Doctor's Notes on Asthma in Children
Asthma is a chronic disorder caused by inflammation in the airways that causes the airways to tighten and narrow, blocking air from flowing freely into the lungs and making it hard to breathe. The inflammation of the airways makes them very sensitive and an asthma attack can occur when a person is exposed to certain “triggers.” Common asthma triggers include exercise, allergies, viral infections, and smoke. In most children, asthma develops before 5 years of age, and in more than half, asthma develops before 3 years of age.
Symptoms of asthma include wheezing, breathlessness, chest tightness, and cough, particularly at night or after exercise or physical activity. During severe asthma attacks in older children symptoms may include restlessness, being out of breath while resting, sitting upright, speaking just words and not sentences), sleepiness, and confusion. Other symptoms of asthma in infants or young children may include lung infections (bronchitis) or pneumonia, stomach breathing (use of abdominal muscles to breathe), and lack of interest in feeding.
Asthma in Children Symptoms
- Wheezing is when the air flowing into the lungs makes a high-pitched whistling sound.
- Mild wheezing occurs only at the end of a breath when the child is breathing out (expiration or exhalation). More severe wheezing is heard during the whole exhaled breath. Children with even more severe asthma can also have wheezing while they breathe in (inspiration or inhalation). However, during a most extreme asthma attack, wheezing may be absent because almost no air is passing through the airways.
- Asthma can occur without wheezing and be associated with other symptoms such as cough, breathlessness, chest tightness. So wheezing is not necessary for the diagnosis of asthma. Also, wheezing can be associated with other lung disorders such as cystic fibrosis.
- In asthma related to exercise (exercise-induced asthma) or asthma that occurs at night (nocturnal asthma), wheezing may be present only during or after exercise (exercise-induced asthma) or during the night, especially during early part of morning (nocturnal asthma).
- Cough may be the only symptom of asthma, especially in cases of exercise-induced or nocturnal asthma. Cough due to nocturnal asthma (nighttime asthma) usually occurs during the early hours of morning, from 1 a.m. to 4 a.m. Usually, the child doesn't cough anything up so there is no phlegm or mucus. Also, coughing may occur with wheezing.
- Chest tightness: The child may feel like the chest is tight or won't expand when breathing in, or there may be pain in the chest with or without other symptoms of asthma, especially in exercise-induced or nocturnal asthma.
- Other symptoms: Infants or young children may have a history of cough or lung infections (bronchitis) or pneumonia. Children with asthma may get coughs every time they get a cold. Most children with chronic or recurrent bronchitis have asthma.
Symptoms can be different depending on whether the asthma episode is mild, moderate, or severe.
- Symptoms during a mild episode: Children may be out of breath after a physical activity, such as walking or running. They can talk in sentences and lie down, and they may be restless. The feeding may be with interruption, therefore, the infant takes longer to finish the feed.
- Symptoms during a moderately severe episode: Children are out of breath while talking. Infants have a softer, shorter cry, and feeding is difficult. There is feeding with interruption and the child may not be able to finish the usual quantity of the feed.
- Symptoms during a severe episode: Children are out of breath while resting, they sit upright, they talk in words (not sentences), and they are usually restless. Infants are not interested in feeding and are restless and out of breath. Infant may try to start feeding but cannot sustain feeding due to breathlessness.
- Symptoms indicating that breathing will stop: In addition to the symptoms already described, the child is sleepy and confused. However, adolescents may not have these symptoms until they actually stop breathing. The infant may not be interested in feeding.
In most children, asthma develops before 5 years of age, and in more than half, asthma develops before 3 years of age.
Asthma in Children Causes
Although people with asthma have some type of allergy, the allergy isn't always the primary cause of asthma. Even if allergies are not your child's primary triggers for asthma (asthma may be triggered by colds, the flu, or exercise for example), allergies can still make symptoms worse.
Children inherit the tendency to have allergies from their parents. People with allergies make too much "allergic antibody," which is called immunoglobulin E (IgE). The IgE antibody recognizes small quantities of allergens and causes allergic reactions to these usually harmless particles. Allergic reactions occur when IgE antibody triggers certain cells (called mast cells) to release a substance called histamine. Histamine occurs in the body naturally, but it is released inappropriately and at too high an amount in people with allergies. The released histamine is what causes the sneezing, runny nose, and watery eyes associated with some allergies. In a child with asthma, histamine can also trigger asthma symptoms and flares.
An allergist can usually identify any allergies a child may have. Once identified, the best treatment is to avoid exposure to allergens whenever possible. When avoidance isn't possible, antihistamine medications may be prescribed to block the release of histamine in the body and stop allergy symptoms. Nasal steroids can be prescribed to block allergic inflammation in the nose. In some cases, an allergist can prescribe immunotherapy, which is a series of allergy shots that gradually make the body unresponsive to specific allergens.
Children who have exercise-induced asthma develop asthma symptoms after vigorous activity, such as running, swimming, or biking. For some children, exercise is the only thing that triggers asthma; for other children, exercise as well as other factors, trigger symptoms. Young children with exercise-induced asthma may have subtle symptoms such as coughing or undue breathlessness after physical activity during play. Not every type or intensity of exercise causes symptoms in children with exercise-induced asthma. With the right medicine, most children with exercise-induced asthma can play sports like any other child. In fact, a significant portion of Olympic athletes have exercise-induced asthma they've learned to control.
If exercise is a child's only asthma trigger, the doctor may prescribe a medication that the child takes before exercising to prevent airways from tightening up. Of course, asthma flare-ups can still occur. Parents (or older children) must carry the proper "rescue" medication (such as metered-dose inhalers) to all games and activities, and the child's school nurse, coaches, scout leaders, and teachers must be informed of the child's asthma. Make sure the child will be able to take the medication at school as needed.
Asthma in children usually has many causes, or triggers. These triggers may change as a child ages. A child's reaction to a trigger may also change with treatment. Viral infections can increase the likelihood of an asthma attack. Common triggers of asthma include the following:
- Respiratory infections: These are usually viral infections. In some patients, other infections with fungi, bacteria, or parasites might be responsible.
- Allergens (see below for more information): An allergen is anything in a child's environment that causes an allergic reaction. Allergens can be foods, pet dander, molds, fungi, roach allergens, or dust mites. Allergens can also be seasonal outdoor allergens (for example, mold spores, pollens, grass, trees).
- Irritants: When an irritating substance is inhaled, it can cause an asthmatic response. Tobacco smoke, cold air, chemicals, perfumes, paint odors, hair sprays, and air pollutants are irritants that can cause inflammation in the lungs and result in asthma symptoms.
- Weather changes: Asthma attacks can be related to changes in the weather or the quality of the air. Weather factors such as humidity and temperature can affect how many allergens and irritants are being carried in the air and inhaled by your child. Some patients have asthmatic symptoms whenever they are exposed to cold air.
- Exercise (see below for more information): In some patients, exercise can trigger asthma. Exactly how exercise triggers asthma is unclear, but it may have to do with heat and water loss and temperature changes as a child heats up during exercise and cools down after exercise.
- Emotional factors: Some children can have asthma attacks that are caused or made worse by emotional upsets.
- Gastroesophageal reflux disease (GERD): GERD is characterized by the symptom of heartburn. GERD is related to asthma because the presence of small amounts of stomach acid that pass from the stomach through the food pipe (esophagus) into the lungs can irritate the airways. In severe cases of GERD, there may be spillage of small amounts of stomach acid into the airways initiating asthmatic symptoms.
- Inflammation of the upper airways (including the nasal passages and the sinuses): Inflammation in the upper airways, which can be caused by allergies, sinus infections, or lung (respiratory) infections, must be treated before asthmatic symptoms can be completely controlled.
- Nocturnal asthma: Nighttime asthma is probably caused by multiple factors. Some factors may be related to how breathing changes during sleep, exposure to allergens during and before sleep, or body position during sleep. Furthermore, as a part of biological clock (circadian rhythm), there is reduction in the levels of cortisone produced naturally within the body. This may be a contributing factor for nighttime asthma.
- Recent reports of possible association between asthma and acetaminophen use may be due to the fact that children with severe asthma may be more likely to be take acetaminophen for viral or other infections that may actually be due to asthma or may precede an asthma diagnosis.
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Asthma : Test Your Medical IQ QuizQuestion
Asthma is a chronic respiratory disease.See Answer
Kasper, D.L., et al., eds. Harrison's Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.