Childhood Asthma

What happens in asthma

In a child with asthma, the airways are chronically inflamed and overly sensitive. When exposed to a trigger:

• the muscles around the airways tighten (bronchospasm)
• the airway lining swells
• extra mucus is produced

The airways narrow and air struggles to get in and out, causing wheezing, coughing and breathlessness. Between episodes, many children seem completely well, but the underlying inflammation continues, which is why daily controller medicine matters for many.

Symptoms of asthma in children

• cough, often dry, worse at night, early morning, with exercise, laughing or crying
• wheezing, a high-pitched whistle on breathing out
• shortness of breath or fast breathing
• chest tightness ("my chest hurts" in younger children)
• tiring quickly during play or sports
• colds that "go to the chest" and last longer than in other children

Signs in babies and toddlers

Young children cannot describe symptoms. Watch for:

• fast breathing, with the belly moving a lot
• skin pulling in between the ribs or below the breastbone (retractions)
• flaring nostrils
• trouble feeding, grunting
• repeated wheezing with colds

Many toddlers wheeze only with viral infections and outgrow it by school age. Bronchiolitis in infancy and croup can mimic asthma.

Causes and risk factors

• Family history of asthma or allergies
• Atopy: eczema, food allergies or allergic rhinitis; the "allergic march"
• Exposure to tobacco smoke, before or after birth
• Severe viral chest infections in infancy (RSV, rhinovirus)
• Premature birth and low birth weight
• Obesity
• Air pollution and living near heavy traffic
• Male sex in childhood (girls catch up in adolescence)

Common triggers

Diagnosis

Doctors diagnose asthma from:

• a history of recurrent symptoms and triggers
• examination, which may be normal between episodes
• spirometry, usually possible from about age 5 to 6, showing airflow limitation that improves after a bronchodilator
• peak flow monitoring at home in older children
• FeNO (exhaled nitric oxide) testing in some clinics, which measures airway inflammation
• a trial of treatment: improvement with asthma medicine supports the diagnosis, especially in children under 5
• allergy testing to identify triggers
• a chest X-ray only if another diagnosis is possible

Treatment

Quick-relief (rescue) medicine

Albuterol (salbutamol) relaxes the airway muscles within minutes and lasts 4 to 6 hours. It is used for symptoms and before exercise. Always use with a spacer (valved holding chamber), with a face mask for young children. In older children and teens, some guidelines also use a combination inhaler of an inhaled steroid with formoterol as both controller and reliever.

Controller (preventer) medicine

For children with frequent symptoms, night waking or attacks:

• Inhaled corticosteroids (such as fluticasone, budesonide, beclomethasone) used daily reduce inflammation, symptoms and attacks. At recommended doses they are safe; they may reduce final adult height by about 1 cm on average, which doctors weigh against the large benefits.
• Combination inhalers (steroid plus long-acting bronchodilator) for older children who need more.
• Montelukast, a tablet, as an alternative or add-on. It carries an FDA warning about mood and behavior changes, which parents should watch for.
• Biologic injections for severe allergic or eosinophilic asthma under specialist care.
• Allergen immunotherapy for selected children with allergic asthma.

Treating an asthma attack

Children often need oral corticosteroids for a few days, plus frequent albuterol, for moderate to severe attacks. Severe attacks are treated in the ER with oxygen, nebulized medicines and sometimes IV medicines.

Inhaler technique

Poor technique is a common reason asthma seems uncontrolled. With a spacer: shake the inhaler, attach it to the spacer, put the mouthpiece in the mouth (or mask over nose and mouth), press once, and breathe slowly in and out 5 to 6 times (or take one slow deep breath and hold for 10 seconds). Wait 30 to 60 seconds between puffs. Rinse the mouth after steroid inhalers.

The asthma action plan

A written plan from your child's doctor explains:

• Green zone: doing well. Daily controller medicine, pre-exercise treatment.
• Yellow zone: getting worse (cough, wheeze, night waking, cold symptoms). Add rescue doses, and other steps as written.
• Red zone: medical alert. Severe breathlessness, rescue inhaler not helping. Give rescue medicine and get emergency help.

Share copies with school, child care and caregivers. Children should have access to their rescue inhaler at school.

Is asthma well controlled?

Asthma is considered well controlled when a child:

• has daytime symptoms no more than 2 days a week
• wakes at night with asthma no more than 1 to 2 times a month
• uses the rescue inhaler no more than 2 days a week (not counting before exercise)
• has no limits on play or sports
• has had no more than one attack needing oral steroids in the past year

Outlook

Many children's asthma improves in adolescence, though it can return in adulthood. Children with more severe asthma, allergies or smoke exposure are more likely to keep symptoms. Good control protects lung growth and allows a normal, active life.

Frequently asked questions

What are the first signs of asthma in a child?

Common early signs are a cough at night or with exercise, wheezing, breathlessness during play, and colds that settle on the chest and last longer than usual. In babies and toddlers, fast breathing, skin pulling in between the ribs and repeated wheezing with colds are clues.

Can a child outgrow asthma?

Some do. Many toddlers who wheeze only with colds stop by school age, and asthma often improves in the teen years. However, it can return later, and children with allergies or severe asthma are more likely to have ongoing symptoms.

Are inhaled steroids safe for children?

Yes, at recommended doses. Inhaled steroids deliver small amounts directly to the lungs and are the most effective long-term treatment. They may slightly slow growth in the first year of use, but the benefits of fewer attacks, hospital visits and missed school are much greater.

How do I know if my child's asthma attack is an emergency?

Call emergency services if your child is struggling to breathe, cannot speak or eat, has blue or gray lips, skin pulling in at the ribs or neck, is drowsy, or the rescue inhaler is not helping or is needed every few hours.

Can my child with asthma play sports?

Yes. With good control and a rescue inhaler taken before exercise if advised, most children with asthma can play any sport. Frequent symptoms during exercise mean the asthma needs better control, not less activity.