As a pediatrician, I shouldn't be surprised that two of my three children suffer from asthma. It's the most common chronic childhood disease in the United States, affecting an estimated 6.8 million kids. Asthma, which causes the airways to inflame and narrow, ranks as a leading cause of missed school days for children between the ages of 5 and 17. Nearly a quarter of kids with asthma in this age group report missing out on at least some events due to the disease.
Fortunately, medications can usually control children's wheezing, shortness of breath, and coughing so that they can enjoy all of their favorite activities. Most of these medicines are given with metered-dose inhalers (MDIs), or "puffers." (There are also dry-powder inhalers, but for our purposes, I'll focus on MDIs.) Lots of children and their parents, however, find it hard to use an inhaler correctly, and that leads to thousands of preventable emergency-department visits and hospitalizations, as well as countless lost days of school and work. You have to wonder: What is it about these meds that makes them so hard to use, and is there anything we can do to make it easier? The answer to the second question is yes -- so keep reading.
Inhalers look pretty simple. They have two pieces: a metal cylinder that contains medicine, and an L-shaped plastic holder that ends in a mouthpiece. The cylinder sits in the holder; when a child (or a parent) presses down on the cylinder, a fine mist of medicine sprays from the mouthpiece, hopefully into the child's lungs. Some inhalers even include built-in counters that display how many doses are left.
From there, however, things get more complicated. For example, if a child puts the mouthpiece directly in her mouth (a logical thing to do), much of the medicine hits the back of her throat and never reaches her lungs. For this reason, doctors prefer that children also use a plastic tube called a spacer, or valved holding chamber. The inhaler fits into one end of the spacer and the other end goes in the mouth. Many spacers come with a face mask which makes it easier for young children to use. Spacers allow the droplets of medicine to spread out and slow down, so that more of the medicine reaches the lungs. They also hold the medicine as a mist until the child is ready to inhale so that even a crying, uncooperative kid can get the right dose of medicine.
It would be great if an inhaler came with a spacer, but you have to buy one separately; the price ranges from less than $10 to $40. It's important to keep it clean. Even though having a spacer greatly increases the chance that your child will breathe in her asthma medicine properly, using an inhaler and a spacer still requires following ten steps correctly (see "How to Use an Inhaler With a Spacer and Mask," on page 74). In fact, a recent study in the Journal of Asthma found that only one caregiver out of the 169 observed got all ten steps right. But that's not to say it can't be done right, once you know how.
Doctors classify asthma as being either intermittent, mild-persistent, moderate-persistent, or severe-persistent. These grades help them guide the use of medicines, which work in very different ways. Some drugs, called bronchodilators, are known as rescue medicines. They quickly open up the airways and immediately relieve the coughing, wheezing, and chest tightness that patients have during an attack. Kids with asthma should keep a rescue inhaler at home and at school.
To help prevent future asthma attacks, doctors will also prescribe controller medicine--usually an inhaled corticosteroid--that reduces underlying inflammation in the lungs. Taking controller medicine every day is essential for keeping many kids with asthma healthy and active. However, it works slowly and won't do anything to relieve the symptoms of an asthma attack. I advise parents and kids to keep their controller medicine in a place where they can't miss it. Leave it in front of the coffeepot, by the toothbrush, even next to the car keys -- anywhere that will help you remember to use the drug as prescribed.
Many people find it difficult to take a daily medicine for a chronic illness, and they find it even harder to give daily medicine to a child. Research shows that only one in five children take their asthma controller medication as often as their doctor prescribes. It's a tough concept to grasp: You have to take your medicine while you're well in order to stay well. Even though I know how important it is for kids to take their medicine properly, I admit there have been nights when I chose not to awaken my own kids so they could use the inhalers that I'd forgotten in the bedtime rush. But it's crucial to establish a routine to make giving medicine a habit.
Since proper asthma care is both critical and challenging, national guidelines recommend that children with asthma see their doctor at least every six months and leave with an asthma action plan. This plan is simply a sheet that uses a stoplight approach to help families remember what medications to give when a child is in the "green zone" (no symptoms), the "yellow zone" (some coughing and/or wheezing, waking up at night from a cough), or the "red zone" (having a really hard time breathing). Many doctors now have an asthma educator in their office who specializes in helping families understand how to better manage the condition.
I don't have an asthma educator in my practice yet, so I spend lots of time talking to parents and patients about asthma control. We schedule our asthma patients for 30-minute visits, but it often takes longer to cover all we have to discuss. Don't be afraid to ask questions; this stuff is confusing, and I promise that whatever you ask, your doctor has already answered it many times. How well this conversation goes can make the difference between your child having a winning soccer season or winding up in the emergency department.
At this time of year, it's important to discuss allergies too. Doctors group asthma together with allergic rhinitis in a category we call "atopic disease." These conditions develop when the immune system responds inappropriately to substances that it mistakes for threats, such as pollen, mold, animal saliva, and dust mites.
While allergies trigger asthma symptoms in many children, they don't cause every case of asthma. Kids exposed to irritants such as cigarette smoke can develop asthma without having allergies. Some children have exercise-induced asthma and may find that symptoms come on within a few minutes of being active. For these reasons, an allergy assessment is considered routine in evaluating and managing asthma, to make sure a child is getting the proper medicine and avoiding allergens. A good medical history is a great start to the process. Sometimes allergy skin or blood tests can help identify triggers.
You should never hesitate to call your child's doctor if his medicines don't seem to be working. Ultimately you all share the same goal: for your child to practically forget that he has asthma -- but not forget his meds!
Some kids have obvious symptoms such as wheezing, chest tightness, or shortness of breath. Other children may just cough. In fact, many parents are so used to their child coughing at night or during exercise that they never suspect that he has a serious and treatable problem. But any cough that goes on longer than three weeks should be checked.
At the visit, your child's doctor will ask about any triggers that seem to make the symptoms worse. Asthma and allergies are closely related; for many people, anything that worsens allergies can cause asthma attacks. Other signs, such as swelling of the lower eyelids, narrowed nasal passages, or a crease across the tip of the nose, can all point to allergies.
It's tricky to diagnose young children because colds and other viruses can cause wheezing. But kids ages 6 and older can take breathing tests. A peak flow test is quickest and easiest; it uses a handheld plastic tube to measure how fast your child can expel air from his lungs. When possible, doctors prefer to give a computerized test called spirometry, or pulmonary-function testing. As with a peak flow, the child breathes as hard as he can into a tube. Sensors then calculate total lung capacity. A computer program checks the best three breaths based on sex, age, and height. The results help point to asthma as well as a variety of other conditions that affect breathing.
Originally published in the May 2015 issue of Parents magazine.
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