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Family Health Magazine
CHILDHOOD

Asthma and Your Child
Steps to keep asthma under control

Asthma is a chronic condition affecting children as well as adults. It cannot be cured, only controlled. To understand what a severe asthma attack feels like, breathe in very deeply and hold for a second. Now, try to take another breath. This unpleasant sensation occurs when a trigger causes airways to the lungs narrow. Symptoms of asthma are wheezing, coughing, chest tightness, short​ness of breath and mucous production.

Steps to keep asthma under control

Asthma is a chronic condition affecting children as well as adults. It cannot be cured, only controlled. To understand what a severe asthma attack feels like, breathe in very deeply and hold for a second. Now, try to take another breath. This unpleasant sensation occurs when a trigger causes airways to the lungs narrow. Symptoms of asthma are wheezing, coughing, chest tightness, short​ness of breath and mucous production.

Although struggling for air can be very frightening, asthma is not caused by anxiety. Never brush it off as ‘just nerves.’ Those who do not understand the condition may think someone with asthma is just puffing to get attention or avoid activity. However, asthma is very real and must be taken seriously.

Asthma is often inherited, affecting both adults and children. If both parents have asthma, the child’s risk of developing it is even higher. Mothers who smoke are more likely to have children with asthma. Although a diagnosis is rarely made before age one, roughly 10 per cent of children have asthma.

In Canada and across the world, more and more people are being diagnosed with asthma. Each decade, the number rises by 50 percent. Although we do not understand exactly why, increasing urban dwelling may be related. Modern medical treatment and medication have allowed the death rate from asthma in Canada to slowly drop since 1990. Still, around 20 children and 500 adults die of asthma each year. Whether you care for a child with asthma or have it yourself, the following information on managing the condition can help.

How asthma affects the lungs

People with asthma have airways that are very sensitive to one or more triggers. Exposure makes airways begin to spasm, becoming red, swollen and narrow. Mucous is produced and gathers in the airways.

Next, small muscles around the airways go into spasm. As they become active, they shorten and tighten around the tubes in the lung. This narrows the airways and reduces airflow, much like wrapping your hand around a soft garden hose and squeezing to reduce the flow of water. During an asthma attack, both inflammation and resulting airway spasm cut the air flow. This causes shortness of breath, coughing, and often wheezing through the narrowed airway tubes.

Diagnosing asthma in a child

The pulmonary (lung) function tests ordinarily used to diagnose asthma are usually impractical before six years of age. Instead, doctors use a good history, physical examination and follow-up of the child. Lab tests are usually done only to rule out other conditions that might cause similar symptoms. Response to bronchodilator medication can help confirm the diagnosis of asthma.

For some children, unrestricted play is just a dream. Others with asthma are able to control it so effectively that they are able to participate in world class sporting competitions.

Caring for a child experiencing an asthma attack

• Have the child stop any physical activity.
  
• Reassure the child that everything will be okay and that you will help.
  
• Have the child use the (blue) puffer [usually salbutamol (Ventolin™ or bricanyl)].
  
• If the attack does not subside after two puffs and it is not your child, call the parents.
  
• If the child is struggling for air and not settling down after using the puffer, call an ambulance or go to the nearest hospital emergency department. Use the salbutamol or bricanyl inhaler as often as needed until help arrives.
  
• Do not send the child home unattended and do not leave the child alone.

Preventing an attack

As with most illnesses, the best treatment is prevention. Think about what irritates your child’s airways and triggers an attack. Then, reduce exposure to triggers (see sidebar).

• Keep your home as allergen-proof as possible. Do not allow smoking in the house.
  
• Most children spend at least a third of their lives sleeping, so the bedroom is particularly important. Vacuum and dust it often. Remove large carpets and rugs, and replace them with easily cleaned surfaces such as linoleum.
  
• If your child has a house dust mite allergy, use zippered mattress and pillow covers. Make sure bedding, rugs and curtains are all made of washable materials, such as cotton, nylon and polyfil. Every week, wash bedding in hot water and dry it in a hot dryer. Avoid having wool, animal skins and plants in the bedroom.
  
• Many children are allergic to animal dander. If your child is truly allergic to a cat or dog, the only remedy is removing the pet from the home.
  
• Be aware of materials used in your child’s stuffed animals. Kapok and straw fillings may cause trouble.
  
• Special air-conditioner filters may help at times, as spores from some moulds and particles of house dust are so small they slip through conventional filters. Controlling moulds is more difficult than controlling pollens, since some moulds grow indoors.

Exercise-induced asthma

Some children only have symptoms of asthma when they exercise. They seem to experience more problems when exercising in cold dry air. Coughing after exercising may be the only symptom. Children may not mention breathing difficulties, but avoid physical activity because they cannot keep up with their friends. Stop-and-go sports such as baseball and volleyball may cause fewer problems than hockey and soccer. Water sports in an indoor pool and exercise in an indoor gym cause the least trouble because the air is warm and moist.

To prevent symptoms of exercise-induced asthma, make sure your child:

• stays in good physical condition.
  
• does warm-up exercises before starting any vigorous sport, and cools down slowly for at least ten minutes after exercising - don’t stop suddenly.
  
• wears a face mask when exercising in cold weather, to help warm air before it enters the lungs.
  
• breathes through the nose as much as possible, to warm and moisten air before it reaches the lungs.
  
• talk to your doctor about using rescue medication (Salbutamol) 15 to 20 minutes before exercising.
  
• avoid having your child exercise outdoors on days when pollution or pollen counts are high–exercise indoors instead.

All about asthma medications

Asthma medications fall into two major groups: relievers (rescue) medications (bronchodilators) and preventor medications (anti-inflammatories). If you have any questions about your child’s asthma medication, or concerns about how your child feels while taking it, talk to your doctor or pharmacist.

Reliever (rescue) medications

Rescue medications (fast-acting bronchodilators) quickly relieve symptoms (see table below). They bring rapid relief by relaxing bronchial muscles. Only use a brochodilator when needed:

• for quick relief during an asthma attack (it should bring relief within five to 10 minutes)
  
• for relief of symptoms such as cough, chest tightness, wheezing and shortness of breath
  
• 15 minutes before exercising, if prescribed by your doctor.

If your child is using rescue medication more than three times a week, other than once a day with exercise, the airways are likely swollen and need treatment. Follow your action plan or tell your doctor. You may need to increase asthma prevention medication or add another medication until the asthma is under control.

Trembling, nervousness, flushing, and increased heart rate are all common side effects of rescue medication.

Preventer medications

Inhaled corticosteroids

If your child has asthma, your doctor is likely to prescribe an inhaled corticosteroid to keep it under control. These medications reduce swelling, redness and mucous in the airways. Inhaled corticosteroids are taken daily even if there are no symptoms to prevent swelling and mucous in the airways.

Inhaled corticosteroids do not have the same side effects as the performance enhancing anabolic steroids some athletes take illegally. Nevertheless, their use requires regular check-up as recommended by a family doctor. Oral yeast infections, hoarseness and sore throat are the most frequent problems. Remedy this by rinsing the mouth out with water after each dose.

Other asthma medications

Corticosteroid pills

For asthma attacks corticosteroids are sometimes taken systemically (by mouth or injection). Doctors often prescribe these pills for a short time to get swelling and mucous under control quickly. For prescriptions lasting three to seven days, side effects may include increased appetite, mood changes, water retention, and, in children, hyperactivity. When used for a few days, side effects are expected to be minimal compared to the benefits.

Long–acting bronchodilators

Long-acting bronchodilators help keep airways open and muscles relaxed, preventing asthma attacks for up to 12 hours. They are always prescribed with inhaled corticosteroids and should not be taken alone. Long acting bronchodilators may be used in children four years and older. Combination products containing inhaled corticosteroid and a long acting bronchodilator are available for children who need to be on both medications. Combinations make it easier to take medication on a regular basis.

Leukotriene receptor antagonists

Leukotriene receptor antagonists help reduce inflammation or swelling in the airways and keep airway muscles relaxed. Montelukast (Singulair) comes in pill form and is taken once daily. It can be used in children as young as two.

Zafirlukast (Accolate) is an oral tablet taken twice daily and used by children over 12. Leukotriene receptor antagonists are usually added to existing inhaled corticosteroid therapy when optimal asthma control has not been reached. They can be used in patients who cannot or will not take inhaled corticosteroids.

Theophylline

Theophylline is a bronchodilator in pill form. Today it is seldom used. It works directly on the airway muscle to relax it, making it easier to breathe. Theophylline has many side effects and needs to be closely monitored.

Antibody Neutralizers (Xolair)

Antibody neutralizers are used when moderate to severe asthma is triggered by allergies and inhaled steroids do not help. Xolair works by decreasing the amount of the antibody (the substance in the body that makes airways swell with an allergic reaction).

Asthma medication devices and how to use them

Metered dose inhalers (puffers)

Asthma medications are often given through a metered dose inhaler (MDI). This system delivers a fine medication mist directly to the airway. A metered-dose inhaler can be used with an open or closed mouth technique. The preferred method for children is the closed–mouth version.

Helping your child to use a metered-dose inhaler

• Remove the cap from the inhaler.
  
• Shake well.
  
• Have your child breathe normally and slowly through the mouth, then breathe out.
  
• Seal lips around mouthpiece.
  
• As your child begins to breathe in, push down on the cartridge once. Your child should continue to breathe in slowly and deeply through the mouth until finished taking in that breath.
  
• Tell your child to hold the breath for five to ten seconds, and then breathe out slowly.
  
• Replace the cap.
  
• If an additional inhalation is prescribed, wait 60 seconds before giving another dose.

Caring for a metered-dose inhaler

Once a week, remove the medication canister from the plastic casing and wash the casing in warm, soapy water. When the casing is dry, replace the medication canister and put the cap on the mouthpiece. Ensure the hole is clear.

Spacers

A spacer device is an add-on that attaches to the mouthpiece of a metered-dose inhaler. Acting as a holding chamber for aerosol medication, a spacer makes it easier to take the medication.

It reduces the amount of medication deposited in the throat and increases the amount that reaches the lungs. A spacer is recommended for use with all metered dose inhalers.

Spacers are available with either a mouthpiece or a face mask. Spacers with face masks are used for young children. As soon as your child is able to use a spacer with a mouthpiece, make the switch. With face masks, as much as two-thirds of the drug may not be deposited in the lungs.

Turbuhaler

The turbuhaler is a multidose powder inhaler. Since the particle size and volume of powder is so small, your child may not taste or feel anything while inhaling it. Children three years and older can be taught to use a turbuhaler.

Helping your child to use a turbuhaler

• Unscrew and remove the cap.
  
• Hold the turbuhaler in an upright position and turn the coloured base as far as possible in one direction, then turn back until a click is heard.
  
• Have your child breathe out away from the turbuhaler.
  
• Place the mouthpiece between the teeth and ask your child to close the lips around it.
  
• Tell your child to breathe in quickly and deeply through the mouth. Remove turbuhaler from mouth. Your child should hold the breath for ten seconds, then breathe out.
  
• Repeat the process for the prescribed number of inhalations.

Caring for the turbuhaler

Clean mouthpiece using a dry tissue or cloth, gently wiping away any particles which have collected inside the mouthpiece. Never wash the turbuhaler. Check the dose window counter - once a red mark appears in the window, there are approximately 20 doses left. Some turbuhalers use numbers to indicate doses left. Note that the sound heard when shaking a Turbuhaler is not the medication but an agent that keeps the medication dry. Hearing the sound does not mean that there is still medication in the container.

Diskus

A diskus is a multi-dose (60) dry powder inhaler. Children as young as age three may be able to use a diskus.

Helping your child to use a diskus

• To open, hold the outer case in one hand and put the thumb of the other hand on the thumb grip.
  
• Push the thumb grip as far as it will go until a click is heard.
  
• Slide the lever away as far as it will go until you hear another click.
  
• Have your child exhale completely.
  
• Put the mouthpiece of the diskus to your child’s lips. Ask your child to inhale quickly and deeply through the inhaler.
  
• Remove the inhaler.
  
• Tell your child to hold the breath for about 10 seconds, and then to breathe out slowly.
  
• Close the diskus by sliding the thumb grip as far as it will go until a click is heard. The lever is automatically reset for the next dose.

Caring for the diskus inhaler

Store the device in a dry place, and close it when not in use. Never wash a diskus inhaler. Use a dry tissue or cloth to clean the mouth piece.

Nebulizers

Nebulizers are usually reserved for hospital in-patients or out-patients who cannot use other inhalation devices. The amount of drug breathed in is the same as for metered-dose inhalers with spacers or breath-activated powdered inhalers. The same degree of bronchodilation occurs as with a properly used inhaler. As a result, it makes more sense for most people with asthma to use an inhaler.

Written Action Plan

An asthma action plan is a written set of instructions developed with your doctor or asthma educator. It explains what medication your child should take regularly when feeling well. It also discusses how to increase the medication if breathing problems occur. An asthma action plan can be used with or without a peak flow meter to help manage asthma.

ASTHMA ACTION PLAN FOR: ______________________________

Using a Peak Flow Meter

A peak flow meter measures how fast air is blown out of the lungs. It can help you and your doctor determine peak lung capacity to get a sense of the pattern of your child’s asthma. Take readings one or two times a day, as recommended by your doctor. Record the reading in a diary and take it with you each time you visit the doctor. The reading can be used to find your child’s personal best. A peak flow meter is used in conjunction with a written action plan.

To use the peak flow meter properly

• Set the scale to zero.
  
• Always take the reading in the same position, preferably standing up.
  If your child is unable to stand, find another comfortable position.
  
• Breathe in deeply.
  
• Place the meter in mouth and close lips around the mouthpiece.
  
• Do not cough or let the tongue block the mouth of the meter.
  
• Blow out as hard and as fast as possible.
  
• Check the value on the scale and write it down.
  
• Take two more readings.
  
• Record the highest of the three numbers in the peak flow diary.
  
• Be sure to check in the early morning when asthma tends to be worse.

Every week in Canada, people die from asthma. Many are children. However, asthma can be controlled and treatment is better than ever. Take asthma seriously, learn about it and work closely with your doctor to keep the illness under control. If you need more information, contact your family doctor.