Diagnosing childhood asthma

Children and asthma
Diagnosing asthma in children
Treating children with asthma
Questions to ask during treatment
Stepping down treatment

Children and asthma

Asthma is one of the most common conditions among children in the UK. It often starts in childhood. It may get better or disappear completely during teenage years, but about a third of children with asthma will continue to have problems as adults.

There is a tendency for asthma to run in families, but many children with asthma do not have relatives with the condition. Asthma cannot as yet be cured, but it can be controlled so that attacks can be prevented.

Most children with asthma who receive proper treatment, taken regularly, can live entirely normally, without losing time from school, and enjoy full involvement in sport and other recreations.

In children with asthma, the bronchial tubes are irritable because they are inflamed. This makes them more likely to narrow, making it harder to get air in and out of the lungs. In children, asthma is normally suspected if a child has a whistling noise in the chest (or wheeze). Not all children who wheeze go on to develop asthma. The symptoms of asthma tend to vary, and they tend to come and go. They also tend to be worse at night.

Although the specific cause of asthma is unknown, many factors contribute. On many occasions, asthma gets worse for no apparent reason. Some things which often make asthma worse are:

• The common cold
• Allergies, particularly amongst the under16s, and especially relating to grass pollen, house dust and animal fur
• Exercise. However, exercise-induced asthma can be well controlled
• Irritants like tobacco smoke, fumes and a dusty atmosphere
• Pollution, especially from traffic

The British Guideline on the Management of Asthma, produced by the British Thoracic Society and the Scottish Intercollegiate Guidelines Network, has been given to all doctors.

This may lead to your child being offered different treatment. For more details about the British Guideline, please go to www.brit-thoracic.org.uk, where you can download the British Guideline and other relevant information.

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Diagnosing asthma in children

Asthma is very difficult to diagnose in young children. The diagnosis will be based on a wide range of questions, including whether your child has wheezing, a dry cough, breathlessness or noisy breathing.

As a parent you will be asked about any family history of asthma or eczema, the pattern of your child's illness, its severity and incidence, as well as possible triggers - such as allergies, colds or exercise. Your child may be asked to take a skin prick test, blood test, a chest X-ray or simple lung function tests

The following factors will help your doctor decide whether your child has asthma:

• A family history, particularly in the mother, of asthma and/or rhinitis
• Signs of allergies, e.g. to pollen, dust, animals or exercise
• Gender. Before puberty boys are more at risk than girls. Boys are more likely to 'grow out' of it, while girls are more likely to have persistent asthma when growing from childhood to adulthood
• Viruses. A virus causes many young children to wheeze, but this will not necessarily mean they have asthma. Children often find this viral wheeze gets less as they grow older.
• Whether the mother smokes. Maternal smoking leads to a higher likelihood of wheezing in their small and young children
• Whether the baby was born prematurely
• Wheezing is more common in young children born prematurely, although this link disappears when premature babies are in their teens. The earlier your child starts to wheeze the better the final outcome. Most under 2s who wheeze become free of symptoms by the ages of 6. However, this is not likely to be true if the wheezing is due to an allergy
• The frequency and severity of wheezing. The more often and the worse a child wheezes makes the wheezing more likely to carry on in adult life.

Sometimes your child may be referred to a specialist. This happens when:

• The diagnosis is unclear
• The symptoms are present from birth
• The child vomits or regurgitates a lot
• There is a severe infection in the respiratory tract
• The child has a persistent cough which produces phlegm
• There is an unusual family medical history of chest disease
• The child fails to thrive
• There are some unusual symptoms, i.e. an abnormal cry or voice, or strange noises made when breathing
• The child doesn't respond to normal treatment

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Treating children with asthma

Medicines aim to control symptoms and enable your child to lead as near a normal life as possible. This should mean that your doctor will assess the medicine the child needs against the following standards:

• Minimising the symptoms during the day and night
• Minimising the need for reliever drugs
• Ensuring no flare-ups take place
• Enabling the child to be as physically active as he/she would like to be

Your doctor will work through this list seeking to achieve each one in turn, and your child will be put on the most appropriate level of treatment. You will be the person asked to judge how well or badly the treatment is working.

GPs and nurses will want to check how your child uses his/her inhaler and whether the medication is taken when it should. The British Guideline puts medicine use in the context of its five 'steps' for treating children with asthma. These steps are graded according to how bad the asthma is.

Step 1: The child has mild intermittent asthma All these medicines help (widening your airways):

• Inhaled short-acting beta-2 agonists
• Inhaled ipratropium bromide
• Beta-2 agonist tablets or syrup
• Theophyllines

Inhaled short-acting beta-2 agonists should be prescribed for all people with symptomatic asthma. There is no evidence of harm from using short-acting beta-2 agonists up to four times a day. They should be used as needed but if you are using more than four puffs each day then your child's asthma is poorly controlled and you should go back to the doctor for a review.

Step 2: The child may need regular drugs to prevent inflammation The aim of steps 2, 3 and 4 is to provide treatment to improve symptoms, lung function and to prevent flare-ups.

Inhaled steroids
These are recommended for children trying to reach their overall treatment goal. The starting dose in mild to moderate asthma will be two puffs of the lowest dose per day. In children under five it may be higher if there are problems with getting enough steroid into the lungs.

If your child is prescribed more than 400 micrograms (mcg) a day, there is a possibility of side-effects. These include suppression of the adrenal gland, near the kidney, and suppressed growth. Adrenal insufficiency has recently been identified in a small number of children who have hypoglycaemic attacks, when the blood sugar level is low. The smallest appropriate dose of inhaled steroids should be used.

Doctors should monitor children's height on a regular basis. Your GP should also monitor your child for any problems with his/her level of consciousness. If this happens the blood sugar levels of your child should be checked urgently. Simple sugary drinks will probably suffice. Inhaled steroids will be the doctor's first choice preventer drug. There are other preventer drugs which are less effective.

These include:

• Leukotriene receptor antagonists, which are helpful in some children
• Theophyllines - side effects are more common and blood levels need to be checked
• Long-acting inhaled beta-2 agonists are not recommended as first-line preventer medicines
• Antihistamines and ketotifen are ineffective

Step 3: The child may need extra (add-on) therapy The doctor should always check your child's willingness and agreement to take the medicines and that the inhaler technique is good before starting on the next step outlined in the British Guideline. Long-acting beta-2 agonists are the first choice as add-on therapy to inhaled steroids. If they do not work then the dose of inhaled steroids can be increased to see if this helps.

Combination inhalers are neither more nor less effective in giving inhaled steroids and long-acting beta-2 agonists than using two separate inhalers, but may be more convenient and preferred by some children.

Step 4: The drugs do not control the child's asthma adequately In a small number of children asthma cannot be controlled adequately on a combination of longacting beta-2 agonists and inhaled steroids, and short-acting beta-2 agonists as needed. If so, the doctor may give your child one of the following:

• An increased dose of inhaled steroids
• A leukotriene receptor antagonist
• A theophylline

It will be a matter of judgement which of these treatments will be the most effective. If it is not effective then your child should be referred to a specialist.

Step 5: The child may need more comprehensive treatment This could include being put on frequent courses of steroid tablets, taking these tablets over a longer period or being put on a high dose of inhaled steroids. Steroid tablets will be prescribed at the lowest possible dose to help. They help to improve breathing but there is an increased risk of side effects, for example, growth may be affected. Screening for blood pressure and the presence of diabetes should be undertaken.

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Questions to ask during treatment

1. How will I know that my child's treatment is working?
2. How long should I go on trying each step before going back to the GP?
3. My child seems to get no benefit from the inhaler. Why is that?
4. My son/daughter wheezes some of the time even though he/she has taken the medicine - is this bad? Should I go back to the doctor?
5. I am very worried about all these medicines - what are they and how will they affect my child?
6. My son/daughter is very small. Is this because of the medicine?
7. My child's asthma spray is different from all the others we know - why is this?
8. What does using an inhaler do to my son/daughter so that he/she breathes better?
9. Do I have to wash my inhaler?
10. What happens if none of these steps and medicines work?
11. When can I see a specialist?
12. I don't know that my son/daughter is using the inhaler properly. What can I do about it?
13. Can we lower the dose of my son/daughter's medicine now he/she seems so much better?
14. Does he/she really have to take these sprays every day? Surely they are only for using when he/she is bad?
15. Won't steroids make him/her fat like the weightlifters?
16. Why does he/she have to have two inhalers?

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Stepping down treatment

Many children 'grow out' of asthma and it is important that medication is stopped at this point.

Once your child's asthma is controlled then it is important to step down treatment so that the child is not receiving medicines unnecessarily. Reductions should be discussed every three to six months with your GP if your child seems well. The GP is likely to decrease the dose of inhaled steroids by approximately 25-50% each time. If your child then seems worse the dose may have to be increased again.

Page last medically reviewed: February '05