Dr. Greene’s Answer:

Even stubborn allergies can often be brought under control. Marie, it sounds like you and your son have both been through quite a lot. He’s on a powerful arsenal of medications and already under the care of specialists.

With allergies and asthma causing this much trouble, I’m a big fan of allergy testing to identify the specific offending allergen(s), to be able to be smart about reducing exposure to the triggers, and perhaps to treat those allergies specifically.

Whether or not something specific is identified, when the symptoms are in the nose, lungs, and the rest of the respiratory system, the problem is usually something in the air. A powerful study published in the New England Journal of Medicine looking at 1000 kids with asthma serious enough to hospitalize them or send them to the ER on more than one occasion. They found that taking control of the air in the home was as powerful as steroid medications. Those kids had 34 fewer days with symptoms than their peers.

A mold problem in the home is something to consider.

Certain houseplants can be powerful ways to remove problem-causing chemicals from the air. (Chemical fragrances and other volatile compounds (VOCs) can trigger asthma or rhinitis and not show up on allergy testing. They can come from furniture, paint, carpeting, air fresheners, computers, etc.)

There are also a number of treatment alternatives for the symptoms.

For nasal allergies, I like Ortho Molecular D-Hist Jr, which uses quercetin, stinging nettle N-acetyl cysteine, and bromelain to reduce the allergic response and reduce phlegm.

For cough variant asthma I like traditional Chinese medicine herbs, such as Kan Herbals Deep Breath. The NIH Center for complementary and alternative medicines has published a statement on these herbs that the preliminary evidence for using these herbs is promising, with all the studies showing positive results.

At Stanford, my colleague who was across the hall from me for years, pulmonologist John Marks, MD, has had success with mind-body relaxation techniques in kids, such as massage or guided imagery — sometimes being able to reduce the over-active immune response enough to get kids with asthma off of controller medicines.

Both honey and dark chocolate can be powerful at reducing coughs. The dark chocolate contains a compound similar to theophylline, an asthma drug we quite using, in part, because we had to keep drawing blood tests to be sure the dose didn’t get too high. You don’t have that problem with food.

Speaking of food, how kids eat can have a major impact on asthma symptoms. If they’ll eat that way, a Mediterranean diet such as this has been much-studied and can be a great choice.

With your son’s complex medicine regimen, Marie, you’ll want to discuss any new supplements or remedies with his specialists, though clean air and healthy food are good for any child with allergies and asthma.

Finally, for my own family, I like to brew a cup of Traditional Medicinals Organic Chamomile tea to relax, loosen the phlegm and help calm the cough. It’s a simple, comforting choice you can share.

Today is my final guest blog in this series on asthma. I am deeply grateful to DrGreene.com for inviting me and to all the readers for viewing my posts. I hope you have found them helpful.

Do you have an “asthma action plan” in place for your child? Due to the chronic nature of asthma, it is imperative to pay attention to the progression of symptoms, and one of the best ways to do so is by building an asthma action plan around your “peak flow,” preparing you to successfully deal with asthma when things go awry. “Peak flow” is a measurement of your lung function and can be taken with a “peak flow meter,” a small hand-held device that you can use pretty much anywhere. Taking in a deep breath and then blowing out into the device as hard as you can gives a number – your peak flow. Usually children as young as 5 years can do this maneuver. Measuring peak flow a number of times when you are well gives you your child’s personal best number.

Most current action plans are developed around the traffic signal structure of green, yellow and red zones, each based upon the asthma symptoms present and the current peak flow measurement.  The green zone corresponds to 80-100% of this number, yellow 50-80% and red, less than 50%. For example, if 200 is your child’s personal best, green corresponds to 160-200, yellow to 100-160 and red, less than 100. Since the peak flow is effort-dependent, it may be falsely low if your child is tired and unable to give a good effort, so you’ll want to consider the level of other symptoms, as well.

So, what should you watch out for in each zone, and how should you react?

• In the green zone, your child is experiencing no acute asthma symptoms, peak flow is 80-100% of his or her best, and no action – other than continuing current medications – is necessary.
• In the yellow zone, peak flow is at 50-80%, and you may see coughing and wheezing, nighttime symptoms, or tightness in the chest. Your action steps in the yellow zone need to be discussed ahead of time with your physician. Usually you will need to provide your child with rescue medication several times a day. Additionally, I recommend parents contact me at this stage, because complementary treatment and medications such as prednisone may be needed. (I have some parents keep a small supply of prednisone at home to begin if their child continues in the yellow zone for longer than a day. The goal is always to nip problems in the bud, before symptoms worsen.
• In the red zone, serious symptoms are present such as breathing hard and fast, being unable to talk easily, blue color or duskiness of the lips, skin or fingernails among other things. During this stage, rescue medicines providing no relief. Peak flow is less than 50% of best. This is a medical emergency. It is time to get to a doctor or hospital. Calling 911 to get help is probably the best action.

While this is the basic structure of an asthma action plan, Beating Asthma: Seven Simple Principles offers a more detailed discussion. I also recommend discussing an asthma action plan directly with your family physician.

Thanks again for joining me this week! I truly hope that the topics covered will help you take ownership of your child’s asthma and plan ahead to prepare for (and avoid!) tough times. Be empowered to beat asthma. You can do this. The quality of life will improve for your child and yourself!

I wish you and your family easy breathing!

Dr. Hall’s Answer:

I’m sorry to hear that your child has been ill. Certainly frequent colds are part of the package when your child starts daycare. In fact, studies estimate that a child in their first year of daycare will experience up to 10 colds! Unfortunately, if your child doesn’t attend daycare, they aren’t off the hook – he or she will likely experience that same burst of frequent illnesses when they start school.

The use of over-the-counter cough medications, such as Tussin DM, for children is strongly discouraged by the American Academy of Pediatrics (AAP). In fact, in 2007, drug companies voluntarily began withdrawing children’s preparations from the shelves due to the dangers of side effects, and in 2008, the Food and Drug Administration recommended that no cough and cold medications be used in children younger than 4 years of age due lack of evidence that they help relieve symptoms and due to the risk of side effects.

Over-the-counter adult preparations are especially dangerous because:
¹ no safe dose for children or infants is known – toxicities and dangerous side effects can occur at any dose and ² many medicines are combinations of several drugs, such as acetaminophen, diphenhydramine, pseudoephedrine, etc. – all of which have their own side effects and toxicities. Side effects specifically due to Dextromethorphan (the “DM” in Tussin DM) include dizziness, drowsiness, nausea, vomiting, decreased breathing, apnea (no breathing), rapid or irregular heart rate and death. Scary stuff!

So what can you do for your child when they are feeling miserable with a cold? For cough treatment, the AAP recommends for children older than one year of age, ½ to 1 teaspoon of honey, taken as needed. Honey helps to thin mucous and soothe cough. Recent research (1,2) showed that honey is better than drugstore cough syrups at decreasing the frequency and severity of coughing at nighttime. For congestion, saline nasal drops and suction, and a cool mist vaporizer in the bedroom at night is helpful.

Regarding your question of asthma, in young children, frequent viral infections are the most typical cause of cough, congestion and fever. Wheezing can occur as part of viral or bacterial infection, so wheezing alone cannot clinch a diagnosis of asthma. Predictors of asthma include eczema or allergies in the patient, and a strong history of asthma in the parents of the patient. Pulmonary testing is usually not practical before school age. Careful follow-up with your pediatrician and monitoring of the breathing symptoms over time is required for a diagnosis of asthma.

^{1) Paul IM, Beiler J, McMonagle A, Shaffer ML, Dada L, Berlin CM., Jr Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Arch Pediatr Adolesc Med. 2007;161:1140–6.}

^{2) Shadkam MN, Mozaffari-Khosravi H, Mozayan MR. A Comparison of the effect of honey, dextromethorphan and diphenhydramine on nightly cough and sleep quality in children and their parents. J Altern Complement Med. 2010 Jul;16(7):787-93.}

Creating a healthy home by reducing toxins and improving indoor air quality can have a direct effect on whether your child develops asthma. And in families already affected by the condition (as many as 10% of American children have asthma), the choices you make when purchasing home furnishings and cleaning agents can be as important as medicine in preventing attacks.

Whether a child develops asthma is determined both by genetics and by environment. While many diseases are becoming less common, incidence of asthma has steadily increased since 1980. It has become the most common chronic disease in children. Research suggests that young children who are exposed to high levels of airborne volatile organic compounds (VOCs) are four times more likely to develop asthma than other children.

VOCs are chemicals that release fumes and are found in many solvents, cleaning products, air-fresheners, polishes, adhesives, paints, new carpeting and furniture. Recent medical evidence indicates that VOCs can cause lung damage, resulting in asthma. Reducing your child’s exposure to VOCs at home is one way you can lessen his risk of developing asthma. For those who already have asthma, these fumes can trigger wheezing. Changes in the home environment can be as powerful as medication in treating this condition.

In 2004, the New England Journal of Medicine reported on an NIH-funded study that followed almost 1,000 elementary schoolchildren for two years, all of whom had severe allergic asthma. Half of the children received routine asthma treatment. The other half got home evaluations by environmental counselors. The counselors identified, reduced and in some cases eliminated allergens by providing environmentally safe sleep zones, with hypoallergenic covers for each child’s mattress, box spring and pillows. Parents used a vacuum cleaner equipped with a high-efficiency particulate air (HEPA) filter and some ran a HEPA air purifier in their child’s bedroom. The results were outstanding, comparable to those attained by children using inhaled steroid medicines. During the two-year span, the benefits of the changes translated into 34 fewer days with reported wheezing as compared with similar children who did not have the home changes. They also had fewer absences from school (missing 2 weeks less than the control group over the two years), and had four fewer urgent doctor- or emergency-room visits.

The results of this study were achieved only after multiple possible triggers of asthma were eliminated. In previous studies, where only a single change was made, success rates were lower. And even after you’ve made major alterations in your home, medicines may still be necessary to control your child’s asthma, so it’s important that you work with your doctor as you prepare to make alterations to her treatment regimen.

Because allergies to pets are common, people long assumed that exposure to pets made allergies more likely. A number of studies have turned this assumption upside down. The August 2003 Pediatrics Synopsis Book summarizes the current understanding.

For a newborn coming into a home, or for a child who has not developed allergies, exposure to a dog or to multiple pets appears to decrease the risk of allergies, eczema, and perhaps (in one study) even asthma. In the studies summarized, as the numbers of cats and dogs went up, hay fever, eczema, and other allergies decreased.

For a child who is already allergic, but not to pets, getting pets does not appear to help or hurt. For a child who is already allergic to pets, there is no allergic benefit to keeping the pets, and exposure will make symptoms worse. If a child has asthma and is pet-allergic, then it may be wise to move the pet from the home.

Introduction to wheezing:

Our airways are designed to be responsive to harmful substances in the air. If we walk through clouds of smoke, our airways will shrink, protecting our delicate lung tissues from the noxious ingredients in the smoke. They should return to normal when we begin to breathe fresh air.
Some people – those with asthma – have an exaggerated tightening response.

What is wheezing?

Wheezing is the noise made by air moving through tight airways in the chest. Classically, wheezing is heard when children are breathing out, and these tiny airways collapse.
Wheezing does not necessarily mean asthma – and vice versa.
Wheezing can progress to respiratory distress.

Who gets wheezing?

Wheezing is the classic symptom of asthma, but it is also an important feature of other problems such as inhaled foreign bodies, RSV infections, other types of bronchiolitis, or cystic fibrosis. Wheezing might be a symptom of gastroesophageal reflux or of a food allergy. It can also be present during many common viral infections, especially during the first two years of life.
Not all children with asthma wheeze. Some cough instead, as a way to move air through the narrowed airways.

What are the symptoms of wheezing?

Tight, noisy breathing during expiration.

Is wheezing contagious?

No – although the causes of wheezing may be contagious.

How long does wheezing last?

Wheezing lasts as long as the airways are too tight. The duration depends on the underlying cause.

How is wheezing diagnosed?

The cause of wheezing should be carefully considered. Inhaled foreign objects should always be suspected – especially with the first episode of wheezing. They are most common at the age when the child is unlikely to be able to describe what happened.
Reflux should also be considered as a possible cause, as should other sources of airway obstruction.
Wheezing and asthma are so linked in many people’s minds that other causes are often missed.

How is wheezing treated?

Wheezing is treated by reversing the tightness of the small airways of the chest. This might be done with bronchodilator medicines to relax the smooth muscles around the airways. It might be done with anti-inflammatory medicines to reduce swelling within the airways. Or it might be done by removing an inhaled object.

How can wheezing be prevented?

Wheezing can often be prevented by taking steps to prevent the individual underlying causes. See separate articles

Related A-to-Z Information:

Adenovirus, Asthma, Bronchiolitis,Common Cold, Cough, Cystic Fibrosis, Food Allergies, Gastroesophageal Reflux, Peanut Allergy, Pneumonia, RSV (Respiratory syncytial virus)

Related concepts:

Food hypersensitivity, Oral allergy syndrome, Allergic proctocolitis

Introduction to food allergies:

Many parents of infants and toddlers are told that food allergies don’t happen that young, or that they are very rare. We’ve learned that food allergies certainly do happen and that they are common – affecting about 1 in 18 children before the 3rd birthday.

What are food allergies?

Food allergy is the name given to a variety of situations in which specific foods provoke some type of over-zealous immune response, which produces symptoms.
Because the developing immune system is quite complex and has mechanisms to protect us from what we swallow, food allergies are also complex, and can result from a variety of different mechanisms and cause a variety of symptoms.
Celiac disease is an immune response to gluten – proteins found in wheat and other grains.
Lactose intolerance is not a food allergy. A missing enzyme makes milk difficult to digest, creating gas and loose stools. And the flushed cheeks that some children get when eating citrus or tomatoes are not usually an allergy.

Who gets food allergies?

Food allergies are common, especially in the first 3 years of life. They are more common in those with a family history of food allergies, or in those with a broader allergic family history (allergy, eczema, or asthma).
Food allergies are also more common in babies who are exposed to allergic foods at an early age. About 90 percent of food allergies in babies and children are to one of 5 foods: cow’s milk, soy, eggs, peanuts, or wheat.
Most children with food allergies have an allergy to only one food, although multiple allergies are possible. A sizeable minority of those allergic to cow’s milk are also allergic to soy.

What are the symptoms of food allergies?

Food allergy can be so severe that the most trivial contact with the food causes immediate itching, tingling, and/or swelling of the lips, tongue, and throat.
A food allergy can trigger full-blown anaphylactic shock. Most life-threatening food allergies are to peanuts, nuts, shellfish, or fish.
Usually the symptoms of food allergy are much more mild. Still, babies with food allergies may well be fussier than their peers. Colic can be caused by food allergies (either to the formula or to a food in the mother’s diet).
Gastrointestinal symptoms are often the easiest to recognize. A food allergy might cause loose stools, excess gas, diarrhea, nausea, or vomiting. Infants will sometimes have streaks of blood or mucus in the stools, especially with allergies to cow’s milk. Sometimes the amount of blood is too small to see, but still enough to cause anemia. Sometimes food allergies cause constipation.
Symptoms elsewhere in the body are also common. These include hives, ear infections, stuffy noses, runny noses, watery or red eyes, wheezing, asthma flare-ups, and eczema. Sometimes eczema (or fussiness) is the only sign of a food allergy, and the eczema (or fussiness) will disappear if the offending food is eliminated.

Is food allergies contagious?

Food allergies are not traditionally contagious.

How long does food allergies last?

Most young children outgrow their food allergies. Outgrowing milk and soy allergies is common by the 1st birthday. The great majority have outgrown them by the time they are 3. Even those who still have food allergies at 3 will often outgrow them, especially if they are not exposed to the offending foods for a year or two.
Some food allergies, however, are lifelong. Allergies to peanuts, nuts, shellfish, and fish are classic examples.

How is food allergies diagnosed?

Food allergies might be diagnosed when eliminating a food improves symptoms and reintroducing the food causes the symptoms to recur.
Allergy testing can also be helpful. Skin testing and RAST testing can both be used to detect food allergies. In babies, a positive result is usually a sign of a real allergy, but a negative result doesn’t give much information either way.
In preschool kids, the opposite is true. A negative result is a good indication that a child is not allergic to the food. A positive result, however, may or may not represent an allergy.
Also, many people think that having been allergy tested once tells the whole story. Allergy testing is a snapshot in time. Allergies themselves are a moving picture. Repeat allergy testing is very helpful.

How is food allergies treated?

Eliminating the offending food is the core of treatment. This can be difficult because some foods occur as hidden ingredients in many other foods. Usually symptoms will improve greatly within 3 days of eliminating the food that causes them.
Breastfeeding is wonderful for babies with food allergies. Sometimes, however, offending foods are best removed from the mother’s diet. When a baby with a cow’s milk protein allergy is fed formula, it often needs to be a protein hydrolysate formula. Lactose-free formulas and partial hydrolysate formulas do not help with real milk allergies.
If food allergies cause wheezing or other respiratory symptoms, an allergist should be involved in the care. If necessary, parents should have access to emergency medications.

How can food allergies be prevented?

Breastfeeding can prevent many food allergies. This is especially true if the mother forgoes some of the most allergic foods (especially peanuts and perhaps milk or eggs). On a positive note, mothers who eat beneficial bacteria, as in yogurt, while pregnant and nursing may help prevent food allergies.
Delaying the introduction of solid foods until the latter part of the acceptable window may prevent some allergies. Delaying particularly allergic foods even longer can further reduce the risk of allergies.

Related A-to-Z Information:

Allergies (Allergic Rhinitis), Anemia (Low hemoglobin), Asthma, Attention Deficit Hyperactivity Disorder (ADHD), Blocked Tear Duct, Celiac Disease, Colic, Common Cold, Conjunctivitis (Pink eye), Constipation, Cough, Croup, Diaper Rash, Diarrhea, Ear Infection, Enuresis, Food Poisoning, Galactosemia, Gastroenteritis, Gastroesophageal Reflux, Giardia Lamblia, Head Banging, Headache, Hives, Otitis Media with Effusion (OME), Peanut Allergy, Poison Ivy, Oak, and Sumac, Pyloric Stenosis, Reye Syndrome, Rotavirus, Sinusitis, Vomiting, Wheezing

Introduction to bronchiolitis:

Worried parents stand over the crib, listening to their baby cough and struggle to breathe. He may have bronchiolitis. Most parents have heard of pneumonia or bronchitis, but what does bronchiolitis mean?

What is bronchiolitis?

Bronchitis is inflammation of the large airways in the chest and pneumonia is inflammation of the lung tissue. Bronchiolitis is inflammation of the smaller airways connecting the two.
Bronchiolitis is usually a viral infection. RSV is responsible for the illness in many children. Adenovirus, parainfluenza (croup), and other viruses can also cause bronchiolitis.
In adults and older children, RSV usually appears as a bad cold. However, in babies and toddlers whose bronchioles are smaller and easier to plug, these viruses often cause bronchiolitis when inhaled.

Who gets bronchiolitis?

Bronchiolitis is primarily a disease of young children before their second birthdays. The most common age for bronchiolitis is about 6 months.
Winter and early spring are bronchiolitis season. Children in day care are usually much more likely to get bronchiolitis. Kids who are exposed to cigarette smoke are at even higher risk. Babies who attend day care are less likely to get bronchiolitis than those who stay home with a parent who smokes.
Boys are more often affected, as are formula-fed infants. Those at high risk for asthma also appear to be prone to bronchiolitis.
Most kids who get bronchiolitis have been exposed to an adult or another child with a cold in the previous week.

What are the symptoms of bronchiolitis?

Bronchiolitis usually begins with cold symptoms such as a runny nose, sneezing, and perhaps a mild cough. The appetite is often decreased. The child may have a fever or might be a bit cooler than normal.
After a day or two, breathing becomes faster and the cough becomes more severe. It may be a deep or wheezy cough. The child may develop wheezing and respiratory distress.
Breathing difficulties can make it hard for babies to feed.

Is bronchiolitis contagious?

Bronchiolitis is very contagious. It spreads most commonly by contact transmission, droplet transmission, and fomites.

How long does bronchiolitis last?

Mild bronchiolitis may last only for a day or so. Often the disease lasts 5 to 12 days. The first 3 days are the most critical.

How is bronchiolitis diagnosed?

Diagnosis is often based on the history and physical exam. A chest x-ray can give additional information, as can a pulse oximeter to measure oxygen levels. A nasal swab for RSV and other viruses might be done to identify the specific cause of bronchiolitis.

How is bronchiolitis treated?

There are no specific medicines for treating bronchiolitis at home. It is important to give plenty of fluids to prevent dehydration. Also, a humidifier or saline nose drops might be recommended to thin the mucus.
Some children need supplemental oxygen or even mechanical help to breathe.  A powerful aerosol treatment specifically against RSV is sometimes used for hospitalized children.
Steroids and antibiotics are not usually helpful. It is unclear whether inhaled medications such as albuterol are helpful.

How can bronchiolitis be prevented?

If possible, protect your baby from exposure to sick individuals during the peak bronchiolitis season. In addition, good hand washing, particularly just before anyone handles susceptible infants, can decrease spread. Don’t forget to use a tissue when you cough or sneeze.
Two products are now available to prevent RSV infection in children at high risk for serious disease. RSV-IGIV (RespiGam) and palivizumab (Synagis) have been approved for high-risk children (such as premature babies and infants with severe heart or lung diseases).

Related A-to-Z Information:

Adenovirus, Asthma,Common Cold, Contact Transmission, Cough, Croup, Cystic Fibrosis, Dehydration, Droplet Transmission, Fomites, Pneumonia, Respiratory Distress, RSV (Respiratory syncytial virus, Sudden Infant Death Syndrome (SIDS), Wheezing

Related concepts:

Reactive airway disease, wheezy bronchitis, viral-associated wheezing, bronchiolitis

Introduction to asthma:

Asthma is one of the most common disorders affecting children. As many as 10 percent of children have some degree of asthma, and the number has been rising steadily since about 1980. Thankfully, advances in the diagnosis and treatment of asthma have dramatically improved life for these children.

Today most children with properly managed asthma can lead a life unhindered by their disease. It shouldn’t hold them back from even the highest levels of athletic competition, as recent Olympic Gold Medals have shown. With proper education and medical management, it is possible to control this disease on a daily basis and prevent asthma attacks.

Having said that, asthma is still a deadly disease. In 2009, 3,388 people died of asthma (http://www.lung.org/finding-cures/our-research/trend-reports/asthma-trend-report.pdf).
A major cause of this mortality is improper use of inhalers. Too often,, families are handed several inhalers and they never really understand the different functions and uses of each one.

What is asthma?

Asthma is a chronic lung disease characterized by tight airways — a result of airway hyper-responsiveness. Our airways are designed to be responsive to harmful substances in the air. If we walk through clouds of smoke, our airways will shrink, protecting our delicate lung tissues from the noxious ingredients in the smoke. They should return to normal when we begin to breathe fresh air. People with asthma have an exaggerated tightening response.

Different people with asthma respond to different “triggers.” Viral infections are the most common triggers in young children. Other triggers include smoke, animal dander, pollens, molds, house dust mites, fumes and fragrances, or cold air.

When we exercise, we breathe rapidly and are unable to bring air temperature all the way up to 98.6 degrees — particularly if we breathe through the mouth. Thus, asthmatics who are sensitive to cold air will often wheeze with exercise. (Wheezing, the classic asthma symptom, is the noise made by air moving through these tight airways.) Because asthmatics respond differently to different triggers, their airways are tighter at some times than at others.

Hyper-responsive airways tighten in three ways in response to triggers. First and most immediately, smooth muscle surrounding the airways constricts, narrowing the caliber of the airways. Second, the airways are narrowed by inflammation and swelling of the airway lining. This leads to the third component of airway narrowing, which is the accumulation of mucus and other fluids, which can plug the airways.

The inflammation is the most important part of the disease. It perpetuates the cycle of airway narrowing. It also is the slowest to respond to treatment.

Who gets asthma?

The risk of getting asthma depends both on genetics and on the environment.

Asthma tends to run in families (along with eczema and hay fever).

It is more common in premature infants and in those who have had RSV bronchiolitis. Those who are obese are at much higher risk.

Asthma is an over-exuberant response to substances in the environment. Both too much and too little immune response is unhealthy. Experiences in early childhood can teach the body to set the level of immune protection ‘just right.’ This may be a reason why children who are raised on a farm have a significantly reduced risk of asthma, eczema, and hay fever. Along the same lines, a recent study found that children whose parents “cleaned” their pacifiers by sucking on the pacifier were less likely to have allergies, eczema, and asthma than children whose parents used other pacifier cleaning techniques (Pediatrics 2013; 131; e1829).

What are the symptoms of asthma?

Although wheezing (a tight noise when breathing out) is the classic symptom of asthma, many children’s major symptom is a cough. The cough is nonproductive and often sounds tight. It tends to get worse at night, with exercise, or after being exposed to a trigger (e.g. cigarette smoke, animal dander, or house dust). Children with asthma often have a prominent cough when they catch a cold.

Some children with asthma have wheezing with no cough; some have cough with no audible wheezing; and some have both.

As the airways narrow, breathing becomes faster. The child might have to work hard to breathe, as evidenced by grunting, flaring of the nostrils, or pulling in of the muscles between the ribs. The shortness of breath may exhaust the child, who becomes slow moving and talks only with difficulty.

If a child with asthma has difficulty speaking or sleeping because of wheezing, cough, or shortness of breath, it is important to seek medical care immediately.

Is asthma contagious?

No

How long does asthma last?

Many children with asthma will outgrow it. The older children are when they start wheezing, the more likely they are to wheeze as adults. According to a study published in the January 2002 issue of the American Journal of Respiratory and Critical Care Medicine, wheezing in children before their second birthdays does not appear to make them any more likely than others to have asthma as adults – even among children who are at high risk for asthma and allergies.

In this study, children with a strong family history of asthma and/or hay fever were followed from birth to age 22. Most children who wheezed as toddlers outgrew it before age 11, but among those who wheezed before age 2, 38 percent went on to eventually develop asthma. However, the same percentage of those who did not wheeze as infants, toddlers, or preschoolers also went on to develop asthma. Early wheezing does not seem to make a difference.

How is asthma diagnosed?

Asthma is sometimes diagnosed based on the history and physical exam. Recurrent episodes of coughing or wheezing are suggestive, especially if they follow exposure to asthma triggers and respond to asthma medications. Pulmonary function testing can confirm the diagnosis, if necessary.

How is asthma treated?

We know what to do, but we are not doing it! Asthma is a chronic inflammatory disease of the lungs. Inflammation can cause ongoing damage.
Albuterol helps children breath better for the moment, but does nothing to treat the inflammation.

The guidelines for treatment are clear: Kids with asthma who have symptoms more than twice a week or nighttime wheezing more than twice a month benefit greatly from using a preventive, anti-inflammatory medicine rather than using albuterol alone.

Certainly, someone who uses albuterol daily should be on a preventive medicine instead or in addition to the albuterol. Preventive and anti-inflammatory medicines are greatly underused.

If your child has asthma, ask that the National Asthma Education and Prevention Program (NAEPP) guidelines be followed. Preventing inflammation prevents damage to the lungs and can greatly improve the long-term outcome.

How can asthma be prevented?

Breastfeeding seems to decrease the rate of wheezing in young children, but may or may not prevent eventual asthma (Eur Respir J. 2012 Jan;39(1):81-9).

For older children, following a Mediterranean diet, or at least eating fruits and vegetables daily appears to prevent developing asthma, and to decrease asthma attacks in those who have asthma.

Many people underestimate the impact of nasal allergies, or allergic rhinitis. While only about 10 to 40 percent of those with allergies go on to develop asthma (as compared to 1 percent in the general population), over 80 percent of people with asthma develop allergies first or at the same time. These allergies may be seasonal (pollen allergies) or year-round (dust allergies). This has led to the World Health Organization (WHO) Initiative on Allergic Rhinitis and its Impact on Asthma (ARIA) (http://www.whiar.org/docs/ARIA-Report-2008.pdf). They are trying to get the word out that properly treating allergies from the very beginning can be very effective at preventing asthma. Don’t settle for just treating the symptoms!

For those children who already have asthma — it may not be too late. Properly treating the nasal allergies might still have a big impact on the course of their asthma.

Again, if your child has asthma, ask that the National Asthma Education and Prevention Program (NAEPP) guidelines be followed, including the implementation of an “Asthma Action Plan” to help control the disease between attacks. Preventing inflammation may prevent future asthma for your child.

Related A-to-Z Information:

Allergies (Allergic Rhinitis), Bronchiolitis, Common Cold, Cough, Cystic Fibrosis, Eczema, Gastroesophageal Reflux, Obesity, Peanut Allergy, Pertussis (Whooping cough), Pneumonia, RSV (Respiratory Syncytial Virus), Wheezing

Dr. Greene’s Answer:

Asthma is one of the most common disorders affecting children. As many as 10% of children have some degree of asthma, and the number has been rising steadily since about 1980. Thankfully, advances in the diagnosis and treatment of asthma have dramatically improved life for these children. Today most children with properly managed asthma can lead a life unhindered by their disease. It shouldn’t hold them back from even the highest levels of athletic competition, as recent Olympic Gold Medals have shown.

Having said that, the death rate from asthma increased 46% in the last decade in spite of these treatment advances. A major cause of this increase in mortality is improper use of inhalers. Often children are handed several inhalers and never really understand the different functions and uses of each one.

Asthma is a chronic lung disease characterized by tight airways — a result of airway hyper-responsiveness. Our airways are designed to be responsive to harmful substances in the air. If we walk through clouds of smoke, our airways will shrink, protecting our delicate lung tissues from the noxious ingredients in the smoke. They should return to normal when we begin to breathe fresh air. People with asthma have an exaggerated tightening response.

Different people with asthma respond to different “triggers,” such as smoke, allergens, air pollution, irritating fumes, viral infections, or cold air. When we exercise, we breathe rapidly and are unable to bring air temperature all the way up to 98.6 degrees — particularly if we breathe through the mouth. Thus asthmatics who are sensitive to cold air will often wheeze with exercise. (Wheezing, the classic asthma symptom, is the noise made by air moving through these tight airways.) Because asthmatics respond differently to different triggers, their airways are tighter at some times than at others. Reducing exposure to triggers can be a powerful way to improve asthma and reduce the need for medications.

Hyper-responsive airways tighten in three ways in response to triggers. First and most immediately, smooth muscle surrounding the airways constricts, narrowing the caliber of the airways. Second, the airways are narrowed by inflammation and swelling of the airway lining. This leads to the third component of airway narrowing, which is the accumulation of mucus and other fluids, which can plug the airways.

The goal of asthma therapy is for children to maintain their normal activity levels while free from symptoms such as wheezing, coughing, or breathlessness. The different inhalers that you mentioned, albuterol (Proventil or Ventolin) and cromolyn (Intal) belong to two different classes of asthma medications which work entirely differently. Albuterol (Ventolin or Proventil) works almost instantly to relax the smooth muscles surrounding the airways. It quickly opens the airways and reduces symptoms.

Unfortunately, its success is its greatest danger. All too often, children with wheezing will use a Proventil inhaler alone to treat the symptoms. Each time they use a puff of the inhaler they feel better, but all the while the airway lining is swelling and filling with mucus and fluid. Finally the symptoms come back, but the Proventil inhaler is no longer effective since the airway muscles are already as relaxed as they can get. At that point it is too late to relieve the swelling and inflammation and the child suffocates.

Cromolyn (Intal) is an anti-inflammatory agent which works slowly to prevent inflammation and swelling. It helps blunt the airways’ hyper-responsiveness. It is not useful as an emergency drug.

More recently, the use of medications called “inhaled corticosteroids” (i.e. Beclovent, Flovent) has been emphasized. Like Cromolyn, these medications work by preventing inflammation and decreasing the sensitivity of the lungs to inciting agents.

The National Asthma Education and Prevention Program (NAEPP) and National Heart, Lung, and Blood Institute (NHLBI) convened an expert panel in 2007 to propose guidelines for the stepwise management of asthma. Asthma severity is divided into four categories based on frequency of symptoms including wheezing, cough, shortness of breath, or chest tightness. For older children, pulmonary (lung) function tests can also be used to differentiate the categories.

1. Severe persistent- continual symptoms including frequent night symptoms. Extremely limited activity; requiring oral steroids >2 times a year.
2. Moderate persistent- symptoms daily and night symptoms greater than 1 night a week. Some limitation in activity; requiring oral steroids >2 times a year.
3. Mild persistent- symptoms greater than 2 days a week and night symptoms greater than 2 nights a month. Minor limitation in activity; requiring oral steroids >2 times a year.
4. Mild intermittent- symptoms less than or equal to 2 times a week with night symptoms less than or equal to 2 times a month. No limitation in activity; requiring oral steroids 0-1 time a year.

The classification criteria are slightly different in children under 4 years of age. The summary of guidelines can be found at www.nhlbi.nih.gov/guidelines/asthma.

Those who fall into the mild intermittent category do not require any preventative treatments. Those in the mild persistent, moderate persistent, and severe persistent categories will benefit from preventative therapy such as cromolyn, steroids, combination inhaled medications, or montelukast (Singulair).

Regardless of the category of asthma, children should be given albuterol to treat immediate asthma symptoms. There is no virtue to holding off treatment with albuterol if your child has symptoms. It is better to go ahead and use the Proventil (albuterol). If the use becomes frequent, an additional anti-inflammatory medicine is needed. For some children, a home peak-flow meter is used to assess the amount of airway obstruction and the amount and type of medications needed. I would recommend this for anyone who is old enough to use a peak flow meter.

Your son’s physician can help you devise an “Asthma Action Plan” which tells you what medications to use based on your son’s symptoms and/or peak flow meter readings. One good template was created by the Community Clinic Association of Los Angeles County and can be found at www.asthmala.com/docs/asthmatoolkit/2b%20My%20Asthma%20Action%20Plan%20Eng.pdf.

I applaud you for recognizing that your son’s inhalers serve different functions. All too many families are left with the mistaken understanding that the inhalers are interchangeable. The more you and your son understand about asthma and its treatment, the less it will impact his life.