Childhood asthma

In childhood asthma, the lungs and airways become easily inflamed when exposed to certain triggers. Such triggers include inhaling pollen or catching a cold or other respiratory infection. Childhood asthma can cause irritating daily symptoms that interfere with play, sports, school and sleep. In some children, asthma can cause dangerous asthma attacks if it’s not managed properly.

Childhood asthma isn’t a different disease from asthma in adults, but children face unique challenges. The condition is a leading cause of emergency department visits, hospitalizations and missed school days.

Childhood asthma can’t be cured, and symptoms can continue into adulthood. But with the right treatment, you and your child can keep symptoms under control and prevent damage to growing lungs.

Common childhood asthma symptoms include:

• A whistling or wheezing sound when breathing out.
• Shortness of breath.
• Chest congestion or tightness.
• Coughing that gets worse if a child:
  • Has a viral infection.
  • Is sleeping.
  • Is exercising.
  • Is in the cold air.

Childhood asthma also might cause:

• Trouble sleeping due to shortness of breath, coughing or wheezing.
• Bouts of coughing or wheezing that get worse with a cold or the flu.
• Delayed recovery or bronchitis after a respiratory infection.
• Trouble breathing that hampers play or exercise.
• Fatigue, which can be due to poor sleep.

Asthma symptoms vary from child to child and might get worse or better over time. Your child might have only one symptom, such as a lingering cough or chest congestion.

It can be difficult to tell whether a child’s symptoms are caused by asthma. Wheezing and other asthmalike symptoms can be caused by infectious bronchitis or another respiratory problem.

Take your child to see a healthcare professional if you suspect that your child has asthma. Early treatment will help control symptoms and possibly prevent asthma attacks.

Make an appointment with a health professional if you notice:

• Coughing that is constant, is intermittent or seems linked to physical activity.
• Wheezing or whistling sounds when your child breathes out.
• Shortness of breath or rapid breathing.
• Complaints of chest tightness.
• Repeated episodes of suspected bronchitis or pneumonia.

Children who have asthma may say things such as, “My chest feels funny” or “I’m always coughing.” Listen for coughing in children, which might not wake them, when they are asleep. Crying, laughing, yelling, or strong emotional reactions and stress also might trigger coughing or wheezing.

If your child is diagnosed with asthma, creating an asthma plan can help you and other caregivers monitor symptoms and know what to do if an asthma attack occurs.

When to seek emergency treatment

In severe cases, you might see your child’s chest and sides pulling inward when breathing is difficult. Your child might have an increased heartbeat, sweating and chest pain. Seek emergency care if your child:

• Has to stop in midsentence to take a breath.
• Is using stomach muscles to breathe.
• Has widened nostrils when breathing in.
• Is trying so hard to breathe that the stomach is sucked under the ribs during a breath.

Even if your child hasn’t been diagnosed with asthma, seek medical attention immediately if you notice troubled breathing. Although episodes of asthma vary in severity, asthma attacks can start with coughing. This progresses to wheezing and labored breathing.

Childhood asthma causes aren’t fully understood. Increased immune system sensitivity causes the lungs and airways to swell and produce mucus when exposed to certain triggers. Reaction to a trigger can be delayed, making it more difficult to identify the trigger. Triggers vary from child to child and can include:

• Viral infections such as the common cold.
• Exposure to air pollutants, such as tobacco smoke.
• Allergies to dust mites, pet dander, pollen or mold.
• Physical activity.
• Weather changes or cold air.

Sometimes, asthma symptoms happen with no apparent triggers.

Factors that might increase a child’s chance of developing asthma include:

• Exposure to tobacco smoke, including before birth.
• Previous allergic reactions, including skin reactions, food allergies or hay fever, also called allergic rhinitis.
• A family history of asthma or allergies.
• Early childhood airway infections.
• Living in an area with high pollution.
• Obesity.
• Respiratory conditions, such as a chronic runny or stuffy nose, inflamed sinuses, or pneumonia.
• Gastroesophageal reflux disease (GERD).
• Being male.
• Being Black or Puerto Rican.

Asthma can cause a number of complications, including:

• Severe asthma attacks that need emergency treatment or hospital care.
• Permanent decline in lung function.
• Missed school days or falling behind in schoolwork.
• Poor sleep and extreme tiredness.
• Symptoms that interfere with play, sports or other activities.

Careful planning and avoiding asthma triggers are the best ways to prevent asthma attacks.

• Limit exposure to asthma triggers. Help your child avoid the allergens and irritants that trigger asthma symptoms.
• Don’t allow smoking around your child. Exposure to tobacco smoke during infancy is a strong risk factor for childhood asthma, as well as a common trigger of asthma attacks. E-cigarettes or other vaping devices also can make asthma symptoms worse.
• Encourage your child to be active. As long as your child’s asthma is well controlled, regular physical activity can help the lungs work more efficiently.

• See your child’s healthcare team when necessary. Check in regularly. Don’t ignore signs that your child’s asthma might not be under control, such as needing to use a quick-relief inhaler too often.

  Asthma changes over time. Consulting a health professional can help you make needed treatment adjustments to control symptoms.

• Help your child maintain a healthy weight. Being overweight can make asthma symptoms worse. And excess weight puts your child at risk of other health problems.
• Keep heartburn under control. Acid reflux or bad heartburn might make your child’s asthma symptoms worse. To control acid reflux, your child may need prescription medicines or medicines you can buy off the shelf.

Asthma can be hard to diagnose. A healthcare professional considers the symptoms and a child’s medical history. Tests may be needed to rule out other conditions, including:

• Lung function tests. Healthcare professionals diagnose asthma in children with the same tests used to identify the disease in adults. Spirometry measures how much air a child can exhale and how quickly. A child might have lung function tests at rest, after exercising and after taking asthma medicine.

  A peak flow meter is a simple device that measures how hard the child can breathe out.

  Another lung function test is brochoprovocation. Using spirometry, this test measures how the lungs react to certain triggers, such as exercise or exposure to cold air.

• Exhaled nitric oxide test. If the diagnosis of asthma is uncertain after lung function tests, a healthcare professional might recommend measuring the level of nitric oxide in an exhaled sample of a child’s breath. Nitric oxide testing also can help find whether steroid medicines might be helpful for the child’s asthma.
• Allergy tests for allergic asthma. If a child seems to have asthma that’s triggered by allergies, a healthcare professional might recommend allergy skin testing. During a skin test, the skin is pricked with extracts of common allergy-causing substances, such as animal dander, mold or dust mites, and observed for signs of an allergic reaction.

Certain asthma tests aren’t accurate before 5 years of age. For younger children, a health professional will rely on information you and your child provide about symptoms. A trial of asthma medicines may be done to see how your child responds. Sometimes a diagnosis can’t be made until later, after months or even years of observing symptoms.

Conditions that look like asthma

A number of childhood conditions can have symptoms like those caused by asthma. To complicate the diagnosis further, these conditions also commonly happen along with asthma. So a health professional will have to determine whether a child’s symptoms are caused by asthma, a condition other than asthma, or both asthma and another condition.

Conditions that can cause asthmalike symptoms include:

• Rhinitis.
• Sinusitis.
• Acid reflux or gastroesophageal reflux disease (GERD).
• Airway problems.
• Breathing problems.
• Respiratory tract infections such as bronchiolitis and respiratory syncytial virus (RSV).

Initial treatment depends on the seriousness of the child’s asthma. The goal of asthma treatment is to keep symptoms under control, meaning that a child has:

• Minimal or no symptoms.
• Few or no asthma flare-ups.
• No limitations on physical activities or exercise.
• Minimal use of quick-relief inhalers, such as albuterol (ProAir HFA, Ventolin HFA, others). These also are called rescue inhalers.
• Few or no side effects from medicines.

However, if an infant or toddler has frequent or severe wheezing episodes, a health professional might prescribe a medicine to see if it improves symptoms.

Long-term control medicines

Preventive, long-term control medicines reduce the inflammation in a child’s airways that leads to symptoms. In most cases, these medicines need to be taken daily.

Types of long-term control medicines include:

• Inhaled corticosteroids. These medicines include fluticasone (Flovent Diskus), budesonide (Pulmicort Flexhaler), mometasone (Asmanex HFA), ciclesonide (Alvesco), beclomethasone (Qvar Redihaler) and others. A child might need to use these medicines for several days to weeks before getting the full benefit.

  Long-term use of these medicines has been associated with slightly slowed growth in children, but the effect is minor. In most cases, the benefits of good asthma control outweigh the risks of possible side effects.

• Leukotriene modifiers. These oral medicines include montelukast (Singulair) and zafirlukast (Accolate). They help prevent asthma symptoms for up to 24 hours.

• Combination inhalers. These medicines contain an inhaled corticosteroid plus a long-acting beta agonist (LABA). They include fluticasone and salmeterol (Advair Diskus), budesonide and formoterol (Symbicort), fluticasone and vilanterol (Breo Ellipta), and mometasone and formoterol (Dulera).

  In some situations, long-acting beta agonists have been linked to severe asthma attacks. For this reason, LABA medicines should always be given to a child with an inhaler that also contains a corticosteroid. These combination inhalers should be used only for asthma that’s not well controlled by other medicines.

• Biologics. Mepolizumab (Nucala), dupilumab (Dupixent) and benralizumab (Fasenra) might be appropriate for children over the age of 6 who have severe eosinophilic asthma. Omalizumab (Xolair) can be considered for children age 6 and older who have moderate to severe allergic asthma. Tezepelumab (Tezspire) is a biologic approved for children age 12 and older who have severe asthma.

Quick-relief medicines

Quick-relief medicines quickly open swollen airways. Also called rescue medicines, quick-relief medicines are used as needed for rapid, short-term symptom relief during an asthma attack — or before exercise if a healthcare professional recommends it.

Types of quick-relief medicines include:

• Short-acting beta agonists (SABAs). These inhaled bronchodilator medicines can quickly ease symptoms during an asthma attack. They include albuterol and levalbuterol (Xopenex HFA). These medicines act within minutes, and effects last several hours. Sometimes SABAs may be combined with a corticosteroid.
• Oral and intravenous corticosteroids. These medicines relieve airway inflammation caused by severe asthma. Examples include prednisone and methylprednisolone. They can cause serious side effects when used long term, so they’re only used to treat severe asthma symptoms on a short-term basis.

Treatment for allergy-induced asthma

If a child’s asthma is triggered or worsened by allergies, the child might benefit from allergy treatment, including:

• Omalizumab. This medicine is for people who have allergies and severe asthma. It reduces the immune system’s reaction to allergy-causing substances, such as pollen, dust mites and pet dander. Omalizumab is delivered by injection every four weeks.
• Allergy medicines. These include oral and nasal spray antihistamines and decongestants.
• Immunotherapy. Over time, immunotherapy may gradually reduce a child’s immune system reaction to specific allergens. This type of treatment is available as a shot or as a pill dissolved under the tongue.

Don’t rely only on quick-relief medicines

Long-term asthma control medicines such as inhaled corticosteroids are the cornerstone of asthma treatment. These medicines keep asthma under control and make it less likely that a child will have an asthma attack.

If a child does have an asthma flare-up, a quick-relief inhaler, also called a rescue inhaler, can ease symptoms right away. But if long-term control medicines are working properly, a child shouldn’t need to use a quick-relief inhaler very often.

Keep a record of how many puffs your child uses each week. If your child often needs to use a quick-relief inhaler, see a healthcare professional. You’ll probably need to adjust your child’s long-term control medicine.

Inhaled medicine devices

Inhaled short- and long-term control medicines are used by inhaling a measured dose of medicine.

• Older children and teens might use a small, hand-held device called a pressurized metered dose inhaler or an inhaler that releases a fine powder.
• Infants and toddlers need to use a face mask attached to a metered dose inhaler or a nebulizer to get the correct amount of medicine.
• Babies need to use a device that turns liquid medicine into fine droplets, called a nebulizer. The baby wears a face mask and breathes regularly while the nebulizer delivers the correct dose of medicine.

Asthma action plan

Work with your child’s healthcare professional to create a written asthma action plan. This can be an important part of treatment, especially if your child has severe asthma. An asthma action plan can help you and your child:

• Recognize when you need to adjust long-term control medicines.
• Determine how well treatment is working.
• Identify the signs of an asthma attack and know what to do when one happens.
• Know when to call a healthcare professional or seek emergency help.

Children who have enough coordination and understanding might use a hand-held device called a peak flow meter. A peak flow meter measures how well they can breathe. A written asthma action plan can help you and your child remember what to do when peak flow measurements reach a certain level.

The action plan might use peak flow measurements and symptoms to categorize your child’s asthma into zones, such as a green zone, a yellow zone and a red zone. These zones correspond to well-controlled symptoms, partly controlled symptoms and poorly controlled symptoms. This makes tracking your child’s asthma easier.

Your child’s symptoms and triggers are likely to change over time. Observe symptoms and work with your child’s healthcare professional to adjust medicines as needed.

If your child’s symptoms are completely controlled for a time, your child’s healthcare team might recommend lowering doses or stopping asthma medicines. This is known as step-down treatment. If your child’s asthma isn’t as well controlled, the health professional might want to increase, change or add medicines. This is known as step-up treatment.

While some alternative remedies are used for asthma, in most cases more research is needed to see how well they work and to determine possible side effects. Alternative treatments to consider include breathing techniques. These include structured breathing programs, such as the Buteyko breathing technique, the BrEX method and yoga breathing exercises.

Taking steps to reduce your child’s exposure to asthma triggers can lessen the possibility of asthma attacks. Steps to help avoid triggers vary depending on what triggers your child’s asthma. Here are some things that may help:

• Maintain low humidity at home. If you live in a damp climate, talk to your child’s healthcare team about using a device to keep the air drier, called a dehumidifier.
• Keep indoor air clean. Have a heating and air conditioning professional check your air conditioning system every year. Change the filters in your furnace and air conditioner according to the manufacturer’s instructions. Also consider installing a small-particle filter in your ventilation system.
• Reduce pet dander. If your child is allergic to dander, it’s best to avoid pets with fur or feathers. If you have pets, regularly bathing or grooming them might reduce the amount of dander. Keep pets out of your child’s room.
• Use your air conditioner. Air conditioning helps reduce the amount of airborne pollen from trees, grasses and weeds that finds its way indoors. Air conditioning also lowers indoor humidity and can reduce your child’s exposure to dust mites. If you don’t have air conditioning, try to keep your windows closed during pollen season.
• Keep dust to a minimum. Reduce dust that can aggravate nighttime symptoms by adjusting certain items in your child’s bedroom. For example, encase pillows, mattresses and box springs in dustproof covers. Consider removing carpeting and installing hard flooring in your home, particularly in your child’s bedroom. Use washable curtains and blinds.
• Clean regularly. Clean your home at least once a week to remove dust and allergens.
• Reduce your child’s exposure to cold air. If your child’s asthma is worsened by cold, dry air, wearing a face mask outside can help.

It can be stressful to help a child manage asthma. Keep these tips in mind to make life as easy as possible:

• Make treatment a regular part of life. If your child has to take daily medicine, don’t make a big deal out of it — it should be as routine as eating breakfast or brushing teeth.

• Use a written asthma action plan. Work with your child’s healthcare team to develop your child’s action plan. Give a copy to all of your child’s caregivers, such as child care providers, teachers, coaches and the parents of your child’s friends.

  Following a written plan can help you and your child identify symptoms early. An organized plan provides important information on how to treat your child’s asthma from day to day and how to deal with an asthma attack.

• Be encouraging. Focus attention on what your child can do, not on limitations. Involve teachers, school nurses, coaches, relatives and friends in helping your child manage asthma.

  Encourage typical play and activity. Don’t limit your child’s activities out of fear of an asthma attack — work with your child’s care team to control exercise-induced symptoms.

• Be calm and in control. Don’t get rattled if asthma symptoms worsen. Focus on your child’s asthma action plan, and involve your child in each step so that your child understands what’s happening.
• Talk to other parents of children with asthma. Chat rooms and message boards on the internet or a local support group can connect you with parents facing similar challenges.
• Help your child connect with others who have asthma. Send your child to “asthma camp” or find other organized activities for children with asthma. This can help your child feel less isolated and gain a better understanding of asthma and its treatment.

You’re likely to start by taking your child to someone on your primary healthcare team or your child’s pediatrician. However, when you call to set up an appointment, you may be referred to an allergist, a lung doctor, called a pulmonologist, or another specialist. Here’s some information to help you get ready for your child’s appointment.

What you can do

Make a list of:

• Your child’s symptoms, how severe they are and when they happen. Note when symptoms bother your child most — for example, if symptoms tend to get worse at certain times of the day; during certain seasons; when your child is exposed to cold air, pollen or other triggers; or when your child is playing hard or playing sports.
• Key personal information, including any major stresses or recent life changes your child has had.
• All medicines, vitamins and supplements your child takes, including doses.
• Questions to ask during the appointment.

For asthma or asthmalike symptoms, questions to ask include:

• Is asthma the most likely cause of my child’s breathing problems?
• What else could be causing my child’s symptoms?
• What tests does my child need?
• Is my child’s condition likely temporary or chronic?
• What treatment do you suggest?
• My child has other health conditions. How can we best manage them together?
• Are there restrictions my child needs to follow?
• Should my child see a specialist?
• Are there brochures or other printed materials I can have? What websites do you recommend?

Don’t hesitate to ask other questions.

What to expect from your child’s doctor

You’ll likely be asked a few questions, including:

• When did you notice your child’s symptoms?
• Does your child have difficulty breathing most of the time or only at certain times or in certain situations?
• Does your child have allergies such as hay fever?
• What, if anything, appears to worsen your child’s symptoms?
• What, if anything, seems to improve your child’s symptoms?
• Do allergies or asthma run in your child’s family?