Overview
Asthma is a long-term condition of the airways. The lining becomes inflamed and swollen and the muscle around the airways tightens, so less air gets through. It is the commonest long-term illness of childhood.
Symptoms come and go. A child can be completely well for weeks and then have a bad spell when a cold goes round, when dust is stirred up or when the weather turns. The aim of treatment is simple: no symptoms most of the time, no broken nights, no missed school, and no attacks.
Symptoms
The four main symptoms are wheeze, which is a whistling sound on breathing out, cough, breathlessness and a tight feeling in the chest. In children the cough often comes first and may be the only sign: a cough at night that wakes the child, a cough after running about, or one that lingers for weeks after a cold.
During an attack the symptoms get worse together. The child breathes fast, cannot finish a sentence, may be unable to eat or drink, and the reliever does not give the usual relief. A child may also just seem tired, quiet and unwilling to join in, which is easy to miss.
When to see a doctor
See a doctor in the next few days if the reliever is needed more often than before, if the child wakes at night with cough or wheeze, if running brings on symptoms, if school or sleep is being disturbed, or if a cough has not gone weeks after a cold. These are signs the asthma is not controlled, and the treatment can usually be adjusted.
Causes
There is no single cause. Asthma runs in families and is commoner in children who also have eczema or hay fever. Being born early, chest infections in the first years, and exposure to tobacco smoke or polluted air all make it more likely.
Symptoms are set off by triggers, which differ from child to child: house dust, tobacco and cooking smoke, mosquito coils and incense, pollen, animal fur, strong perfumes and cleaning smells, cold air, air pollution, colds and other infections, and exercise. Knowing a child's own triggers is more useful than avoiding everything.
Risk factors
- A parent, brother or sister with asthma, eczema or hay fever
- Eczema or allergies in the child
- Being born prematurely, or with a low birth weight
- Chest infections in the first years of life
- Tobacco smoke in the home, including smoke from someone smoking outdoors on their clothes
- Smoke from cooking fires, mosquito coils and incense
- Outdoor air pollution and traffic fumes
- Being overweight
Complications
- Asthma attacks, which can be life-threatening
- Broken sleep, for the child and the family
- Missed school, and falling behind
- Avoiding sport and play, and losing fitness
- Repeated hospital visits when asthma is not controlled
- Side effects from frequent courses of steroid tablets for attacks
Prevention
- Taking the preventer every day, even when the child feels well
- Keeping a written asthma action plan, with a copy at school
- Checking inhaler technique at every review, and using a spacer
- A smoke-free home and car, with no smoking indoors by anyone
- Better ventilation while cooking, and fewer mosquito coils and incense sticks indoors
- Damp dusting, washing bedding regularly, and keeping the child's room uncluttered
- Flu and other recommended vaccinations
- An asthma review at least once a year
Diagnosis
The doctor asks about the pattern: when the symptoms come, what brings them on, whether they wake the child, and whether they improve with an . A family history of asthma, eczema or hay fever is relevant. The chest is listened to, though it can sound normal between attacks.
Breathing tests help in older children: a peak flow meter, or a lung function test where the child blows into a machine. Children under five often cannot do these tests reliably, so the diagnosis rests more on the story and on whether treatment helps. Allergy tests, a chest X-ray or blood tests may be used to rule out other causes.
Treatment
Treatment is built around two inhalers. The preventer, usually an inhaled steroid, is taken every day to reduce the swelling in the airways, and it works over weeks rather than minutes. The reliever opens the airways within minutes and is used when symptoms appear. Some children are given a combination that does both.
How the inhaler is used matters as much as which one it is. Children should use a spacer, and the youngest use a spacer with a soft mask. Very young children are sometimes given medicine through a . Technique is worth checking at every visit, because a great deal of medicine is lost to a poor technique.
Every child should have a written action plan setting out the daily medicines, what to do when symptoms start, and when to get emergency help. Tablets such as montelukast are added for some children. Attacks are treated with the reliever and often a short course of steroid tablets, and severe attacks are treated in hospital.
Myths and facts
Things people often say about this. Open each one to see what is true.
Myth“Inhalers are addictive, so we should save them for when the child is really bad.”What is true?
Fact
Inhaled medicine is the main treatment for asthma, not a last step. It puts a small dose straight into the airways, and the World Health Organization describes inhalers as what allows people with asthma to live a normal, active life, while warning that asthma is often under-treated, particularly where inhalers are hard to get. A child needing the reliever more and more often is telling you the asthma is not controlled, which is a reason to see the doctor rather than to use the inhaler less.
Myth“A child with asthma should not run, play sport or swim.”What is true?
Fact
Having asthma does not mean a child cannot exercise. Exercise is one of the things that can bring symptoms on, so the answer is a preventer inhaler taken daily and a reliever kept to hand, not giving up games. Exercise is part of living well with asthma, and a child who cannot play without symptoms needs their treatment reviewed.
Myth“The preventer inhaler can be stopped once the child is well again.”What is true?
Fact
The preventer works only while it is being taken, so a child who feels well is often a child whose preventer is doing its job. NHS advice is not to stop a steroid inhaler without speaking to the doctor first. Doses are changed at a review, by the doctor, and reduced gradually when that is right.
Myth“Asthma is caused by cold foods, curd, bananas or ice cream, so those must all be stopped.”What is true?
Fact
The triggers doctors recognise are dust, smoke including tobacco and cooking smoke, pollen, animal fur, strong smells, cold air, air pollution, colds and other infections, and exercise. Every child is different, so it is worth noting what actually brings symptoms on rather than cutting foods a growing child needs. If a genuine food allergy is suspected, that deserves proper testing.
Questions to ask your doctor
Tick the ones you want answered and take them with you.
Common questions
Will my child grow out of asthma?
Symptoms often improve as a child grows, and some children have little trouble as adults. That is not something to wait for, though. Uncontrolled asthma in the meantime means broken sleep, missed school and attacks that can be dangerous, so treatment is what keeps a child well while they grow.
Are steroid inhalers safe for a child?
The dose in a preventer inhaler goes mainly to the airways, and low doses used for a short time usually cause no problems. High doses over a long period can slow growth a little and affect the bones, which is why the doctor prescribes the lowest dose that keeps the asthma controlled and checks the child's height and weight at reviews. Rinsing the mouth after the preventer helps avoid mouth irritation.
Does my child need to use a spacer, or can they use the inhaler on its own?
A spacer is recommended for children. It holds the puff of medicine so the child can breathe it in over several breaths, which means more reaches the lungs and less lands in the mouth and throat. Younger children use a spacer with a mask over the nose and mouth. Ask the doctor or nurse to watch your child use it and to show you how to clean it.
What should the school know?
Give the school a copy of the written action plan, tell the class teacher and the sports teacher which inhaler is the reliever and when to use it, and make sure a reliever inhaler and spacer are kept where staff can reach them. Children with well-controlled asthma should be taking part in games, not sitting them out.
