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Asthma in children

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Asthma affects the airways of the lungs (the bronchi) and causes them to become inflamed and swollen. The bronchi are small tubes that carry air in and out of the lungs.
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Overview

Introduction

In the UK, over 1.1m children have asthma. Asthma in children is more common among boys than girls. Children who develop asthma at a very young age are more likely to 'grow out' of the condition as they get older.

During the teenage years, the symptoms of asthma will disappear in approximately three-quarters of all children with the condition. However, asthma can return in adulthood. If the childhood symptoms of asthma are moderate to severe, it is more likely that the condition will return later in life.

Irritation of the bronchi

The bronchi of children with asthma are more sensitive than those of children without the condition, and certain substances or triggers can irritate them. Common triggers include house dust mites, animal fur, pollen, tobacco smoke, cold air and chest infections.

When the bronchi become irritated, they narrow, the muscles around them tighten, and there may be an increase in the production of sticky mucus, or phlegm. Your child may find breathing difficult, their chest may feel tight, and they may experience wheezing and coughing.

The severity of asthma symptoms differ from child to child – from mild to severe. However, the narrowing of the airways is usually reversible, either naturally or by using medicines.

Common triggers

The cause of asthma is not fully understood, but it is thought that it may be a combination of genetic and environmental factors. Asthma often runs in families, and you can inherit the susceptibility to asthma, which is then triggered by certain factors in the environment. However, symptoms may sometimes occur for no apparent reason.

Environmental factors that may trigger asthma include exposure to air pollutants, such as cigarette smoke, and certain substances that can cause allergic reactions (allergens) such as pollen and animal fur.

Relief and prevention

There is no cure for asthma, but there are a range of successful treatments which can usually successfully manage the condition. The treatment of asthma is based on two important goals:

  • Relief of symptoms.
  • Preventing future symptoms developing.

Successful prevention can be achieved through a combination of medicines, diet, exercise and identifying and avoiding potential triggers.

Exercise-induced asthma

Sometimes, children with asthma find that their symptoms are made worse through physical exercise. This is known as exercise-induced asthma, and is usually the result of poor asthma control.

Symptoms

Symptoms of asthma in children

The common symptoms of asthma include:

  • feeling breathless,
  • wheezing (there may be a whistling sound when your child breathes),
  • coughing (particularly at night), and
  • tight chest.

The severity and duration of the symptoms of asthma tend to be highly variable and unpredictable, and they are often worse during the night, or with exercise. You should be aware of any signs of worsening symptoms in your child. These may include:

  • a drop in peak expiratory flow rate (see the 'diagnosis' section for more information),
  • an increased pulse rate,
  • an increase in wheezing, and
  • feeling agitated, or restless.

If you notice that your child's symptoms are getting worse, do not ignore them - contact your GP, or asthma clinic.

Symptoms of a severe asthma attack include:

  • the symptoms will get worse quickly,
  • difficulty breathing and talking,
  • a racing pulse,
  • lips and/or finger nails may turn blue,
  • the skin around the chest and neck may tighten, and
  • the nostrils may flare as the child tries to breathe.

Call 999 to seek immediate medical assistance if your child has severe symptoms of asthma.

Causes

Causes of asthma in children

Although there is no single known cause of asthma, there are several factors that may contribute to your child having the condition.

These include a genetic predisposition (having something in their genes that makes it more likely that they will develop asthma), diet, and the environment.

Known risk factors for the development of asthma in children include:

  • a family history of asthma, or other related allergic conditions (known as atopic conditions) such as eczema, hayfever or allergic conjunctivitis),
  • developing another atopic condition,
  • being exposed to tobacco smoke, particularly if the child's mother smoked during pregnancy,
  • being born prematurely, and
  • being born with a low birth weight.


Asthma triggers

The symptoms of asthma can be triggered by external factors, such as those described below.

  • Infections of the airways and chest. Upper respiratory infections, affecting the upper airways, are often caused by viruses, and they are a common trigger of asthma. In some children, fungi, bacteria, and parasites may also be responsible for infection.
  • Allergens, such as pollen, dust mites, and animal fur, or feathers.
  • Airborne irritants, such as cigarette smoke, chemical fumes and atmospheric pollution.
  • Medicines, such as the class of painkillers known as non-steroidal anti-inflammatory drugs (NSAIDs), the most well known of which are aspirin and ibuprofen. Children who are under 16 years of age should not be given aspirin.
  • Emotional factors, such as stress, or laughing.
  • Foods containing sulphites. Sulphites are naturally occurring substances found in some food and drink. They are also sometimes used as a food preservative. Food and drink that are high in sulphites include concentrated fruit juice, jam, shrimp, and many processed, or pre-cooked meals. Although certain foods may trigger the symptoms of asthma, it is very rare for diet to actually cause the condition


What happens during an asthma attack

The symptoms of an asthma attack begin when something triggers a biological process called inflammation. Inflammation is one of the ways that your body's immune system helps fight off infection.

If your body detects an infection in your lungs, it will start the process of inflammation. White blood cells will be sent to the site of the infection to destroy it and prevent it spreading. These blood cells cause the airways to swell and produce mucus.

If your child has asthma, their airways are very sensitive to the effects of inflammation. As a result, too much mucus is produced and the airways swell more than they should. Also, as a response to the inflammation, the muscles surrounding the airways begin to contract, making the airways narrower and narrower.

The combination of excess mucus, and the swelling and then narrowing of the airways, makes breathing difficult and produces the wheezing and coughing that is associated with asthma.

The hygiene hypothesis

Some children are less likely to develop asthma than others. For example, studies have found that children who are given fewer antibiotics and those who live on or near farms have less asthma than children with different backgrounds. Medical researchers have tried to explain these findings with the 'hygiene hypothesis'.

Diagnosis

Diagnosing asthma in children

Asthma can be difficult to diagnose in young children because there are many other conditions that can cause similar symptoms. For example, many young children have episodes of wheezing, but never develop asthma.

Most children develop the symptoms of asthma when they are of school age, along with other allergic conditions (atopic conditions) such as hay fever. The reasons for this are unknown.

Your GP will normally be able to diagnose asthma by asking you about your child's symptoms, examining their chest, and listening to their breathing. They will want to know about your child's medical history and whether there is a history of allergic conditions in your family.

Your GP will also want to know about the circumstances surrounding the onset of your child's symptoms, such as when and where it happened, because this could help to identify the possible trigger(s) of their asthma.

Peak expiratory flow rate test

The diagnosis of asthma can typically be confirmed using a number of tests, the most popular being the peak expiratory flow rate (PEFR) test. During a PEFR test, a small hand-held device, called a peak flow meter, is used to measure how much air your child is able to breathe out of their lungs.

A PEFR reading is taken, and your child will then be given a medicine that is effective in treating asthma in the short-term. If, following a second reading, the result is much higher after taking the anti-asthma medicine, the diagnosis is normally confirmed. The PEFR test is only suitable for children who are over five years of age.

You may be given a peak flow meter to take home with you, along with a diary in which you can record measurements of your child's breathing flow rate. This is a good way of recording how your child's asthma symptoms react to different circumstances.

Younger children may be asked to breathe in (inhale) asthma medicine. If this helps with their symptoms, the child probably has asthma. However, sometimes the asthma medicines are ineffective in infants and young children, so a negative response may not rule out asthma.

Exercise-induced asthma

Your GP should be able to identify exercise-induced asthma by asking you, and your child, about their symptoms in relation to exercise. Common symptoms include a cough that usually starts 6-10 minutes after exercise, and chest tightness that develops between 1-2 hours after exercise.

Your GP will also want to know about any symptoms that are not related to exercise, such as coughing at night, or breathlessness. This can rule out the possibility that your child is having difficulties exercising due to them not properly controlling their asthma.

Teenage asthma

If you have a teenager with asthma, try to be sympathetic to their particular problems. Teenage asthma can often go unrecognised or under-treated, and many teens are unwilling to seek help or take medication because they find it embarrassing and have other things they feel are more important. Try to listen and negotiate, rather than criticising.

Treatment

Treating asthma in children

Once asthma has been diagnosed, your child's treatment will begin with an assessment, possibly at an asthma clinic. The purpose of the assessment is to determine the pattern and severity of their symptoms and the treatment that is required to manage those symptoms. The plan will also investigate any possible asthma triggers. You should then be able to determine the potential impact of asthma on your child's daily life.

As your child gets older, it is important for them to be able to recognise the signs and symptoms of their asthma, and how they can effectively manage the condition. As part of the assessment, you and your child will be encouraged to draw up a personal asthma plan during discussion with your GP, or asthma nurse. The plan will include information about your child's asthma medicines.

Both you and your child will be taught how to recognise when their symptoms are getting worse and the appropriate steps to take. You will also be given information about what to do if they have an asthma attack.

Both you and your child will also be encouraged to contribute to the asthma plan by keeping a track of their symptoms, and noting how well they respond to treatment. You should stay alert for any associated triggers that may be causing their asthma. Your child should review their personal asthma plan with their GP, or asthma nurse, at least once a year, or more frequently if their symptoms are severe.

As part of their asthma management, your child may be given a peak flow meter, so that they can monitor their symptoms and the effects of treatment.

Medical treatment of asthma - the stepwise approach

Treatment of asthma is carried out using what is known as 'stepwise management'. This is where the severity of your child's asthma symptoms is assigned a 'step', from one to five, and treatment follows accordingly. As their symptoms get better, or worse, they may move up or down a step in their treatment plan. The aim of treatment is to find the lowest possible step that successfully manages your child's condition.

Treatment involves both relieving symptoms and preventing them from recurring. Prevention can be achieved through the use of medicines, but exercise and diet also play an important role. The information below will cover the use of medicines for prevention. For further information about other prevention methods, see the 'prevention' section of this article.

Step one - mild intermittent asthma

If your child's symptoms are infrequent and mild, they will be given an inhaler containing a medicine called a short-acting beta2-agonist that they should to use to relieve the symptoms of asthma. Short-acting beta2-agonists work by relaxing the muscles of the airways and decreasing the amount of mucus. They also prevent the muscles around the airways tightening. Medicines that are used to relieve symptoms are known as reliever medicines.

Step two - regular preventer therapy

Medicines that are used to prevent asthma symptoms are known as preventer medicines. If your child's symptoms are more frequent they will probably be given regular preventer therapy. This treatment is normally recommended if your child:

  • has asthma symptoms more than twice a week,
  • wakes at least once a week due to asthma symptoms,
  • has had an asthma attack in the last two years, or
  • has to use a short-acting beta2-agonist inhaler more than twice a week.

In step two, your child will be given a second inhaler containing a medicine called an inhaled corticosteroid. They are normally recommended to take two doses of inhaled corticosteroids a day to prevent symptoms. They should still use their short-acting beta2-agonist inhaler to relieve symptoms.

Exactly how inhaled corticosteroids work is not entirely clear, but they are known to reduce the amount of inflammation in the airways, and prevent asthma attacks. However, inhaled corticosteroids have been known to cause yeast infections (oral thrush) in the mouth, so your child should rinse their mouth thoroughly after inhaling a dose.

Step 3 - add-on therapy

If your child's asthma symptoms are still not under control, they will be given a second preventer inhaler to take with the first. This will normally contain a medicine called a long-acting beta2-agonist. These work in the same way as short-acting beta2-agonists, but they take longer to take effect. However, they can last up to 12 hours, compared with short-acting beta2-agonists that only relieve asthma symptoms for 3-6 hours, but start working within five minutes.

If your child's asthma still does not respond to treatment, the doses of inhaled corticosteroids, and long-acting beta2-agonists that are used can be increased. Your child should only use their long-acting beta2-agonist inhaler in combination with their inhaled corticosteroids inhaler, and not by itself. Studies have shown that using only long-acting beta2-agonists can increase the chance of an asthma attack.

If your child is under two years of age, they may be referred to a specialist in children's asthma.

Step 4 - persistent poor control

If treatment is still unsuccessful, the amount of inhaled corticosteroid used, will be increased to its maximum safe dose and additional preventer medicines will be tried. Two possible alternatives are outlined below.

  • Leukotriene receptor antagonists - this is an oral medication, in the form of a tablet, that works by blocking a chemical reaction that can lead to inflammation of the airways.
  • Theophyllines - this oral medication helps to widen the airways by relaxing the muscles around them. However, theophyllines have been known to cause a number of side effects in some people, including headaches, nausea, insomnia, vomiting, irritability, and stomach upsets.

If your child is under five years of age, and has poorly controlled asthma, they should be referred to a specialist in children's asthma.

Step 5 - continuous or frequent use of oral steroids

The final step involves the use of oral steroids. As in step four, this treatment should be supervised by a specialist in children's asthma. Long-term use of oral steroids carries possible serious side effects, so it is only used once all other treatment options have been tried, and all trigger factors have been eliminated as far as possible.

Most children only need to take a course of oral steroids for one or two weeks. Once their asthma is under control, they can then be 'stepped-down' to their previous treatment.

Children taking oral steroids for more than three months, or taking frequent courses of oral steroids (3-4 times a year) are at risk of possible side effects. The side effects are:

  • fragile bones (osteoporosis),
  • high blood pressure (hypertension),
  • diabetes, and
  • cataracts (an eye disorder where the lens becomes clouded).

Your child will require regular examinations to check for the development of these conditions. Vitamin D and calcium supplements may be recommended to help strengthen bones.

The use of steroids can temporarily slow down growth in children. In a study where children who were taking steroids were monitored until they had finished growing, all of them reached their predicted adult height.

Exercise-induced asthma

If your child has asthma symptoms during or after exercise, they could have exercise-induced asthma.

It is likely that your child's general symptoms and personal asthma plan will be reviewed, in case their exercise-induced asthma is a result of poor asthma control.

However, if this is not the case, they will be advised to:

  • use a short acting beta2-agonist, 10-15 minutes before they exercise, and again after two hours of prolonged exercise, or when they finish,
  • try to structure their exercise plan around short-burst activities,
  • exercise in humid environments, and
  • breathe through their nose to avoid excessively rapid and deep breathing (hyperventilation).

If they do not respond to treatment, and they are already taking an inhaled corticosteroid, they may be given an additional preventer medicine, such as a long-acting beta2-agonist, or leukotriene receptor antagonists.

If they still do not respond to treatment, they may be referred to a doctor who specialises in conditions that affect breathing (a respiratory specialist).

Asthma attacks

As part of your child's assessment, and when drawing up their personal asthma plan, your child will be taught to recognize the initial symptoms of an asthma attack, how they should respond, and when they should seek medical attention.

Treatment typically involves taking one or more higher doses of their reliever medicine. If the symptoms of your child's asthma attack progress and worsen, they may need hospital treatment. If admitted to hospital, your child may be given a combination of oxygen and preventer and reliever medicines to bring their asthma under control.

Your child's personal asthma plan will need to be reviewed so that the reasons for the asthma attack can be identified and then avoided in future.

Alternative medicine

A number of alternative therapies have been suggested for treating asthma:

  • traditional Chinese medicine
  • acupuncture
  • ionizers (a device that uses an electric current to charge molecules of air)
  • the Alexander technique
  • homeopathy
  • breathing exercises, including yoga and the Buteyko method
  • dietary supplements.

However, there is little scientific evidence that any of these treatments are effective, particularly when used on their own. If you're interested in trying a therapy that's not medically prescribed, it's best to try it alongside your conventional medicine, as a complementary therapy.

Prevention

Reducing the risk

There are certain things you can do to lower the risk of asthma attacks in your child, including avoiding triggers such as pet fur and quitting smoking.

Smoking

If you are a smoker, you should never smoke around your children. Smoking around children will make the severity and frequency of their asthma worse. Also, children who grow up exposed to cigarette smoke are much more likely to develop asthma.

The NHS Smoking Helpline will be able to offer you advice or encouragement on how to quit smoking. You can call on 0800 022 4 332, or visit the NHS 'Go smokefree' website. See the 'selected links' section for more information. Your GP, or pharmacist, will also be able to provide help and advice about giving up smoking.

If you are unable to give up smoking, you should smoke in another room or, ideally, outside of the house.

Vaccinations

Due to the increased risk of complications, it is recommended that some children with severe asthma receive vaccinations for flu (influenza) and pneumococcal, a bacteria that can cause pneumonia, meningitis and infection of the blood.

Avoiding triggers

It is important that, where possible, you identify the triggers of your child's asthma, by making a note of worsening symptoms, or using their peak flow meter during exposures to certain situations. Some triggers, such as air pollution, viral illness, or certain weather conditions, can be hard to avoid. However, many other triggers, such as dust mites, fungus spores, or pet fur, can sometimes be avoided.

Weight, diet and exercise

Maintaining a healthy weight will help your child to improve control over their asthma. The key to maintaining a healthy weight is a healthy, balanced diet, and regular exercise.

A low fat, high fibre diet is recommended including plenty of fresh fruit and vegetables (five portions a day) and whole grains.

It is recommended that children get at least 60 minutes of physical activity a day. This does not have to be all in one go; it can be in chunks of about 15-20 minutes throughout the day. The exercise should be of moderate intensity, which means your child should be slightly out of breath, and slightly sweaty, but not so out of breath that they cannot talk.

If your child's asthma is well-managed, moderate exercise should not normally cause any problems. If they do experience asthma symptoms during or after exercise, they should see their GP.

General health

There are a number of other medical conditions that are known to aggravate asthma. Therefore, if your child gets any associated symptoms, you should report them to your GP. Treating these conditions will not necessarily make your child's asthma better, but it should help stop it getting out of control. These conditions are listed below.

Rhinitis
Rhinitis is inflammation of the lining of the nose. It can be caused by an infection, such as the common cold, or as a response to an allergen, such as hay fever. The symptoms are sneezing, a blocked, stuffy, itchy, or runny nose, and a sore throat and eyes.

Sinusitis
Sinusitis is an inflammation of the small, air-filled cavities inside the cheekbones and forehead. It is caused by infection. The most common symptoms are a throbbing pain that is worse when your child moves their head, a blocked or runny nose, and a high temperature.

Gastro-oesophageal reflux disease (GORD)
Gastro-oesophageal reflux disease (GORD) is a condition of the digestive system where acid leaks back from the stomach into the oesophagus (gullet). The main symptoms of GORD are heartburn (a burning pain behind the breastbone), stomach pains, and bloating and belching. However, GORD is a very rare condition in children.

Sleep apnoea
Sleep apnoea is a sleep disorder where the upper airway in the throat collapses repeatedly, at irregular intervals, during sleep. Children who are affected by sleep apnoea are often unaware that they have the condition. However, it is very rare for children to have sleep apnoea.

If a child has sleep apnoea, their sleep will be disrupted, they may begin to experience symptoms during the day, and you may witness an apnoea, or other symptoms that occur at night. Symptoms include snoring, lack of concentration during the day, and frequent awakenings during the night.

Complications

Complications of asthma in children

Badly controlled asthma can have an adverse impact on your child's quality of life. The condition can lead to:

  • fatigue,
  • underperformance or absence from school, and
  • psychological problems, including stress, anxiety and depression.

Children may also feel excluded from their school friends, if they cannot take part in games and sports.

If you feel that your child's asthma is seriously affecting their quality of life, you should contact your GP, or asthma clinic. Their personal asthma treatment plan may need to be reviewed in order to better control their asthma.

Asthma charities and support groups will also be able to provide you with help and advice.

Respiratory complications

Asthma (particularly in adults) can lead to a number of possible serious respiratory complications, including:

  • infection of the lungs (pneumonia),
  • collapse of part, or all, of the lung,
  • respiratory failure (a condition where the levels of oxygen in the blood become dangerously low, or the levels of carbon dioxide become dangerous high), and
  • severe asthma attacks that do not respond to treatment (status asthmaticus).

All these complications are potentially life-threatening and will need medical treatment.

Death

In 2005, over 1,300 people in the UK died from asthma. And, on average, one person dies from asthma every seven hours. However, as the risk of dying from asthma increases with age, asthma-related deaths in children are extremely rare.

For example, in England, between 1996-2004, there were 16,384 asthma-related deaths in people over 65 years of age, compared with 239 deaths in children under the age of 15.

Expert view

Asthma expert Professor John Price on the questions to ask

John Price, professor of paediatric respiratory medicine at King’s College London, answers the questions often asked by parents of children with asthma.

What do you think triggers my child’s asthma?
The triggers vary from child to child. In some children, colds trigger their attacks. In others, it can be exercise. Allergies may also be a big factor, and excitement, e.g. laughing and crying, may be another factor. Unfortunately, excitement at birthday parties is a well-known trigger of attacks.

Which treatments are available and how should my child take them?
Some children should only take treatment when they wheeze. Others need to take treatment more regularly as a preventative measure, as well as when they wheeze. Children with persistent symptoms tend to need regular treatment to prevent asthma.

Where possible, your child’s asthma should be treated with an inhaler. There are a couple of very good treatments that can be taken by mouth, but generally, the best treatments are taken with an inhaler. There are different inhalers for different ages, so ask your doctor or nurse which type of inhaler is most appropriate for your child.

Are the treatments safe?
Largely, the treatments taken to relieve wheezing are very safe. The most commonly taken treatment is an inhaled steroid. If this is taken in a large dose, it can have side effects. If you're worried about the dose your child is taking, talk to your doctor or nurse.

If one of my children has asthma, are my other children also at risk of getting it?
Yes. If a parent has asthma, the risk of their child getting it doubles. If both parents have it, it doubles again. And, if one of your children has asthma, the risk of your other children getting it increases, but we don’t know by how much.

Should I avoid getting pets?
The short answer is yes. It’s better not to have pets because most children who have asthma are also at risk of developing allergies. If they get a pet cat or dog and become allergic to it, the pet may have to go.

Top tips for parents

  • Ensure your child takes their prescribed treatment regularly and in the right way. If they do, they should be able to lead a normal life.
  • If your child’s asthma is getting worse and not responding to the usual treatment, make sure you get help. Don’t struggle along.
  • Don’t smoke. If you can't stop smoking completely, don't smoke around your child, as that will make their asthma worse.

Lifestyle

Living with asthma

Managing your child's asthma

You should try to minimise the factors that may be triggering the child's asthma. This includes reducing contact with anything they are allergic to, such as animal hair or pollen. You should ensure that they avoid general irritants such as tobacco smoke (see 'Prevention').

Some people find it helpful to try and reduce house dust mite residues, if their child has a house dust mite allergy. Using mattress covers, vacuum cleaners with allergy filters and damp dusting may help.

It is important that the child takes all prescribed preventive medicines, even when they have no symptoms. Also, check they are using their inhaler devices correctly. Children should have their asthma reviewed every six to 12 months.

You should discuss their treatment with their GP or asthma nurse, so that you always know what to do when they have an asthma attack. Use a peak flow meter to monitor whether their asthma is getting worse.

If the child has a serious attack and their symptoms do not improve in five minutes, contact their GP or local hospital immediately.

Useful links

NHS Choices

External links

This article was originally published by NHS Choices

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