September 18, 2003
For any parent, watching your child struggle to breath during an asthma attack is a terrifying experience. Asthma in children under age five may be particularly frightening because they are not always able to communicate about what is occurring. Asthma is marked by inflammation of the airway and narrowing of breathing structures, primarily set off by a variety of triggers. Diagnosing asthma in very young children is also a challenge because their symptoms may be easily confused with those of a cold and because it's not always possible to perform diagnostic tests.
Properly treating very young children with asthma is important, however, in order to prevent asthma attacks and allow them to lead active lives. According to Dr. James Kemp, of the University of California, San Diego, asthma is the number one illness that affects preschool children. Below, Dr. Kemp discusses the challenges of diagnosing and treating young children with asthma.
When does asthma usually occur?
If you look at studies, they can show us that up to 80 percent of asthma appears before the child goes to school, meaning before five years of age.
So physicians and parents have a very unique opportunity to recognize asthma early, and hopefully treat it earlier. We believe that recognizing asthma early and starting good preventative therapies earlier may prevent the lung from losing some of its function.
Are asthma symptoms in the very young different than asthma symptoms in older kids?
While some asthma symptoms in the very young may be the same as in an older child, some may be different. Many children who have mild asthma have just chronic coughing and wheezing. Wheezing is basically a noise that is often heard with a stethoscope, but not always. And indeed, one of the biggest dilemmas that we have in diagnosing asthma early is recognizing what type of sound is being produced by the airway obstruction, which is what asthma is.
How hard is it for parents to recognize asthma symptoms?
Parents may have a very difficult time recognizing that the child has asthma and not just an infection such as a common cold. One of the reasons is that children often have their first asthma attack during a cold and it's the cold virus that stimulates their asthma.
The other reason is that many of the symptoms of asthma are similar to symptoms of colds or bronchitis, such as coughing and difficulty breathing. It's always important to remember that many children who have asthma may also have upper airway allergies, or what we call allergic rhinitis.
Parents are better about making the assumption that it's asthma if they've had another child with asthma.
What's the cause of asthma in little kids?
There are varied causes of asthma in little kids. We do find, though, that children with asthma have allergies more than any other underlying condition, and that's why such conditions as eczema or skin allergies or allergic rhinitis might be also be present in that individual.
Children can also inherit the tendency to have asthma from their parents. This genetic tendency to have asthma causes children to make IgE, which is an antibody that is directed towards allergy substances. It's directed, for example, against a cat or a dog or dust. When you're in or near these substances there's a reaction that then causes sneezing if you have nasal allergy, wheezing if you have asthma, itching if you have atopic dermatitis.
What are triggers for asthma in young children?
There are certain triggers for asthma that go beyond allergies, such as viral infections. With a respiratory tract infection, wheezing occurs, which may continue for long periods of time after that cold is over.
Environmental triggers can be a problem for children. The very young infant doesn't have much in the way of an environmental stimulus because they're not outdoors much, so they don't have grass exposure, pollen exposure from trees and weeds. Their exposure is indoors, so they're more likely to be allergic to indoor substances, like mold or dust mites, or an animal that's indoors.
Young children also might react to foods. So you have to look at the environment that the child is in to help sort of determine where you want to place your focus. And yet, many children may still at the very early parts of their life only have asthma during a viral infection.
Is it hard to diagnose asthma in very young kids?
Asthma can be very difficult to diagnose in a very young child, because they may have the sounds of asthma when you listen to their chest with a stethoscope, but may be having these problems just from a viral infection.
For example, there is a virus called respiratory syncytial virus that seems to make every infant wheeze. Now if that's the situation in this individual and they do not have the asthma genes or makeup, that'll be their only episode of wheezing. But in the child who has asthma genes, this virus infection may then stimulate the asthma to occur and to continue to occur thereafter from a variety of other stimuli. So it is sometimes very difficult to sort out with that first episode.
With the second episode, particularly if the child has a strong family history of allergy or asthma, or if they have that atopic dermatitis or allergic nasal symptoms, you're on more certain ground that this is an asthmatic child.
Are there any tests that doctors can perform on kids this age?
One of the best ways to be sure this individual has asthma is to do a breathing test, which we call a pulmonary function test. What we see in these tests is an obstruction of airflow. With a narrowed airway, you can't get the air through as fast or as completely, and that's what these tests measure. They can also measure an improvement in this obstruction after you've given an asthma medicine.
Now, the problem with that is it requires effort and cooperation. You have to take a deep breath in and blow out very forcefully and very completely, and anything less will give you a distorted value. We find it hard to do these types of tests in children much younger than five or six years of age. Obviously, some children, with work and cooperation, can do it earlier.
Since you can't do the test in very young children, you have to rely on the medical history, the stethoscope and your intuition. Although if you put a very young child on an asthma medicine and they get better, that's a good diagnostic tool.
What kind of treatments are available to very young children?
Well, treatment options today are sort of categorized into two general categories: reliever medications and controller medications. Reliever medications, which we generally call bronchodilators, relieve symptoms such as wheezing. They can be taken by mouth, by inhalation, and, in the hospital, by injection or intravenously. When children are older, they usually take these medicines by inhalation. The very young child, under five or six, probably takes a syrup or a tablet.
These medicines usually provide asthma relief within a half hour, sometimes less, sometimes a little longer. The effect may last as little as two hours or as long as four or more hours. It depends a little bit on the severity of the asthma attack and how well the patient is responding to the therapy.
The medicines that we, as specialists, deal more with are what we call the controller therapies, medicines that try to get at the underlying process, which is inflammation. So we use antiinflammatory medicines.
There are several different categories of those, but the most effective and the most important are the inhaled corticosteroids. Generally, we feel that if patients take these medicines regularly, the number and the severity of asthma attacks that they have will be diminished considerably.
Are controller medications available to infants?
Controller medications are available to infants. Since infant can't use an inhaler because they cannot cooperate in breathing as the medicine is flowing out, liquid medicine is put in a chamber. This chamber is connected to an oxygen or air source, and the medicine comes out as sort of a mist, continuously over 10 or so minutes. That type of therapy can be given to very young children, either as a mouthpiece where they can breathe in and out over a period of time, or as a facemask. This type of therapy, I think, has revolutionized the treatment of the very young child and infant.
There are some therapies to control asthma that can be taken, of course, by mouth, but a majority of the studies have shown us that those medicines are just not as effective.
How safe are the corticosteroids for young kids?
There has always been a concern about the safety of steroids, and part of that is because people misinterpret that word. But the steroids that we use to treat asthma and inflammatory processes are entirely different than those used by some athletes.
When you inhale a steroid, as we often recommend for the treatment of asthma, or use it as a spray into the nose, as we often do for allergic rhinitis, the majority of the effects are topical. These topical sprays don't get into the body, or if they get into the body, they are what we call metabolized or broken down very quickly and eliminated, so side effects are minimized.
In medicine, there's always exceptions, and sometimes there are what we call outliers, or people who are just very sensitive to a therapy. A good physician who knows how to use steroids in people with asthma can detect these outliers quite easily.
In young children, the best way to detect sensitivity is by measuring their growth, because if a young child is getting a body effect from the inhaled steroid, their growth may be slowed for a short period of time, and that's very easy to measure and follow.
What would you tell a parent who has learned their child has asthma?
Parents have a variety of responses to a diagnosis of asthma in a very young child. They may have another child who has asthma, or they may have it themselves, so they may not be so shocked. I don't think anyone likes to hear their child has a chronic illness, but they can accept it pretty well, particularly if you show them that there are good ways to treat this disorder that they may not have been available when they were younger, and that although asthma may be a cause of death, it can be well controlled if followed by a doctor who knows what they're doing.
Do children outgrow their asthma?
Many people have said that their child is going to outgrow asthma. I don't like that particular term, because I'm not so sure that it truly is due to growth, or if other things are going on. But if a child who has early-onset asthma is going to get better, it can happen during adolescence. We don't quite know why. It may be due to hormonal changes, or have something to do with growth. Obviously, a small airway is easier to obstruct than an adolescent's airway, or the cartilage that keeps that airway open might be more rigid and able to compensate a bit for the obstruction that has occurred in the younger child.
Sometimes we can get an idea of what is going to happen to a young child when we measure their breathing tests or their lung function tests, because if, for example, it's 70 percent normal when they're six years old, 80 percent when they're nine years old, and 90 percent normal when they're 12 years old, that's certainly a good trend.
But it doesn't always happen, and I never like to tell a family that we're going to wait and hold off our treatment until adolescence because your child might outgrow their problem. So much can be done earlier to prevent the attacks of asthma, the missing of school, the parent missing work, the emergency room visits and hospitalizations, that I'm more likely to want to focus on today and see what happens later.
© 2003 Healthology, Inc.