Managing pediatric asthma

Posted by: admin on: January 13, 2012

Asthma, a chronic lung disease that affects more than seven million children under the age of 18, occurs when lung inflammation causes the airways to narrow, triggering symptoms including wheezing, breathlessness, tightening in the chest and coughing. A variety of environmental irritants and allergens — cigarette smoke, pets, dust mites, mold, air pollution and respiratory infections — may cause symptoms.


  • Asthma symptoms often affect a child’s quality of life, disrupting sleep, resulting in missed school days and affecting ability to participate in sports and other activities. Occasionally, asthma results in hospitalizations and may even be fatal.
  • Appropriate asthma diagnosis and treatment hinges on a clinician’s ability to recognize the disorder’s signs and symptoms.
  • Clinicians should keep in mind pediatric symptoms may differ from those observed in adults, Norman Edelman, MD, chief medical officer for the American Lung Association told Clinical Advisor.
  • Children may not experience the standard wheezing typically seen in adults, but instead may experience coughing or disrupted sleep, Edelman said.
  • Sometimes kids experience tightening in the chest, but won’t be able to describe the sensation, they might just appear anxious.
  • Another sign is inability to keep up with peers in games that involve exercise.
  • But confirming a pediatric asthma diagnosis can be challenging, as some young children develop wheezy bronchitis in response to infection, which typically resolves as the child’s lungs increase in size.
  • Symptom and family history are important during diagnosis, as well as spirometry to assess pulmonary function.

Diagnosis & treatment

  • Asthma is typically under-diagnosed, as many clinicians may hesitate to commit to a diagnosis, Derek Johnson, MD, a pediatric allergist in Fairfax, Va., said.
  • But accurately recognizing asthma is critical to providing proper treatment, which should be comprehensive and involve many facets, including environmental management, treatment and planning.
  • The first step after a patient is diagnosed is identifying asthma triggers.
  • Asthma is often triggered by environmental causes, so clinicians should determine what a child is reacting to in order to prevent attacks.
  • Consider referring patients to an allergist at least once for testing and evaluation, Johnson recommended.
  • Clinicians should also encourage parents to advocate for necessary changes at school, such as removing potential asthma triggers like pet hamsters from classrooms, Edelman said.
  • Clinicians should treat other conditions that may worsen asthma, such as chronic sinusitis or acid reflux.

Overcoming medication hesitation

  • Pediatricians sometimes hesitate to prescribe inhaled corticosteroids and combination treatment for patients with asthma even when a patient’s asthma is poorly controlled, due to concerns about adverse effects.
  • While clinicians should always weigh risks of medication against the benefits, avoiding medication may deny patients the opportunity to get their asthma under control,” Johnson said.
  • Additionally, clinicians should take time to explain to patients and parents how the medications work to alleviate potential concerns.
  • Inhaled corticosteroids are topical medications that treat the surface of the lung, but are not absorbed into the child’s system.
  • If an inhaled corticosteroid is swallowed or absorbed, it is quickly excreted and does not act on any other organs or body systems, he explained.

 Re-evaluate patients regularly

  • Whatever treatment clinicians choose, they should be sure to carefully and regularly monitor patients with asthma, as it is common to overestimate symptom control.
  • This often happens because patients do not tell their health-care providers about problems they are having, or because clinicians are unclear about how symptoms appear in patients with properly controlled asthma.
  • Most children with well-controlled asthma should be able to play sports, maybe not running, but most other sports, Edelman said.
  • The first rule of thumb, is to avoid asking general questions, like “How’s your asthma?” Johnson advised. Many patients will respond to this question with the answer they believe the clinician wants to hear.
  • Instead of asking how’s your asthma, ask specific questions. In general, children with well-controlled asthma are not kept awake at night coughing, do not miss school regularly and can exercise normally.
  • If a patient confirms the following events, their asthma is likely not under control and it may be time to re-evaluate treatment:
    1. Coughing or wheezing two days per week or two nights per month
    2. Refilling rescue medication more than two times per year
    3. Emergency treatment or oral corticosteroid use for asthma exacerbations at least two times a year
    4. Another valuable tool is an Asthma Control Test, which is a written form that patients can fill out in the waiting room that enables clinicians to rapidly assess the patient’s asthma, Johnson said.

Debunk asthma myths

  • In addition to treatment and management, clinicians should be prepared to debunk common and persistent asthma myths.
  • The first myth is that asthma is a psychological condition, this isn’t true, Edelman said, children may get very anxious as they get short of breath and this anxiety may occur before the child starts wheezing. But typically this is caused by the feeling of an attack coming on, not the other way around.
  • Another myth is that influenza vaccine can cause asthma exacerbations.
  • It is particularly important to educate parents about the importance of vaccinating children against influenza, particularly those with asthma, because respiratory viruses can cause asthma complications.
  • The third and final myth is that many people still believe that they need to live with a certain number of asthma symptoms.
  • It’s important to understand that, unlike 20 years ago, asthma is something that can be treated successfully today. Children should not be struggling with asthma symptoms when treatments exist to prevent it,” Johnson said.

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