Asthma in children needs to be carefully monitored. Trish Weller of the National Asthma and Respiratory Training Centre looks at symptoms and treatments

If you’ve ever watched someone coping with a severe attack of asthma, you’ll know how distressing it can be. They fight for breath, wheeze and cough. If you could see inside the lungs you’d notice the muscles around the breathing tubes were tight, making the airways narrow and constricted. If the tightness is not treated, the inside of the airways become sore and swollen and clogged with phlegm. This can lead to permanent damage in the airways and loss of some lung function, if it is not treated.

We don’t know why, but asthma has increased dramatically over the last ten years and affects about 1 in 7 children. It is certainly more common if you suffer from eczema, hay fever or rhinitis and where there is a family history. The most common trigger of asthma in children is a viral infection such as the common cold.

Other asthma triggers are:

• Temperature change
• Exertion
• Excitement especially laughter
• Stress
• Pollen – both grass and tree pollens
• Moulds and spores
• Animal allergy especially to cats or dogs
• Dust
• Tobacco smoke
• Air pollution
• Drugs such as beta blockers and aspirin type pain relievers

Some children under the age of one get wheezy when they have a cold. It is sometimes called viral wheezing, baby asthma, infantile asthma or even wheezy bronchitis, and is different to the asthma that occurs later on in childhood.

Asthma is more likely if the child has symptoms that persist, even when the cold is better and especially if they have eczema as well. It is difficult to diagnose asthma at this age, as there are no specific tests to confirm it.

Wheezing in infancy is difficult to treat because it does not always respond to asthma drugs. However, it is worth trying asthma medicines to see if they do work. These asthma drugs are normally given via inhalers because smaller doses can be used, reducing the risk of any side effects. Using an inhaler, they are also delivered straight to the lungs where they need to work. Giving asthma medicines to very young children is difficult, but there are special inhaler devices for infants and toddlers. Your asthma nurse or doctor will be able to show you how to use them.

Diagnosing asthma

Once a child is about 3 years old, confirming a diagnosis of asthma gets easier. Some children with asthma have restless nights interrupted with fits of coughing, even when they haven’t got a chest infection or cold – this is a symptom to watch for. It is helpful to note the things that you know aggravate your child’s asthma, as well as noting if there is an improvement when asthma drugs are used. After the age of 3, the medication is more effective because the child’s breathing tubes are bigger and respond better to treatment.

When your child is able to blow air consistently (normally around the age of 6) your doctor or asthma nurse will be able to measure the airflow in their breathing tubes, using a peak flow meter. This is a tube device with a gauge on the side. Taking a deep breath and then forcing the air out through the tube will give a reading, that can be compared with pre-defined measurements, related to age and sex. It is a useful aid to diagnosing asthma.

Treating Asthma

The drugs used to treat Asthma can be divided into several groups:

Reliever medications (such as salbutamol or terbutaline) are usually in blue coloured inhalers, which helps to identify them easily. They work by relaxing the muscular coating of the breathing tubes, allowing the air to get in and out more easily. The tightness in the airways can be painful – it’s rather like getting a cramp in a calf, which explains, very simply, why chest tightness due to asthma can be painful.

These short acting relievers start to work within a few minutes and the effects last for up to 4 hours. They are used in bigger doses if there is an asthma attack.

Long acting relievers are given twice a day by an inhaler. They are added when regular preventer treatment fails to control the asthma.

Preventers (such as beclometasone, terbutaline or fluticasone) are packaged in inhalers, which are coloured in shades of brown, or orange (fluticasone). They are steroid medicines which work on the soreness and swelling (inflammation) in the breathing tubes, reducing mucus. They stop the twitchiness (irritability) in the airways, but must be taken on a regular basis to control the asthma and prevent it getting worse.

Leukotriene receptor antagonists (LTRA). This is a tablet form of asthma medication which has been available in the UK for over a year. There are two medicines – montelukast and zafirlukast. They are only used as additional treatment to reliever and preventer medication at the moment, and only for children from 6 (montelukast) or 12 years (zafirlukast) of age. LTRAs work on only one chain of the very complex inflammatory processes within the lungs.

One of the main concerns for parents is whether asthma medicines are safe? The steroids used to treat asthma are very different to the steroids used by some body builders and athletes to build up muscle strength. Those are sex hormones or anabolic steroids and can be harmful, whereas normal doses of asthma steroid medicines are safe with few side effects.

Steroid tablets are only given if a serious asthma attack occurs, or if the asthma is not responding to the usual treatment. They are given for a few days and are very effective in treating asthma that is out of control.

Possible side effects will only occur if long term oral steroids are used regularly. However local side effects are more common and these include:

• Oral thrush (a fungal infection) if high doses of inhaled steroid treatment are used. It can be treated easily.
• Hoarse voice. Using a spacer device to deliver the steroid medication and then rinsing the mouth out after use, usually resolves these local side effects.

Asthma attacks can develop quickly. Signs that the asthma is worsening are:

• Increased cough, wheeze, breathlessness – often worse at night
• Wakening at night with coughing, wheezing or breathing difficulties
• Reliever inhaler (salbutamol or terbutaline) less effective and not lasting as long
• More salbutamol or terbutaline required than usual
• Increased symptoms when exercising

Occasionally a nebuliser is used in the surgery or at hospital to treat acute asthma. This is an electrical machine which can deliver high doses of asthma medication (salbutamol or terbutaline), to relax the tight breathing tubes. If a nebuliser is used in an asthma attack, the amount of medicine delivered is the equivalent of 25-50 puffs salbutamol or terbutaline given via an inhaler.

Does asthma go away?

It’s difficult to predict but this is a likely pattern to asthma in childhood:

• Early viral wheezing with no eczema or family history of asthma, is likely to disappear by the time your child gets to school-age
• Viral wheezing, with eczema, a family history of asthma but the child is well in-between the virus infection – this is likely to improve by around 7-10 years

While asthma may disappear, it is important to remember that it can sometimes return after many years of being symptom free with no treatment.

Smoking
Smoke irritates the breathing tubes. In children who already have sensitive breathing tubes, smoke will make things worse. Another reason to give up for good.

Restrictions on lifestyle
Naturally you’re concerned if your child has asthma, but it is important not to restrict their activities once the asthma is under control. A child with asthma is like any other child; the only difference is that they need to use inhaler medicines.

For more information see the National Asthma Campaign website.