Childhood Asthma

Asthma is a disease which primarily affects the bronchial tubes in the lungs, called the airways. Children affected by asthma typically experience breathing difficulties due to the inflammation of the airways.

Asthma can cause acute discomfort – such as an asthma attack – and can have a debilitating effect on the child’s overall health, including symptoms like tiredness, depleted strength and recurrent coughing.

The most common signs of asthma include:

• Wheezing
• Chest pain
• Shortness of breath

These symptoms may be present every day or only during an asthma attack.

Asthma affects around 6.2 million children in the U.S. 1 If a child experiences recurrent coughing, wheezing, tightness or pain in their chest or shortness of breath, it is important to consult a doctor, as one or more of these symptoms may indicate childhood-onset asthma.

When the respiratory system is functioning normally, as in a healthy child, the airways allow oxygen to pass into the lungs, which supply it to the rest of the body via the bloodstream. The airways of an asthmatic child are hypersensitive and will react by becoming inflamed and swollen when certain physical and environmental triggers enter the airways. This swelling makes it difficult for sufficient air to pass through the airways to the lungs, causing the child to experience breathing difficulties.

The potential impact of childhood-onset asthma on a child’s quality of life and long-term health can be significantly minimised by identifying appropriate treatment to bring their symptoms under control. Children with untreated asthma tire more easily after exercise than their peers and are prone to coughing and wheezing.

With effective treatment, it is possible to reduce the symptoms of asthma, so that asthmatic children can carry out their day-to-day activities as normal, including participating in exercise and outdoor activities.

Children are affected by asthma more commonly than adults. Asthma in children usually starts to develop in early childhood. Asthmatic children often present symptoms at under five years of age. Despite the presence of asthma-like symptoms, it can be difficult to diagnose asthma in infants and young children, as their lungs may not be developed sufficiently to carry out certain tests.

One of the first signs that a child might be affected by asthma is an involuntary whistling sound which accompanies their breathing. This is commonly known as “wheezing.” Typically, wheezing is especially prominent when the child exhales.

Other possible signs and symptoms of childhood-onset asthma include:

• Chest pain
• Chest tightness
• Depleted stamina after play or exercise
• Diminished energy throughout the day
• Difficulty drawing breath
• Recurrent coughing, typically at night
• Retractions (involuntary pulling in of the chest which occurs as a result of laboured breathing)
• Shortness of breath

If you are concerned that your child, or a child that you know, may be showing signs of asthma, get a free symptom assessment with the Ada app.

When a child experiences an asthma attack, their airways are reacting to specific triggers in the environment. 2 The absolute cause of asthma is still unknown, but there are many different triggers (stimuli) which are associated with bringing on asthma attacks or aggravating asthmatic symptoms.

Triggers affect every child differently. Children may appear to outgrow, or become immune to, certain triggers. Equally, they may develop new sensitivities as they mature. The intensity of their adverse reactions to specific triggers may also increase or decrease.

Environmental triggers of asthma in children include:

• Airborne irritants (such as pet dander) and pollutants (such as scented cleaning products)
• Weather conditions, especially changes in temperature or humidity

Physical triggers of asthma in children include:

• Allergies
• Emotional extremes such as stress, anger or nervousness
• Exercise
• Gastroesophageal reflux
• In infants, feeding
• Negative reactions to pharmaceutical medications such as painkillers
• Respiratory infections such as colds and/or flu

Skin or food allergies can cause asthma symptoms to occur in some children. This is called allergy-induced asthma or allergic asthma.

Allergy-induced asthma is the most common type of asthma. Allergic asthmatic children are simultaneously affected by allergies and asthma. It is possible to confuse an allergic reaction, such as hay fever, with a flare-up of asthma. It can be difficult to determine whether a child’s symptoms relate to either condition, or to a combination of both. This is further complicated by the fact that it is possible for both reactions to be stimulated by the same trigger.

Allergens which commonly trigger allergic asthmatic reactions in children include:

• Dander from pets
• Dust mites
• House dust
• Pollen

If a child appears to be affected by asthmatic symptoms, allergic reactions or a combination of the two, it is advisable to visit a health care provider or an allergist, who will be able to help identify the principal triggers, and suggest further stimuli to be avoided.

An allergist may also decide to prescribe medications against allergy symptoms, such as antihistamines. These will need to be factored into the child’s overall treatment plan, which will involve measures to manage their asthma. These may include asthma medications, immunology programmes and/or the use of a nebulizer, depending on the severity of the child’s condition and how often they experience a flare-up. (See Treatment for more information.)

It is not always possible to identify the cause of asthma in children, and a child may develop the condition with no apparent triggers. The main possible causes of asthma in children are:

• Genetic predisposition. Children with a family history of asthma, eczema, hives and/or allergic rhinitis develop asthma more commonly than those without.
• Environmental factors. Exposure to air pollutants, including cigarette smoke and potential triggers of asthma, including dust mites, pollen and pet dander, may cause children to develop asthma.
• Infections. Children may develop asthma as a result of certain types of infections that affect the airways, including viral infections such as the common cold.

Some children are at greater risk of developing asthma than others. Risk factors for developing asthma include:

• A family history of asthma and related conditions such as eczema
• A medical history of allergic reactions, including food and pet allergies, skin reactions and hay fever
• Living in an urban area, where there is greater exposure to pollution
• Regular exposure to potential triggers of asthma such as cigarette smoke and pet dander
• Obesity
• Other respiratory conditions, including sinusitis (inflamed sinuses) and/or a chronic blocked nose (rhinitis)
• Gastroesophageal reflux disease (GERD)

Before puberty, boys are at greater risk of developing asthma than girls; the biological reasons for this are not yet medically understood. 3

Each child experiences asthma differently, and a child may not exhibit all of the symptoms or respond to all the triggers listed. Within individual children, asthma symptoms and their severity may change. It is usual for the doctor to consider a range of possible causes for the child’s symptoms, in order to eliminate other conditions before offering a definitive diagnosis of asthma.

Non-allergic conditions that typically cause asthma-like symptoms include:

• Aspiration (when pieces of food or other small items accidentally pass into the airway)
• Pulmonary Aspergillosis (a fungal infection of the lung)
• Respiratory tract infections such as bronchiolitis and respiratory syncytial virus (RSV)
• Rhinitis (runny, stuffy nose)
• Sinusitis
• Vocal cord dysfunction
• Acid reflux or gastroesophageal reflux disease (GERD)
• Airway abnormalities caused by such as an esophageal disorder(where acid from the stomach triggers a reaction that inflames the airways) or neuromuscular respiratory diseases

Many of these conditions commonly co-occur with asthma. A diagnosis of asthma in a child therefore requires the doctor to determine whether the child’s symptoms are purely asthmatic, caused by a condition other than asthma, or whether the child has developed another condition in addition to asthma.

A variety of tests are available to help diagnose asthma in children, including lung function tests and allergy skin tests. These tests usually work best for children of five years and older.

To diagnose asthma in children of 5 years and older, doctors tend to use the same tests that are used to identify the disease in adults. The main tests used to identify asthma are:

Lung function tests (spirometry) are primary tests used to measure how much air the child can exhale and how quickly. They involve using a device called a spirometer, attached to a mouthpiece by a cable. 4 To determine the severity of the asthma diagnosis, the child’s lung function is usually measured during three levels of activity: after taking asthma medication, after exercising and at rest.

Lung function tests employ flow volume loops to measure how quickly the child can inhale, and their maximum intake of breath in one inhalation. This helps detect obstruction of air in the neck, such as vocal cord paralysis or dysfunction- which helps to identify any non-asthmatic conditions that may be a correct or additional diagnosis.

When a child is diagnosed with asthma, and the doctor suspects that they may be affected by allergic asthma, allergy skin tests may be used in addition to the tests for asthma to test for possible triggers which may be causing the symptoms. The skin is pricked, and solutions containing extracts of common allergy-causing substances are applied, such as animal dander, mold or dust mites. The child is then observed for signs of an allergic reaction.

The Methacholine challenge test (MCT) is used to diagnose mild or intermittent (occurring at irregular intervals) asthma. If lung function tests do not result in the child’s asthma diagnosis, a doctor may order a methacholine challenge test. During this test, the child inhales increasing amounts of a mist of methacholine before and after spirometry. Methacholine is a drug that stimulates the nervous system and causes wheezing and shortness of breath.

In some cases, a body plethysmography test may be carried out in addition to the diagnostic tests above. In this test, a child will breathe in and out in an instrument called a body box. The body box is airtight, and breathing in and out of it causes changes to the air pressure inside the box.

Medical professionals can monitor the air pressure inside the box to add many details to their understanding of how well a child’s respiratory system is performing. This test can be used to measure factors including the volume of air present in the lungs after breathing normally, the specific airway resistance (how much the respiratory tract resists airflow when a person breathes in and out) of the lungs and their total lung capacity. 5

It is often very hard for doctors to provide a conclusive diagnosis of asthma in children under 5 years of age, as their lungs are not sufficiently developed to accurately carry out lung function tests. Many other conditions such as rhinitis, sinusitis, and respiratory tract infections, such as bronchitis, have the same symptoms as asthma.

For this reason, doctors often opt to observe a child’s symptoms over a longer period with regular check-ups, until it is possible to provide an asthma diagnosis.

There is no cure for asthma, but asthma can be managed with proper prevention and treatment. Treatment for childhood asthma focuses on minimising exposure to any identified triggers, so as to avoid flare-ups. With the right treatment options identified, it should be possible for a child to pursue their activities, including sports and exercise, as normal.

As children learn to avoid asthma triggers, it is possible for them to manage their symptoms so effectively that they appear to “outgrow” their asthma. More than three-quarters of children who develop asthma symptoms before age 7 no longer exhibit perceptible symptoms by age 16.

However, there is always the possibility of further flare-ups, and asthma, which has been successfully managed for long periods, can resurface later in childhood, or in adulthood. Types of medication for childhood asthma include long-term medications, courses of immunology and quick-relief medications to unblock the airways during an asthmatic flare-up.

Good to know: Children with asthma may also be referred to an allergist who will be able to advise on specialised treatment, if their asthma is allergy-induced.

A range of different medications are available, depending on the severity of a child’s asthma. When a child’s symptoms respond well to treatment and the asthma is eventually running a lighter course over time, doctors may suggest switching to milder medications.

These medications are considered to be the most effective medications for controlling asthma when taken regularly. They work on a continuous basis to reduce swelling of the airways. The most commonly prescribed ICSs include fluticasone (Flovent Diskus, Flovent HFA), budesonide (Pulmicort Flexhaler), mometasone (Asmanex), ciclesonide (Alvesco) and beclomethasone (Qvar). These medications need to be taken regularly for several days to weeks, adhering to the prescription, before the child feels their full anti-asthmatic effects.

These medications are nebulized medications which provide immediate relief of asthma symptoms. They work by relaxing the inflamed airways, making breathing easier. SABA medications, for example, include albuterol (ProAir HFA, Ventolin HFA) and levalbuterol (Xopenex HFA).

These medications work by relaxing the muscles surrounding the bronchial tubes, which causes a widening of the airways. It is recommended that the long-acting beta agonists be used in combination with an anti-inflammatory medication, such as the inhaled corticosteroids.The most commonly prescribed LABA medications in the U.S. are salmeterol (Serevent), formoterol (Foradil) and a formoterol solution for nebulizers called Perforomist.

These medications contain both a long-acting beta agonist (LABA) and a corticosteroid. These drugs have very different ways of influencing the airways and have been found to offer a child the most benefit when they are combined. This allows a child to profit from both of their mechanisms of action at the same time and makes combination nebulizers an effective treatment option for childhood asthma (as well as adult asthma) in many cases. Commonly prescribed combination nebulizers include combinations of fluticasone plus salmeterol (Advair), mometasone plus formoterol (Dulera) and budesonide plus formoterol (Symbicort).

These medications are oral medications that can reduce asthma symptoms for up to 24 hours. They include montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo). Care should be taken when taking leukotriene modifiers as they have been, in rare cases, linked to psychological reactions, such as agitation, aggression, hallucinations, depression and suicidal thinking. Medical advice should be sought immediately if the child has any unusual reaction.

These medications are another treatment option for severe asthma. They work by widening the airways to allow for easier breathing. The most commonly prescribed anticholinergic medication is tiotropium (Spiriva).

These medications can be used to treat very severe cases of asthma in children, where symptoms persist despite the use of SABA, LABA and corticosteroid medications. This treatment involves introducing antibodies (biological agents which interact with the bodies cells to fight and interrupt the usual progression of an asthma attack) into the body.

The antibodies which are used to treat asthma in children are Anti-IgE (omalizumab) and anti-IL-5 (mepolizumab). Both of these medications have been found effective for treating asthma in children. In particular, in reducing exacerbation rate; the medical term for the condition becoming worse, or more symptoms developing, which can happen in a flare-up or an asthma attack. Their other benefits include helping bring a child’s asthmatic symptoms under control and improving their quality of life.

Mepolizumab (Nucala) may be appropriate for children with eosinophilic asthma, a subtype of asthma which is often severe, in which the whole respiratory tract becomes involved in obstructing the airways. mepolizumab works by reducing the number of eosinophils in the blood; the white blood cells that in large numbers interact with other factors in the blood and cause the airways to become inflamed, and thereby reduces the likelihood of an asthma attack for children with this type of asthma.

Omalizumab (Xolair) is used to treat children affected specifically by allergic asthma. It works by targeting immunoglobulin E, the substance produced by the body that causes inflammation of the airways in children with allergic asthma. This medication reduces the immune system's reaction to allergy-inducing substances, such as pollen, dust mites and pet dander, and calms inflammation. It is usually delivered by injection every two to four weeks.

Omalizumab is the only medication for asthma which must be administered by injection only. If it is recommended for treating a child, they will need to visit their healthcare provider to have the medication administered.

The Global Initiative for Asthma (GINA) provides a five-stage treatment plan which is very helpful in devising the right treatment plan to suit the individual asthmatic child. The GINA guidelines arrange a series of asthma treatment options as a sequence,

Following the GINA guidelines, a doctor will prescribe a treatment plan and assess its efficacy during regular check-ups. They will adjust the plan accordingly, continually measuring the child’s response to their treatment and refining the plan as needed, until the symptoms of asthma improve.

The guidelines recommend a five-step plan for the ongoing treatment of asthma, according to the severity of the child’s condition. Children with mild asthma will be treated according to the guidelines outlined in Step 1 (see below) and children with more severe symptoms will begin treatment according to the guidelines outlined in Step 2, 3, 4 or 5, depending on the severity of their asthma at the time of starting treatment. A step down to a milder treatment option can be considered during a monthly check-up, if the doctor considers the child’s symptoms to have improved sufficiently.

The GINA approach to controlling asthma symptoms aimed at reducing risk and improving asthma management includes the following steps:

The doctor will consider prescribing a low-dose inhaled corticosteroid (ICS) and will prescribe a short-acting beta-agonist (SABA) for relief as needed. Acting within minutes, and lasting several hours, short acting beta agonists are nebulized medications which can quickly relieve symptoms during an asthma attack. ICSs work by relieving airway inflammation caused by asthma.

Good to know: Long-term corticosteroid use is generally associated with severe side-effects, but the inhalatory steroids used in ICSs do not carry the same risks. When an ICS is administered correctly, the corticosteroid medication goes straight to a child’s airways and very little is absorbed into the rest of their body. ICSs are therefore safe for use on a long-term basis and tend to show their best effects after around three months of use. 6

The doctor will definitely prescribe a low-dose ICS, as is considered for children at Step 1, as well as prescribing a SABA for relief as needed.

A low-dose ICS or a long-acting beta-agonist (LABA) will be prescribed and a SABA or ICS for relief as needed. In some situations, long-acting beta agonists have been linked to severe asthma attacks if they are taken only by themselves without an ICS. For this reason, LABA medications should always be given to a child with a nebulizer that also contains a corticosteroid (ICS). These combination nebulizers should be used only for asthma that's not well-controlled by other medications.

A medium to high ICS/LABA will be prescribed and additionally SABA or another low dose ICS for relief as needed.

The doctor will refer the child for an add-on treatment for severe asthma, such as anticholinergic agents or immunomodulatory agents. They will also prescribe a SABA or ICS for relief as needed.

• Desensitization or hyposensitization (immunotherapy): Allergen-containing injections or oral medication gradually reduce any reaction of the child’s immune system to specific allergens over a period of months or years. The length of the course and intervals between injections vary according to the individual’s symptoms.
• Oral and nasal medications: The child may be prescribed antihistamines and decongestants in pill form, as well as, or as an alternative to corticosteroid, cromolyn (a drug that prevents the release of inflammatory chemicals such as histamine from mast cells) and ipratropium nasal sprays.

Q: Does childhood asthma damage the lungs?
A: It is important to diagnose and begin treating asthma in children promptly, in order to prevent it causing long-term damage to the lungs. Chronic (long-term) asthma, or asthma which is not treated effectively over the course of many years, has the potential to damage the lungs on a permanent basis in two main ways: by causing airway fibrosis (scarring) of the tissue in the airways and by causing remodelling (permanent narrowing of the airways). 7

Both of these changes result from the respiratory system being inflamed regularly for long periods. Not everybody has the potential to develop permanent lung damage from the inflammation associated with asthma, but it is important that all children with asthma begin effective treatment as soon as possible to avoid this outcome. The Asthma Center recommends that early and intensive treatment of childhood asthma should be focussed particularly on calming inflammation in order to reduce the risk of long-term lung damage.

Q: Can childhood asthma cause chronic obstructive pulmonary disease (COPD)?
A: Not usually, especially if asthma in children is treated promptly and effectively. The primary causes of COPD – a type of obstructive lung disease associated with long term breathing problems and poor air flow which usually develops in adulthood – are smoking tobacco and exposure to poor quality air, for example, living in an area with high pollution.

However, COPD can also be caused by genetic factors and people, who are affected by asthma or who have been affected as children, are believed to be at greater risk than the general population of developing the condition. 8 Recent research indicates that persistent (long term, severe or ineffectively treated) childhood asthma can lead to reduced lung growth and function in adulthood, an outcome which is found to increase the possibility of developing COPD. 9

Q: Can childhood asthma come back during pregnancy?
A: Many children appear to “outgrow” childhood asthma. However, there is no cure for asthma and there is always the possibility that a child may encounter new triggers and re-experience the symptoms as an adult. Pregnancy may place unfamiliar stresses on the body, which could trigger asthmatic symptoms. 10 Feeling unwell? Get a free symptom assessment with the Ada app.

• Asthma in children
• Bronchial asthma in children
• Pediatric asthma