Asthma - and children - includes related articles

You awaken in the middle of the night and hear your son coughing again. He coughs a lot when he has a cold; he even coughs when he does not have a cold, usually at night. You check on him--no fever, no cold symptoms. And you begin to wonder if he has something more serious than a cold, something like asthma.

What Is Asthma?

Symptoms of asthma typically include a dry cough (especially at night), wheezing (high-pitched whistling sounds on exhalation), and a feeling of tightness in the chest or difficulty breathing. Some children have only one of these symptoms. Pediatricians tend not to confirm a diagnosis of asthma unless symptoms have occurred at least three times, the child has a strong family history of asthma, or there is some other reason to suspect that symptoms will recur.

Asthma symptoms are caused by three changes in the small airways (bronchioles) of the lung: inflammation, increased mucus production, and constriction in the muscles surrounding the bronchioles (known as bronchospasm). The illness is considered mild if symptoms occur less than three times a week, and moderate if symptoms occur three or more times a week, lasting several hours, yet not severe enough to warrant emergency room treatment. A child who has more frequent symptoms, a history of hospitalization, or symptoms serious enough to limit daily activities is said to have severe asthma.

Chronic cough and wheezing need not be caused by asthma, however. They may instead be caused by aspiration (inhalation of food or a tiny object into the small airways), congenital abnormalities of the lung or airways, or genetic diseases such as cystic fibrosis. X rays, blood tests, and skin tests may be needed to arrive at a correct diagnosis.

If your child is in fact found to have asthma, do not be alarmed. Currently, about 4 to 5 percent of children in the United States have this illness--a rate of incidence that distinguishes asthma as the most common chronic disease of childhood. Not only that, but asthma has been on the increase over the past 20 years, and mortality rates have climbed, particularly among African American children. Asthma is most prevalent among boys, African Americans, children living in impoverished and crowded conditions, and children exposed to frequent parental criticism and verbal abuse.(1) Asthma, along with allergies and eczema, tends to run in families. Premature infants with lung problems also have a high rate of asthma. Many children with this condition show improvement during adolescence.

Triggers and Warning Signs

Very few children with asthma have symptoms all the time. Most youngsters experience symptoms only after exposure to a sensitizing agent or situation. Sometimes, reactions are immediate. Other times, they are delayed. Exposure may occur in the afternoon, for example, and not produce symptoms until several hours after the child has gone to bed that night.

Flare-ups are triggered by different stimuli in different children. Parents who keep a diary of their child's exposures and symptoms are often able to identify the particular set of triggers responsible for their child's condition.

The most common culprits are these:

* Cigarette smoke. This is the number one preventable trigger of asthma. Exposure to cigarette smoke will almost certainly intensify your child's symptoms. Therefore, do not light up around your child, and do not allow others to either.

* Air pollution. Children who live in cities, near factories, and downwind of power stations and other sources of air pollution have the highest incidence of severe asthma. Increased levels of ozone, sulfur dioxide, and particulate matter have been associated with decreased lung function and higher rates of asthma among school-age children. City emergency rooms have been shown to log in many more visits when particulate levels rise. Indeed, worsening air pollution may be directly responsible for the increasing frequency of severe asthma among children in the United States. Those who live in rural areas, however, are not protected from airborne pollutants. Animal dander and wood smoke, for example, can trigger asthma symptoms.

* Cold air. Playing outdoors on a cold day can provoke an asthmatic attack.

* Allergens. Ragweed touches off hay fever in some children and asthma symptoms in others. Additional allergens associated with asthma include other pollens, molds, grasses, goose down, feathers, dust, dust mites, and cat and dog dander. Certain foods, iced drinks, and acidic sodas and fruit juices can also trigger asthma flare-ups.

* Exercise. Although exercise is a surprisingly common trigger for asthma, the symptoms it triggers can be effectively treated and prevented. Good prevention strategies include warming up for 15 to 30 minutes before engaging in vigorous sports, and accentuating nose breathing rather than mough breathing. Swimming is an especially good exercise for children with asthma. There is no reason for your child to avoid exercise just because he or she has been diagnosed with asthma. Many Olympic gold-medal winners have exercise-induced asthma.

* Colds. Cold viruses are probably the most common triggers of asthma flare-ups in children. Many of these viruses stimulate wheezing and coughing in children who do not have asthma.

* Sinus infections in children can be subtle and difficult to diagnose. If your child has frequent bouts of asthma and is troubled by nighttime coughing or has had a cold lasting more than 10 days, you may want to ask your healthcare provider about the possibility of a sinus infection. Treating a sinus infection can dramatically lessen the severity of asthma symptoms.

* Medications. Certain medications can worsen asthma symptoms. The most common offenders are aspirin and beta-blockers, a class of drugs used to treat high blood pressure.

* Stress. Emotional stress can cause tightness in the chest and irregular or labored breathing in almost anyone. It is therefore not surprising that some children with asthma are more prone to flare-ups in times of stress, such as the first day of school, in anticipation of major tests, during a family move, following a death in the family, or during divorce. Stress management techniques may prove especially helpful to such children.

How can you tell if your child's asthma is flaring up--and if it is, what should be done? If your child is having a hard time breathing, is breathing much more rapidly than usual, is grunting with each exhalation, is becoming exhausted or agitated from breathing, is turning blue in the lips or fingertips, or is sucking in the spaces between the ribs with each inhalation, seek immediate medical attention. Asthma can be deadly and should not be taken lightly. It is also wise to ask for help if your child is coughing and either not sleeping well, spiking a high fever, or missing school or everyday activities.

Observations of coughing, wheezing, and breathing patterns have for years been the mainstay of asthma monitoring. Today, children with asthma can have their lung function monitored regularly by a peak flow meter--a device that measures the efficiency with which air is passing out of the lungs. A low peak flow meter reading serves as a warning signal that serious symptoms may arise, and that additional therapy or closer observation is warranted.

Peak flow meters come in two basic varieties: sophisticated, heavy-duty spirometers available in many doctors' offices and hospitals, and simple home-monitoring devices sold at pharmacies for under $50. Home monitoring allows children as young as six to reliably participate in the day-to-day management of their health care. Children with moderate or severe asthma may need to measure and record their peak flow one to three times daily. These readings, along with a listing of triggers and symptoms, can be kept in an asthma journal--which can be used to help your child, you, and your healthcare provider determine the best treatment plan possible.

An Ounce of Prevention...

Avoiding triggers is the most straightforward way to prevent a recurrence of asthma symptoms. In addition to limiting your child's exposure to cigarette smoke and other air pollutants, think of carpooling, using buses or bicycles, and working for tougher antipollution laws to help your child stay eternally healthy. If your child appears sensitive to animal fur or dander, keep your family pet outdoors or in a noncarpeted room that can be easily cleaned. Select a room that your child does not spend a great deal of time in.

To ward off allergens, keep your child's room free of feather pillows, dust ruffles, wool blankets, and down comforters; encase your child's mattress and pillow in a plastic or vinyl fitted sheet; engage in a regularly scheduled clean-up campaign to reduce dust and mold in your child's room (wash those stuffed animals!); and regularly change the filters on all heating and air-conditioning units. To control dust mites, remove all carpeting, or spray the carpeting and upholstery every two to three months with a 3 percent tannic acid solution or benzylbenzoate.(2) To control mold, keep your household humidity under 50 percent, and frequently clean any visible mold or mildew with a bleach solution.

Dietary advice ranges from the proven to the uninvestigated. First, be sure that your child drinks plenty of water to prevent the mucus in the lungs from becoming too dry and difficult to clear. Breastfeeding has proven helpful in reducing wheezing episodes in the first month of life,(3) and especially effective in reducing the severity of asthma symptoms in children exposed to tobacco smoke.(4) Researchers are currently investigating the benefits of onion extracts. Although certain active compounds in onions have been shown to reduce the release of histamine, a chemical that causes much of the inflammation associated with asthma,(5) it is not clear how effective these compounds are in preventing or treating asthma symptoms; nor do we know the necessary dosage, or whether cooked or dried onions are as effective as raw onions.

Some parents contend that spices such as mustard, horseradish, and chili peppers are helpful--a hypothesis that has not yet entered the research labs. Many parents believe that milk products, sugar, and fried foods increase mucus production and should be avoided by children with asthma; no large trials have been conducted, however, to prove or refute the claim that children with asthma can be harmed by these foods. The culprit may not be foods themselves, but their acidity or other properties, or the additives and preservatives with which they are prepared.(6) Sensitivity to salad bar items, for example, is often attributed to sulfites that are sprayed on the fruits and vegetables to preserve them.

Herbs used in traditional medicines around the world are currently being tested for their effectiveness in preventing asthma. Among them are Galphimia glauca, used by South American curanderos in the treatment of allergies; Adhatoda vasica and Mullein leaf, used in India for cough, bronchitis, and asthma; and the roots of Picrorhiza kurroa, used in Ayurvedic medicine for lung disease and other ailments. A recent study in China indicates that the combination of herbs known as Shuang Huang Lian, given intravenously, is significantly more helpful than antibiotics in treating infants with bronchiolitis (a wheezing and coughing illness similar to asthma).(7)

Black haw bark was used by Native Americans and early American physicians to treat ailments involving smooth muscle spasm, such as asthma and painful periods. Marshmallow has long been used to reduce inflammation of the mucous membranes. Ephedra (Mormon tea)--source of the pharmaceutical ephedrine--has for years been used as an asthma remedy. Other traditional remedies used specifically for asthma include coltsfoot, yerba santa, wild cherry bark, gingerroot, pepermint, red clover, comfrey, nettle, parsley, and thyme.

Homeopathy shows promising results in the management of allergic conditions. Recommended remedies include Arsenicum album, Antimonium tartaricum, Chamomilla, Ipecacuanha, Nux vomica, and Pulsatilla. No randomized trials have been published to show homeopathy's effectiveness in preventing or treating asthma in children. Homeopaths themselves advise parents not to treat symptoms of acute asthma with homeopathic remedies alone.(8)

Mind-body, relaxation, and imagery techniques are a worthy addition to a comprehensive asthma management program. Hypnosis is useful in reducing the frequency of asthmatic attacks in adults.(9) Some physicians, however, are concerned that a person who becomes overly relaxed may not recognize an intensification of symptoms and may delay treatment. Visualization techniques deserve significantly more study, not only because they make sense, but because they are noninterventive, inexpensive, and effective in reducing anxiety--a primary contributor to asthma flare-ups.

Medications for preventing asthma attacks include Cromolyn (Intal) and Nedocromil. These drugs inhibit the release of histamine and other chemicals that cause inflammation and muscle spasm in the small airways. To be effective, these medications must be taken every day for several weeks, whether or not the child has symptoms. They are taken by inhalation and rarely cause side effects.(10) Inhaled heparin shows promise in adults seeking to diminish symptoms of exercise-induced asthma. Heparin, used for years as an anticlotting medication, works on the lungs by reducing inflammation triggered by exertion.(11) No studies have been published on its use in children.

Shiatsu, a 4,000-year-old Japanese therapy involving the massage of acupuncture points, is an effective approach for adults with asthma.(12) No studies document the effectiveness of this approach in children.

Spinal manipulation is used by both chiropractors and osteopaths in treating adults with asthma. No controlled trials document the effectiveness of this approach in children.

Yoga, particularly yogic breathing, has proven beneficial in reducing the frequency of asthmatic attacks in young adults. The breathing patterns found most effective are slow, regular inhalations and exhalations in a timed ratio of 1 to 2; the effects are enhanced by breathing hot, moist air.(13) Whether yoga is helpful because it promotes general relaxation or because it affects the lungs is unknown. Nevertheless, it is calming, inexpensive, free of side effects, and an effective preventive strategy for children with asthma.

Treating the Symptoms

Medications of many kinds are used to treat asthma. In fact, modern medicine, despite its shortcomings in treating common minor illnesses such as colds, offers life-saving measures for children with asthma. One or more medications may be prescribed, depending on the severity of your child's symptoms.

For children with mild or exercise-induced asthma, the primary therapy is an inhaled beta-agonist such as albuterol. This medication is administered by a metered-dose inhaler (puffer). Children too young to operate the inhaler often learn to if a spacer device is added. For infants and toddlers, inhaled medications are usually given at home by nebulizer (a fine-spray mister). Beta-agonists help relax the muscles around the bronchioles, allowing the air passages to expand. With overuse, the muscles become accustomed to the medication, in which case, higher and higher doses are required to achieve the same results. The main side effects of beta-agonists are similar to the effects experienced after drinking too many cups of coffee: a racing heart, elevated blood pressure, hyperactivity, or appetite suppression.

For children with moderate asthma, additional medications may be prescribed; such children should also have their allergies evaluated. One commonly prescribed medication is theophylline, which is chemically related to caffeine and, like beta-agonists, helps relax the muscles around the bronchioles. Even at therapeutic doses, theophylline has side effects in some children, including increased activity, decreased attention spans, decreased appetite, and an increased risk of seizures in youngsters with epilepsy. Although recent studies indicate that side effects may be less prevalent than they were once believed to be, children with severe asthma who are already receiving high doses of beta-agonists and/or steroids will probably not benefit a great deal from theophylline.(14) Children with moderate asthma who are too young to properly operate a metered-dose inhaler, on the other hand, may find theophylline a useful daily medication as long as levels are monitored closely.(15)

Increasing numbers of physicians are prescribing inhaled corticosteroids such as beclomethasone for children with moderate asthma. These steroids in no way resemble those that athletes use to bulk up. The steroids used to treat asthma work by decreasing the inflammation and swelling in the airways. When taken by metered-dose inhaler, very little medication is absorbed into the bloodstream, resulting in very few side effects. Those such as hoarseness or yeast infections in the mouth can be diminished by adding a spacer to the metered-dose inhaler and having the child gargle with plain water after taking the medicine. Inhaled steroids can prevent the need for hospitalization. Given at the onset of cold symptoms, they can also prevent an asthmatic attack in some children.

Ipratropium bromide, a therapy recently introduced for children with moderate asthma, has long been used to treat adults with chronic obstructive lung disease. This medication is related to atropine, and may cause a dry mouth and rapid heart rate.

Acupuncture, administered by a trained practitioner, can reduce the symptoms of asthma in children experiencing an acute attack, especially if it was triggered by allergies. One study of children shows that acupuncture given 20 minutes before exercise will attenuate the effects of exercise-triggered asthma symptoms.(16) Adult studies show that acupuncture has little sustained effect and is not helpful in treating chronic asthma.(17)(18)

Vitamins and minerals are often helpful. Asthma symptoms have been shown to respond to 500 milligrams a day of vitamin C and 50 milligrams a day of pyridoxine. A recent study indicates that magnesium given intravenously in conjunction with medications can remediate severe asthmatic attacks in adults.(19) Although magnesium is known to help relieve muscle spasm, there exist no data on the usefulness or potential side effects of supplemental magnesium in children with asthma.

If your child is diagnosed with asthma, do not panic. Remember that you are not alone, that children can learn to manage their symptoms, and that many holistic treatments are available.

You may be able to limit the frequency and severity of your child's symptoms by trying the following techniques:

* Think diet. Start your child off right by breastfeeding. Give plenty of fluids, especially when your child has a cold.

* Do not smoke, and do not allow others to smoke around your child.

* Work for cleaner air in your home and in your community.

* Avoid exposing your child to allergens, dust, mold, and foods that seem to trigger your child's asthma symptoms.

* Keep the house clean. thoroughly clean your child's room on a weekly basis.

* Don't limit your child's exercise. Asthma symptoms can be controlled during even the most vigorous exercise. Children with asthma need not become couch potatoes!

* Help your child learn to use a peak flow meter and record symptoms as well as readings.

* Introduce your child to yoga, deep breathing exercises, and relaxation techniques.

* Work with your healthcare provider to develop the best plan for preventing and treating asthma flare-ups. In general, Cromolyn and Nedocromil help prevent a resurgence of symptoms; beta-agonists and steroids help treat symptoms that have arisen; and theophylline helps control severe or frequent asthma, especially if your child is too young to properly operate a metered-dose inhaler.

* When your child has symptoms, treat them promptly. Nothing is to be gained by delaying treatment of an illness that can progress rapidly and seriously.

* Share all vital information with other adults who care for your child. Teachers, baby-sitters, and relatives need to know what symptoms to look for, what your care plan is, and how to reach your child's physician in case of an emergency.

* Remind yourself and your child to have fun! Supported by your love, encouragement, and an appropriate treatment plan, your child will be able to enjoy a happy, active, and fruitful childhood.

Among the vital systems of the body is the respiratory system, and among the most important organs that serve the respiratory system are the lungs--the coneshaped, spongy body parts most affected in asthma. Fortunately, most children with asthma outgrow the condition. Until that time, they can benefit from many effective treatments. The most neglected of these is touch.

The important relationship between the lungs and the skin is now well established. It has long been known, nevertheless, that when a baby is born and fails to draw in air, a "hearty slap" on the buttocks will usually activate breathing. It is known that being in the nude and experiencing a sudden shower of cold water, one is likely to react with a catch of the breath. It should also be well known that putting one's arm around a child having an asthmatic attack will either abort or alleviate it.

I, myself, have seen the difference that touch can make. I have known identical twin sisters, one of whom died during an asthmatic attack at the age of 26, and the other of whom, threatened by a similar fate, took the advice to have herself massaged regularly until her attacks ceased. Now, more than 50 years and hundreds of massages later, she is in excellent health.

Emotional factors play a significant role in asthma. Consequently, drugs alone are incapable of solving the problem. Many times, the problem is not "physical symptoms," but rather a difference between the emotional response of caregivers and the emotional needs of the child.

Caregiving, which is another name for love, means meeting the emotional as well as the physical needs of a child. The opportunities for doing this are numerous, and begin with a mother's care for her baby even before birth. A loving abdominal massage is a caress that the baby in the womb will much appreciate. After birth, a daily baby massage may be combined with that other kind of caressing-- breastfeeding--which is fundamentally important to initiate as soon after the birth as possible. Indeed, children who at birth were separated from their mothers for any durable period of time have a higher incidence of asthma than those who were not.

There are, above all, two things to remember. First, that the skin is the external nervous system, which develops in conjunction with the internal nervous system and from the same specialized system of cells, known as the ectoderm. And second, that at birth, a baby is only half-gestated and still very much in need of nurturing support and stimulation--requirements that, to ensure healthy development, must continue for some years. There is comfort to be drawn from this slow rate of development, for we have a lot to learn about being human, including learning to breathe.

For More Information

Touch Research Institute (TRI) Tiffany Field, Director Department of Pediatrics University of Miami School of Medicine PO Box 016820 Miami, FL 33101 305-547-6781 In September 1991, TRI brought together a multidisciplinary staff of researchers and scientists to conduct controlled studies on the healing capacity of touch in a wide variety of illnesses. Some findings are now available.

Notes

1. R. Schobinger et al., "Childhood Asthma: Mothers' Affective Attitude, Mother-Child Interaction, and Children's Compliance with Medical Requirements," Psychosomatic Research 37, no. 7 (Oct 1993): 697-707.

2. Tannic acid solution is available from Allergy Control Products, 96 Danbury Road, Ridgefield, CT 06877.

3. E. Porro et al., "Early Wheezing and Breastfeeding," J Asthma 30 (1993): 23-28.

4. Y. Chen, "Synergistic Effect of Passive Smoking and Artificial Feeding on Hospitalization for Respiratory Illness in Early Childhood," Chest 95 (1989): 1004-1007.

5. W. D. Dorsch, "New Anti-Asthmatic Drugs from Traditional Medicine?" Int Arch Allergy Appl Immunol 94 (1991): 262-265.

6. N. M. Wilson, "Bronchial Hyperreactivity in Food and Drink Intolerance," Annals Allergy 61 (1988): 75-79.

7. X-T Kong et al., "Treatment of Acute Bronchiolitis with Chinese Herbs," Arch Dis Childhood 68 (1993): 468-471.

8. M. T. Santwani and J. Kishore, Common Ailments of Children and Their Homeopathic Management (New Delhi, India: B. Jain Publishers, 1987).

9. S. A. Isenberg et al., "The Effects of Suggestion and Emotional Arousal on Pulmonary Function in Asthma: A Review and a Hypothesis regarding Vagal Mediation," Psychosom Med 54 (1992): 192-216.

10. National Asthma Education Program Expert Panel, Executive Summary: Guidelines for the Diagnosis and Management of Asthma, US Dept. of Health and Human Services, pub no. 91-3042A (June 1991).

11. T. Ahmed et al., "Preventing Bronchoconstriction in Exercise-Induced Asthma with Inhaled Heparin," N Engl J Med 329 (1993): 90-95.

12. S. Yamamoto, The Shiatsu Handbook (Eureka, CA: Turning Point, 1986), pp. 124-125.

13. R. Nagarathna and H. R. Nagendra, "Yoga for Bronchial Asthma: A Controlled Study," Br Med J 291 (1985): 1077-1079.

14. G. A. DiGiulo et al., "Hospital Treatment of Asthma: Lack of Benefit from Theophylline Given in Addition to Nebulized Albuterol and Intravenously Administered Corticosteroid," J Pediatr 122 (1993): 464-469.

15. O. K. W. Chow and K. P. Fung, "Slow-Release Terbutaline and Theophylline for the Long-Term Therapy of Children with Asthma: A Latin-Square and Factorial Study of Drug Effects and Interactions," Pediatrics 84 (1989): 119-125.

16. K. P. Fung et al., "Attenuation of Exercise-Induced Asthma by Acupuncture," Lancet (20-27 Dec 1986): 1419-1421.

17. Z. Junqi, "Immediate Anti-Asthmatic Effect of Acupuncture in 192 Cases of Bronchial Asthma," J Trad Chin Med 10 (1990): 89-93.

18. D. P. Tashkin et al., "A Controlled Trial of Real and Simulated Acupuncture in the Management of Chronic Asthma," J Allergy Clin Immunol 76 (1985): 855-864.

19. E. M. Skobeloff et al., "Intravenous Magnesium Sulfate for the Treatment of Acute Asthma in the Emergency Department," JAMA 262 (1989): 1210-1213.

For More Information

The Asthma Information Center PO Box 790 Springhouse, PA 19477-0790 National Asthma Education Program PO Box 30105 Bethesda, MD 20824-0105

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