.
For the one-third who may go on to develop full-blown asthma, a definitive diagnosis may not come until the child is at least 5 and can reliably follow directions to fully inhale and then fully exhale for four seconds into a spirometer, an instrument that measures airflow. Still, many pediatricians will diagnose asthma in preschoolers and toddlers. "For a younger child, we base a diagnosis on the pattern of wheezing, the possibility of other conditions, and whether asthma medication helps, but it's still a gray area," says Dr. Liu.
Another gray area: the apparent but still unexplained link between asthma and respiratory syncytial virus (RSV), an extremely common childhood illness that can cause wheezing. "Virtually all children get RSV by age 2, and for most, the virus causes coldlike symptoms," says J.J. LaBella, MD, assistant clinical professor of pediatrics at the University of Pittsburgh. "But it can also be serious, especially for infants born before 35 weeks' gestation, as well as in those with chronic lung or neuromuscular diseases, such as muscular dystrophy, cerebral palsy, and spinal muscular atrophy." Premature babies' underdeveloped, fragile airways are prone to complications, such as bronchiolitis -- an infection of the small breathing tubes -- and pneumonia.
Each year, more than 125,000 babies are hospitalized for RSV, the top cause of hospitalization for kids under age 1. Experts agree that parents should take steps to protect babies from the highly contagious virus -- scrupulous hand-washing as well as avoiding crowds and sick people help. If your baby is among the most vulnerable, ask his doctor about Synagis, a preventive drug injected monthly during RSV season, from October through March. "It's been shown to cut hospitalization risk in half for high-risk babies," says Dr. LaBella.
If your baby does develop RSV, you'll know it. "The symptoms aren't subtle," notes Dr. LaBella. "If your baby starts to wheeze -- you can hear the breathing and see the muscles working on the chest -- you need to call the doctor." Listen for a characteristic high-pitched sound as your child exhales.
Asthma shouldn't sentence a child to a life of juggling drugs to ease breathing. Consider Aidan Meyers, age 4, of Schnecksville, Pennsylvania, who began coughing and wheezing with bronchiolitis at 8 months and continued off and mostly on for months. Finally, at 21 months, he was officially diagnosed with asthma, as well as food and household allergies. Initially, he had to take two medications four times a day as well as four others twice a day, but now Aidan is on just one preventive treatment a day.
All asthma patients have on hand a rescue drug (e.g., albuterol) to quickly open constricted airways, or an oral corticosteroid, such as prednisone (usually reserved for severe attacks and to be used only under a doctor's direction). Then, depending on the severity of the asthma, a child may also be put on a long-term medication -- such as an inhaled cortico-steroid, a leukotriene modifier (e.g., Singulair), or a long-acting bronchodilator -- to reduce inflammation, swelling, and mucus production.
These "controller" drugs make lungs less twitchy and less prone to overreact to triggers -- say, a virus, exercise, dust, pet dander, smoke, or stress. (Inhaled drugs also require equipment -- either a nebulizer, a machine that turns medicine into breathable mist, or a handheld inhaler that delivers a puff of the drug.) "Parents are often reluctant to put their kids on daily medication, but if the inflammation is controlled, everything is better," says Dr. Liu.
Properly controlled asthma, for which rescue drugs are rarely used, should have little effect on a child's life. In fact, experts say, a kid with asthma should be just as active as any other -- without fear that running around will lead to fighting for breath. "Parents need to follow the three-strikes rule," says Dr. Liu. "If a toddler has daytime symptoms three times a week, nighttime symptoms three times a month, or prolonged attacks three times a year, talk to your doctor about adjusting your child's plan."
Beyond administering treatments, you may need to make some household changes if your child has asthma. For example, as many as 80 percent of asthmatic kids have allergies, says Dr. Tracy. So if your child is allergic to something in dust, you might have to get rid of carpeting or stuffed animals, says Dr. Liu. "We let Aidan keep two favorites that fit in the freezer," says his mom, Nicole Meyers. (The cold kills dust mites, but once outside the freezer, stuffed animals will get reinfested, so you may want to dehumidify your home, says Dr. Liu.) Most important: Tell smokers at home to quit. "Smoking outside isn't enough -- smoke clings to hair and clothes and is detrimental to the lung function of sensitive kids," says Dr. Flaherman.
While the diagnosis of asthma might seem devastating, moving ahead is empowering, says Lois McDonald of Denver, a mother of four whose oldest son and daughter have asthma. "When they were toddlers, I took them to the doctor for what I thought were colds," says McDonald. Pinpointing the problem was a relief, she says: "It's a serious disease, but a little education takes away the fear. Now I know exactly how to help them."
Not all wheezing signals an emergency -- a child who seems alert or can still cry or chatter normally isn't in danger (but consult a doctor anyway). Do get emergency assistance if your child:
Rachelle Vander Schaaf, a mother of two, lives in eastern Pennsylvania.
Originally published in American Baby magazine, September 2006.
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