Asthma in children: What every parent must know

Here is the transcript of our interview with Dr. Jagdish Chinnappa. Please note that the transcript has been edited for clarity and brevity and is not verbatim

How is Asthma in children diagnosed?

Asthma is normally confused with other conditions such as pneumonia, recurring respiratory infections, or other common coughs and colds that children often have. Some of the ways to identify asthma positively are:

1. If there is a strong family history of asthma
2. If the child has strong allergic disorders such as allergy of the skin, allergy of the nose (allergy rhinitis) or food allergies
3. If the child gets repeated attacks of wheezing without any pre-disposing factors like a fever or other issues. In these cases the chances of getting asthma is much higher

In babies under the age of 5 diagnosing asthma is not easy. An asthma diagnosis is made only under a high index of suspicion in these children. Only with children above the age of 5, can one reasonably diagnose asthma.

How can a parent recognise an Asthma attack and what are the steps to manage an attack?

Recognising an attack

Some of the indicators that mothers can easily recognise are:

1. The child deteriorates quickly – he may start off with a cold and within a few hours develop a cough
2. The child may have difficulty breathing
3. The child may not feed very well
4. The child may not sleep very well
5. The child may go on crying for an extended period of time – because the only way for the child to get oxygen in his lungs is through crying

Symptoms

A mother can identify if a child with the above symptoms is in distress by these indicators:

1. If the child is breathing fast and with labour
2. If the muscles of the nose are visibly moving
3. If there is pulling of the muscles of the neck (which are known in medicine as accessory muscles of breathing). If these muscles are being vigorously exercised accompanied by a wheezing sound then it is definitely a sign of severe wheezing

Confirming respiratory distress

1. Pulse oximeter — Parents of children who are prone to getting asthma attacks can keep a pulse oximeter at home – a small compact device which helps measure the quantity of oxygen in the blood. You simply place the child’s forefinger in the device and wait for the saturation reading. A reading above 92 indicates that the child is OK, but anything below that means that the child has to be seen quickly in a medical facility.
2. Peak-flow meter — a simple breathing meter which parents can use at home. Children above 3 or 4 years can do this quite well. You have them blow in to it and keep a record of the normal peak flow reading for your child when he is well. On a day when he has severe wheezing he won’t be able to blow as much as the normal value.
3. Counting — have the child count without taking a breath. If he can count to 10 or 15 without taking a breath then he is reasonably alright. But if the child cannot count and he begins panting in between then the child is significantly obstructed.

Action to be taken

1. Administer at home the doctor prescribed medication for the child
2. Contact his doctor and alert him to the situation
3. Reach an emergency unit where adequate monitoring can be done and treatment can be given

How is Asthma treated?

Broad classes of medication:

1. Controllers — Even when a child is not exhibiting symptoms of cough, cold or wheezing, these medicines are prescribed to keep the children under control. Parents must understand that they must give controllers every single day whether the child has a cough or not.
2. Relievers — For children who are experiencing coughing or wheezing, these medicines are given to relieve their symptoms. Relievers have to be given as and when the child gets a cough.

Types of Medication

a. Inhalers – If children have recurrent attacks, doctors will prescribe to parents to use inhalers. Inhalers come in:

1. Spray type metered dose inhaler
2. A dry powder type inhaler, in which you put a medicine capsule to be inhaled
3. Nebulisers — which are bulky machines and are available at the doctor’s office or medical facilities. The advantage of using inhalers is that they provide relief with a very small dose of medicine and therefore their side effects are minimal.
   It is important for parents to understand how to use inhalers properly as they are the key to getting the medication in to the child. Metered dose inhalers and nebulisers are suitable for all children including infants. Dry powder type inhalers are better suited to kids older than 3-5 years.

b. Syrups and Tablets

These are prescribed only to children who have very occasional symptoms or very mild symptoms because the dosage is higher and side effects can occur. We do not normally recommend syrup and tablet medication. We do recommend the inhaler type of medication.

What changes should parents make in the household and lifestyle to control asthma symptoms?

Controlling the allergen exposure and lifestyle goes a long way in managing children with asthma.

Allergen exposure

1. Dust mites — In most Indian homes we have a large amount of upholstered furnishing which collects house dust mites. It is a small mite which is not visible to the naked eye and the droppings of house dust mites are potent allergens which stimulate allergies in children. Therefore one must be careful when you have upholstered sofas, carpets and thick curtains. The best thing is to remove all carpets, cover your sofas with rexine/leatherette fabrics and regularly clean all upholstery to get rid of house dust mites. Especially in the child’s bedroom, be careful and eliminate all breeding grounds for these mites. Soft toys are a problem too, if children have a large number of them; the best thing to do is to restrict the number of soft toys. They can be washed in boiling water and hung out to dry in bright sunshine or alternatively put in ziplock bags in the freezer to get rid of mites from time to time.
2. Cockroaches — The key to this, is proper management of the kitchen and kitchen waste, which is the main attraction for these pests. Regular pest control preferably with natural rather than chemical products is a very good thing to do.
3. Fungus on the walls – Many of our homes have moisture leakage which leads to fungus accumulating on the ceilings and walls of bathrooms, verandahs/ balconies. Children are very prone to develop allergies from fungus and parents must be swift and strict about getting rid of it.
4. Smoke — Indian homes frequently burn agarbattis and camphor which is to be avoided as much as possible. Cigarette smoking is a strict no-no. Parents often ask if it’s OK if they only smoke outside and away from the child, but even that is very detrimental to kids as we now recognise the effects of second-hand and even third-hand smoke.
5. Pets -– There is a raging debate about the effects on having pets at home and dogs vs. cats, but there is no real medical contraindication for pets. They are a less worrying source of allergens. If you can avoid having a pet it is the best; if you must have one try and choose a breed with less fur.

Please remember that a child’s airways are extremely small and if even a small thing goes in there like a drop of mucus it will produce significant obstruction

Lifestyle

1. Diet — most foods are safe for all children including asthmatic children contrary to popular myth. The only child you have to worry about is the asthmatic child who also has a significant food allergy – then you have to be careful. Sometimes when a child is coughing or wheezing you might want to restrict him from consuming cold foods and liquids like ice-cream because the cold can cause a broncho-constriction, but when the child is not exhibiting any symptoms there is no need to restrict their diet intake.
   See that children get a reasonable amount of anti-oxidant rich foods like fruits and vegetables and a reasonable amount of nuts on a daily basis. Be watchful for obesity, because when a child becomes obese it increases the chances of developing severe wheezing. Make sure that de-worming is routinely done. Ensure children get adequate sunlight exposure and/or are given appropriate Vitamin D supplements to maintain good levels. Children’s haemoglobin levels should be normal – if the levels are low it will lead to reduced oxygen being carried in the blood and that is the main thing to be avoided.
2. Sleep — make sure children get a good night’s sleep. Many children with asthma don’t sleep well as they are coughing and wheezing through the night. It is important to relieve their symptoms because without sleep it can lead to a lot of other complications.
3. Exercise — children need to go out and get their exercise contrary to what many parents of asthmatic kids think. Diesel fumes and pollen outdoors can cause problems but control them properly with medication. Encourage them to play outdoors as exercise is what develops lung function and important for the health of the child.

What is a school’s role in assisting children with Asthma?

Schools have to work in partnership with two sets of people – the parents and medical professionals. We have worked with schools and generally talk about these action points:-

1. Indoor Air Quality in classrooms — reduce allergens in classroom environments by actively removing fungus and ensure adequate ventilation. Reduce smoke exposure by banning the burning of leaves on campus .
2. Treatment Room — Provide a place with a nurse and basic equipments to treat kids having an asthma attack. Things a school can easily keep on hand are inhalers with spacers and/or a nebulizers.
3. Student Records -– Schools should have the address and phone numbers of the nearest hospital. Many schools today also maintain databases of emergency contact information for each student – parents as well as physicians, so they can reach out to them directly in the case of an emergency.
4. Health Programs -– Schools now run educational programs on health issues and teach children about asthma which involves the children in managing their own health and educates the community of teachers, students and parents.

Will my child outgrow Asthma?

Asthma is not a disease but a condition. It’s a problem of the immune-system that causes children to react to allergens. There are children who wheeze as a reaction to a viral infection. There are also babies with small airways that cause them to wheeze. These type of children will outgrow the condition. However, a patient with true asthma – an allergy to something – is unlikely to outgrow it completely. A person will go through periods – as his immune system changes and allergens also change there will be periods of normalcy and there will be periods when the condition surfaces. A one-year old who had 10-12 attacks of wheezing in his first year may come back at age 5 and report that he hasn’t had an attack in the last 6 months – he may outgrow it. However a child who begins to have repeated wheezing issues starting at age 4 most likely will have ongoing wheezing issues as he grows.

What are the short & long term side effects of Asthma medication?

Two puffs of an inhaler a day are unlikely to have any significant side-effects. A severe asthmatic who takes 20 or more puffs a day might need oral and inhaled steroids – they may have the side effect of a marginal drop in growth. But do remember that not treating the child will affect their growth more. Severe asthma affects a child’s growth more than the effect of medication, so it important to keep up with the treatment. Less-serious side effects include a fungal infection at the mouth or a hoarseness of voice. These can be avoided by using a spacer along with the inhaler and rinsing the mouth after administration of the inhaler.