Childhood asthma: dispelling some commonly held beliefs

A metered dose inhaler (or MDI) is designed for use with a valved holding chamber, or spacer.

Asthma is the most common chronic disease in childhood. It is often underdiagnosed and undertreated, and can cause unnecessary burden in a child’s life. It accounts for approximately 13 million missed school days a year, as well as many missed workdays for family members. Asthma is also the most common cause of recurrent pneumonia in children.

When treated appropriately, children with asthma can live full and active lives without limitation from their breathing.

Asthma has two components: bronchospasm and inflammation. The lungs are made up of many branching airway tubes — much like and upside-down tree — the larger tubes are called bronchi. When the muscles lining those bronchi squeeze, bronchospasm occurs. This narrows the airway from the outside in.

Various triggers in the environment can cause a bronchospasm, including:

  • Cold viruses
  • Allergens (from pollen, grasses, house dust mite, pet dander, mold)
  • Irritants in the air (cigarette smoke, air pollution, strong odors, perfumes)
  • Exercise
  • Certain weather conditions (hot/humid weather, cold air, abrupt changes in weather, thunderstorms)
  • Emotional stress

Inflammation of the airway results in swelling and excessive production of mucous. This narrows the airway from the inside out. Children with asthma can have varying degrees of bronchospasm and inflammation.

Bronchospasm can happen quickly, causing sudden shortness of breath, chest tightness, coughing, and/or wheezing. Medicines called bronchodilators treat bronchospasm by relaxing the muscles around the bronchi and help open up the airway. The most common bronchodilator is albuterol (Proventil, Ventolin and ProAir), which acts very quickly (within minutes) but the effect only lasts about four hours. Albuterol is described as a rescue medication because it is best used when a child has sudden symptoms, but needs to be taken again if a child is having ongoing symptoms or ongoing exposure to the trigger that caused the bronchospasm.

Inflammation is a slower process and generally takes months or years to develop. When a child has inflammation, the sudden symptoms from bronchospasm can be even worse. For this reason, many children with inflammation require a controller medication to reduce the inflammation over time. This way, when they are exposed to a trigger, the acute symptoms are not as bad. The best preventive medications are inhaled steroids, such as fluticasone (Flovent), budesonide (Pulmicort), or beclomethasone (QVAR).

There are many commonly held beliefs about asthma that can be confusing when making treatment decisions for your child. Some of the more common things we hear in our pediatric pulmonary medicine clinic at Doernbecher include:

Inhaled steroids are bad for my child and will cause side effects.

Inhaled steroids, given in appropriate doses, are very safe and effective in controlling asthma symptoms and allowing children to live active, full lives. When inhaled, they act directly on the airway to reduce swelling and mucous production. Only a tiny amount of the inhaled steroid will enter the bloodstream and they have very few (if any) side effects. The same cannot be said for oral steroids, which can cause increased appetite and behavior changes, as well as others. If your child has needed more than one course of oral steroids in the last 12 months, be sure to talk to their primary care doctor, as this can be a sign that they may do better on an inhaled steroid.

My child will outgrow their asthma.

Children do not outgrow their asthma. As they grow, they can have fewer and less severe symptoms. However, they still have the disease and will have a tendency to overreact to triggers in the environment.

My child does not need to use a spacer anymore because they are too old for one. 

A metered dose inhaler (or MDI) is designed for use with a valved holding chamber, or spacer. Everyone (including adults) should use a spacer with their rescue and controller MDI’s.  Without a spacer, most of the medicine from an MDI will end up in the back of the throat.  This can actually cause more side effects and increase the amount absorbed into the bloodstream. A spacer helps the medicine reach the lungs where it needs be in order to work.

A nebulizer is better than an inhaler.

An MDI is as effective as a nebulizer and much quicker to use, provided you use a spacer! A nebulizer dose contains about the same amount of medicine as in four to six puffs of an MDI. Although it is a larger dose of medicine, it is not better than an MDI.

My child can’t participate in sports because they have asthma.

If asthma is well controlled, your child should be able to participate in any sport they wish. There are many elite athletes who have asthma and as long as they use their prescribed medications, they can participate without limitations.

I don’t have asthma so my child can’t have asthma

Most of the time, a parent or other relative of the child will have asthma or other conditions like allergies or eczema. However, this is not always true, and children can develop asthma without a family history.

My child does not really have any symptoms and thus does not need a daily preventive medication.

There are many levels of asthma and not all children will have symptoms on a day-to-day basis. They may only have symptoms when the narrowing of their airways suddenly gets worse, such as when they have a cold or are exposed to a trigger. However, they may still benefit from a daily controller medication to help prevent symptoms.  Lung function testing can help determine whether your child has significant asthma and might benefit from an inhaled steroid. These tests can generally be performed once your child is around 6-7 years old.

The cough went away, so my child no longer needs the inhaled steroid.

The symptoms went away because the inhaled steroid is working and getting rid of the inflammation. If you stop taking the inhaled steroid, most likely the symptoms (and the inflammation) will come back. Remember that asthma is a chronic condition and can get worse if you stop a controller medication. If you have questions about whether your child really needs a medication, always talk to your child’s doctor before stopping that medication.

My child will need these medications for the rest of their life.

False!!! Asthma triggers can change over time. Experts recommend seeing your doctor regularly to determine if your child can start taking a lower dose of medication or maybe take medications just when they are sick. Children should have lung function testing when they are old enough to do them (typically around ages 6 or 7). Lung function tests should be done at least once a year and also when changes are made to their medications.

Inhaled steroids will stunt my child’s growth.

This is tricky. In the past, we would have said that this is not true, based on a lack of good evidence. However, a recent study suggests that there may be an effect on adult height, albeit very small (1 to 3 centimeters, or less than an inch). This effect is dose-dependent, meaning that higher doses are more likely to cause a decrease in height. This study confirms what we always try to do anyway, which is to keep your child on the smallest amount of medication possible in order to control their symptoms. Be sure to talk to your child’s doctor if you have concerns about this very important issue.

While we cannot cure asthma, we can treat it. The goal of treatment for any child with asthma is to control their symptoms and minimize any limitation they may have to reduce their risk of complications from asthma. We always tell parents, “No one should know your child has asthma unless they see them using their inhaler.”

For more information on asthma, including helpful videos on how to use an MDI with a spacer, see Healthychildren.org.

Alexandra Cornell, M.D.
Assistant Professor of Pediatrics, Division of Pediatric Pulmonology
OHSU Doernbecher Children’s Hospital

 

 

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Comments

  1. Is it true that no child ever outgrows there asthma? My son was diagnosed a few years ago and my father *had* asthma in which he says he has now outgrown. He is a smoker and complains of no asthma symptoms. Is this possible? I had hope that my son would someday outgrow this, but now am not as hopeful. I would like some clarification if you can.

    Thank you ,
    Susan

  2. Great question, Susan. Let me ask our expert and get back to you. -Anne

  3. Hi Susan,

    In some cases, children will have a lot more symptoms when they are younger (age 2-5), but then seem to have fewer symptoms in later childhood years or teenage years. This leads many parents to believe that their children have “outgrown” their asthma. However, if you understand that asthma is basically a tendency of the immune system to over-react to triggers in the environment, and that triggers can change over time, you can understand that they never truly “outgrow” their asthma (basically, they will always have that tendency to over-react). They may just have fewer triggers and thus fewer symptoms. In other cases, asthma can persist or even get more severe as children get older and develop new triggers. In addition, a lot of teenagers and adults do not perceive their asthma symptoms very well, as the changes can be quite gradual such that they don’t notice it – in those cases, objective tests are needed to measure lung function to manage their asthma appropriately. Not knowing the specifics of your situation, I would recommend speaking to his pediatrician or primary care provider about this.

    Best,
    Dr. Cornell

About the Author

Tamara Hargens-Bradley is a senior communications specialist for Oregon Health & Science University and OHSU Doernbecher Children's Hospital. She is the editor of the Healthy Families blog.
Doernbecher Children's Hospital

Doernbecher Children’s Hospital

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