What is asthma in children?
Asthma is a chronic inflammatory disorder of the airways, characterized by recurrent, reversible, airway obstruction. Airway inflammation leads to airway hyperreactivity, which causes the airways to narrow in response to various stimuli, including allergens, exercise, and cold air.
How common is asthma in children?
Asthma is the most common chronic disease of childhood. The prevalence of asthma is increasing. This is also the case with other allergy conditions, including eczema (atopic dermatitis), hay fever (allergic rhinitis), and food allergies. According to recent CDC data, asthma affects approximately 8.5% of the pediatric population in the U.S., or more than 7 million children. Asthma accounts for more school absences and more hospitalizations than any other chronic condition in this country.
Asthma Risk – Who & Why?
Medical Author: Alan Szeftel, MD, FCCP
Medical Editor: William
C. Shiel Jr., MD, FACP, FACR
One of the more frequent questions my patients ask me concerns the relative risk of their child developing allergiesor asthma. In previous Doctors’ Views, I have raised issues relating the environment to the development of allergies or asthma. However, both a genetic predisposition and environmental/lifestyle factors are necessary for these conditions to develop.
The incidence of asthma has risen dramatically in the past 20 years—a period too short to reflect any significant changes in the gene pool. This supports the important role that environmental influences (allergy, infection, lifestyle, and diet) have on the development of asthma.
What role then does genetics (heredity) play in asthma? A genetic link in asthma has long been suspected primarily due to “clustering” of cases within families and in identical twins. This does not prove a genetic cause, since it may also reflect shared environmental exposures. Several studies conclude that heredity increases your chances of developing asthma, particularly if allergies or other allergic conditions are present. Moreover, you may pass this tendency to asthma to the next generation. So, what are the chances that your child will develop asthma?
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What is the treatment for asthma in children?
The goals for the treatment of asthma in children are to
- adequately control symptoms;
- minimize the risk of future exacerbations;
- maintain normal lung function;
- maintain normal activity levels; and
- use the least amount of medication possible with the least amount of potential side effects.
Inhaled corticosteroids (cortisone medication) are the most effective anti-inflammatory agents available for the chronic treatment of asthma and are generally first-line therapy per most asthma guidelines. It is well recognized that inhaled corticosteroids are very effective in decreasing the risk of asthma exacerbations. Furthermore, the combination of a long-acting bronchodilator and an inhaled corticosteroid has a significant additional beneficial effect on improving asthma control.
A complete list of commonly used asthma medications is as follows:
- Short-acting bronchodilators provide quick relief and are used for exercise-induced symptoms (for example, albuterol [Proventil, Ventolin, ProAir, Maxair, Xopenex]).
- Inhaled steroids are first-line anti-inflammatory therapy (for example, budesonide,
fluticasone, beclomethasone, mometasone, ciclesonide). - Long-acting bronchodilators can be added to inhaled corticosteroids as additive
therapy (for example, salmeterol, formoterol). - Leukotriene modifiers can also serve as anti-inflammatory agents (for example,
montelukast, zafirlukast). - Anticholinergic agents can help decrease sputum production (for example,
ipratropium, tiotropium). - Anti-IgE therapy can be used in adolescents with allergic asthma (for example, omalizumab).
- Chromones stabilize mast cells (allergic cells) but are rarely used in clinical practice
(for example, cromolyn, nedocromil). - Theophylline also helps with bronchodilation (opening the airways) but again is rarely used in clinical practice due to an unfavorable side effect profile.
- Systemic steroids are potent anti-inflammatory agents that are routinely used to treat asthma exacerbations but pose numerous unwanted side effects if used repeatedly or chronically (for example, prednisone, prednisolone, methylprednisone, dexamethasone).
- Numerous other monoclonal antibodies are being currently studied but none are currently commercially available for routine therapy of asthma.
There is often concern about potential long-term side effects for even inhaled corticosteroids. Numerous studies have repeatedly shown that even long-term use of inhaled corticosteroids has very few if any sustained clinically significant side effects, including growth in children. However, the goal always remains to treat children (and adults) with the least amount of medication that is effective.
Asthma medications can be administered via nebulized solution, which requires no technique and is very helpful in young children (often under 5 years of age). Around 5 years of age, children can transition to inhalers either with or without an aerochamber and/or a mask. It is important to note that if an individual has proper technique with an inhaler, the amount of medication deposition in the lungs is no different than with using a nebulized solution. When prescribing asthma medications, it is essential to provide the proper teaching on proper delivery technique.
Although the vast majority of children with asthma are treated as outpatients, treatment of severe exacerbations can require management in the emergency department or inpatient hospitalization. These children typically require use of supplemental oxygen, early administration of systemic steroids, and frequent or even continuous administration of bronchodilators via a nebulized solution. Children at high risk for poor asthma outcomes should be referred to a specialist (pulmonologist or allergist). Children with the following factors may be at high risk:
- History of ICU admission or multiple hospitalizations for asthma
- History of multiple visits to the emergency department for asthma
- History of frequent use of systemic steroids for asthma
- Ongoing symptoms despite the use of appropriate medications
- Significant allergies contributing to poorly-controlled asthma
What is the prognosis for asthma in children?
The prognosis is best in young children who wheeze with viral respiratory infections and who have no symptoms in between these episodes. It can often be difficult to differentiate these “early wheezers” from children with true asthma. Children with recurrent symptoms tend to have ongoing asthma later in life. Boys “outgrow” asthma more often than girls, and a child with no evidence of environmental allergies has a better chance of “outgrowing” asthma as compared to a child with concurrent allergic disease (hay fever). Even in children with ongoing asthma, prognosis is excellent for those with preserved activity level and lung function through the use of appropriate medications.
Can asthma in children be prevented?
With the increasing prevalence of asthma, numerous studies have looked at risk factors and ways to potentially prevent asthma. It has been shown that children living on farms are protected against wheezing, asthma, and even environmental allergies. The role of air pollution has been questioned in both the increased incidence of asthma and in regards to asthma exacerbations. Climate change is also being studied as a factor in the increased incidence of asthma. Maternal smoking during pregnancy is a risk factor for asthma and poor outcomes. Secondhand tobacco smoke is also a significant risk factor for development and progression of asthma. Up to 50% of children who experience significant respiratory syncytial virus (RSV) infection are eventually diagnosed with asthma. Evidence suggests that the risk of asthma is reduced in children with a history of certain infections, rural living, exposure to other children (including older siblings), and less frequent use of antibiotics. The development of asthma is ultimately a complicated process influenced by many environmental and genetic factors, and therefore there is no proven way to decrease a child’s risk of developing asthma.
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