Asthma in Children

Treatment Overview

Although your child's asthma cannot be cured, you can manage the symptoms with medicines, especially inhaled corticosteroids and beta2-agonists. You and your child will usually work with your doctor to make an asthma action plan. This plan will help you and your child meet treatment goals:

• Increase lung function by treating the inflammation in the lungs.
• Decrease the severity, frequency, and duration of asthma attacks by avoiding triggers.
• Treat acute attacks as they occur.
• Use quick-relief medicine less (ideally on not more than 2 days a week).
• Have a full quality of life—the ability to participate in all daily activities, including school, exercise, and recreation—by preventing and managing symptoms.
• Sleep through the night undisturbed by asthma symptoms.

For more information, see:

Asthma: Taking charge of your asthma.

Babies and small children need early treatment for asthma symptoms to prevent severe breathing problems. They may have more serious problems than adults because their bronchial tubes are smaller. Although it may appear that occasional treatment with medicines for children who have mild asthma is enough, one review has noted that one-third of fatal asthma attacks occurred in children who had mild asthma.²⁰ Even if your child's asthma does not appear severe, work with your doctor to make the right plan for your child.

The National Asthma Education and Prevention Program (NAEPP) recommends treatment with long-term medicines for infants and young children who:²¹

• Consistently need treatment for symptoms on more than 2 days a week for longer than 4 weeks.
• Have severe attacks more than once every 6 weeks.
• Have had wheezing 4 or more times in the past year lasting longer than 1 day and affecting sleep and who have atopic dermatitis or a parent with asthma.
• Have had wheezing 4 or more times in the past year lasting longer than 1 day and affecting sleep and two of the following four symptoms:
  • Wheezing not associated with colds.
  • Allergic rhinitis.
  • Evidence of sensitivity to some foods.
  • A high eosinophil count. Eosinophils are a type of white blood cell often present in allergic reactions.

Emergency treatment

If your child has a severe asthma attack (the red zone of the asthma action plan), give him or her medicine based on the action plan, and talk with a doctor immediately about what to do next. This is especially important if your child's peak expiratory flow (PEF) does not return to the green zone or stays within the yellow zone after he or she takes medicine. Your child may have to be admitted to the hospital or go to the emergency room for treatment.

At the hospital, your child will probably receive inhaled beta2-agonists and corticosteroids. He or she may be given oxygen therapy. Doctors will assess your child's lung function and condition. Depending on the response, further treatment in the emergency room or a stay in the hospital may be needed.

Medical checkups

Your child needs to monitor his or her asthma and have regular checkups to keep asthma under control and to ensure the right treatment. The frequency of checkups depends on how your child's asthma is classified. Checkups are recommended:

• About every 6 to 12 months for children who have intermittent or mild persistent asthma that has been under control for at least 3 months.
• Every 3 to 4 months for children who have moderate persistent asthma.
• Every 1 to 2 months for children who have uncontrolled or severe persistent asthma.

During checkups, your doctor will check to see that all your goals are being met. He or she will ask you and your child whether symptoms and peak expiratory flow have held steady, improved, or become worse. He or she will also ask about asthma attacks during exercise, at night, or after laughing or crying hard. You track this information in an asthma diary. Your child may be asked to bring his or her inhaler and peak expiratory flow meter to an appointment so your doctor can see if they are being used correctly.

Initial treatment

There are many components to managing asthma. Because asthma develops from a complex interaction of genetics, environmental factors, and the reaction of the immune system, no one plan will be effective for all children. After your child's diagnosis, your doctor may only discuss the components you need to know immediately. These include:

• Oral or injected corticosteroids (systemic corticosteroids). These medicines may be used to get your child's asthma under control before he or she starts taking daily medicine. In the future, your child also may take oral or injected corticosteroids to treat any sudden and severe symptoms, such as shortness of breath (asthma attacks). Oral corticosteroids are used more than injected corticosteroids. Systemic corticosteroids include prednisone and dexamethasone.
• Inhaled corticosteroids. These are the preferred medicines for long-term treatment of asthma. They reduce the inflammation of your child's airways and are taken every day to keep asthma under control and to prevent asthma attacks. Inhaled corticosteroids include mometasone, triamcinolone, fluticasone, budesonide, and ciclesonide.
• Short-acting beta2-agonists. These medicines are used for asthma attacks. They relax the airways, allowing your child to breathe easier. Short-acting beta2-agonists include albuterol and pirbuterol.
• Basic education about asthma. The more you and your child know about asthma, the more likely it is you will control symptoms and reduce the risk of asthma attack. Keep in mind that even severe asthma can be controlled, and cases where the condition cannot be controlled are unusual.
• Instruction on how to use a metered-dose inhaler (MDI) or dry powder inhaler (DPI). An MDI delivers inhaled medicines directly to the lungs. If your child uses the inhaler correctly, he or she can control the symptoms and avoid asthma attacks that can result in emergency care. Most doctors recommend using a spacer with an MDI. A DPI medicine is a dry powder. Your child breathes in sharply to inhale the medicine. How well the DPI works may depend on how well your child inhales. A dry powder inhaler should not be used with a spacer. For more information, see:

  Asthma: Using a metered-dose inhaler.

  Asthma: Using a dry powder inhaler.

The short-term goal is to control your child's current symptoms. The long-term goal is to prevent your child's symptoms so that asthma does not impact your child's daily activities.

Special things to think about in treating asthma include:

• Managing exercise-induced asthma. Exercise often causes asthma symptoms. Steps you and your child can take to reduce the risk of this include using medicine immediately before exercising.
• Managing asthma before surgery. Children with moderate to severe asthma are at higher risk of having problems during and after surgery than children who do not have asthma.

Ongoing treatment

After your child's initial treatment for asthma, it is important for you and your child to learn more about the condition and make an overall plan to manage the disease. You, your child, and your doctor will work together to do this. Because asthma develops from a complex interaction of genetics, environmental factors, and the reaction of the immune system, no one management plan is effective for everyone.

Asthma management consists of:

• An asthma action plan. An asthma action plan tells you which medicines your child takes every day and how to treat asthma attacks. It may also include an asthma diary where your child records peak expiratory flow (PEF), symptoms, triggers, and quick-relief medicine used for asthma symptoms. This helps you identify triggers that can be changed or avoided, be aware of your child's symptoms, and know how to make quick decisions about medicine and treatment. For more information, see:

  Asthma: Using an asthma action plan.

  An example of an asthma action plan (What is a PDF document?).

• Monitoring peak expiratory flow. It is easy to underestimate the severity of your child's symptoms. You may not notice them until his or her lungs are functioning at 50% of the personal best peak expiratory flow (PEF). Measuring PEF is a way to keep track of asthma symptoms at home. It can help you and your child know when lung function is becoming worse before it drops to a dangerously low level. This is done with a peak flow meter. For more information, see:

  Asthma: Measuring peak flow.

• A plan to deal with factors that can make asthma worse (triggers). Being around triggers increases symptoms. Try to avoid situations that expose your child to irritants (such as smoke or air pollution) or substances (such as animal dander) to which he or she may be allergic. See information on:

  Asthma: Identifying your triggers.

• A plan to treat other health problems. If your child also has other health problems, such as inflammation and infection of the sinuses (sinusitis) or gastroesophageal reflux disease (GERD), he or she will need treatment for those conditions.
• Using the prescribed medicines correctly. Your doctor may adjust your child's medicines depending on how well your child's asthma is controlled. Medicines include:
  • Inhaled corticosteroids. These are the preferred medicines for long-term treatment of asthma. Inhaled corticosteroids include mometasone, triamcinolone, fluticasone, budesonide, and ciclesonide.
  • Long-acting beta2-agonists (such as salmeterol and formoterol), which are always used with inhaled corticosteroids.
  • Oral or injected corticosteroids (systemic corticosteroids) to treat any sudden and severe symptoms, such as shortness of breath (asthma attacks). Oral corticosteroids are used more than injected corticosteroids. Oral corticosteroids include prednisone and dexamethasone.
  • Quick-relief medicine, such as short-acting beta2-agonists and anticholinergics (ipratropium) for asthma attacks. If your child is using quick-relief medicine on more than 2 days a week (other than to prevent exercise-induced asthma), he or she probably needs more long-term treatment. Overuse of quick-relief medicine can be harmful.
• Education. Continue to learn about asthma. This questionnaire can help you and your child determine what you already know about asthma and what you may need to discuss with your doctor.

If your child has persistent asthma and reacts to allergens, he or she may need to have skin testing for allergies. Allergy shots (immunotherapy) may be helpful. For more information, see:

Should I take allergy shots (immunotherapy) for allergic rhinitis and allergic asthma?

Your child can expect to live a normal life if he or she controls symptoms by following his or her asthma action plan. Asthma symptoms that are not controlled can limit your child's activities and lower his or her quality of life.

Special things to think about in treating asthma include:

• Managing exercise-induced asthma. Exercise often causes asthma symptoms. Steps you can take to reduce the risk of this include using medicine immediately before exercising.
• Managing asthma before surgery. People with moderate to severe asthma are at a higher risk than people who do not have asthma of having problems during and after surgery.

Treatment if the condition gets worse

If your child's asthma is not improving, talk with your doctor and:

• Review your child's asthma diary to see if he or she has a new or previously unidentified trigger, such as animal dander. Talk to your doctor about how best to avoid triggers.
• Review your child's medicines, to be sure he or she is using the right ones and using them correctly.
• Review your child's asthma action plan, to be sure it is still suitable for his or her condition.
• Find out whether your child has a condition with symptoms similar to asthma, such as sinusitis.

If your child's medicine is not working to control airway inflammation, your doctor will first check to see whether your child is using the inhaler correctly. If your child is using it correctly, your doctor may increase the dosage, switch to another medicine, or add a medicine to the existing treatment. You can work with your doctor to educate your child about the importance of taking medicines correctly and to encourage your child's teachers, babysitters, and other adults to help your child follow his or her plan.

Your doctor may suggest other medicines, such as leukotriene pathway modifiers (zafirlukast, zileuton, or montelukast). Less commonly, your doctor may recommend a mast cell stabilizer (cromolyn) or theophylline (such as Uniphyl).

If your child's asthma does not improve with treatment, he or she may require more intensive treatment, including larger doses of corticosteroids or other medicines. An asthma specialist generally prescribes these medicines.

If your child has persistent asthma and reacts to allergens, he or she may need to have skin testing for allergies. Allergy shots (immunotherapy) may be helpful.

What to think about

If your child has been diagnosed with asthma, it is important that you treat it. He or she may feel good most of the time—so much so that it may be hard to believe your child has a long-lasting condition. But all asthma—even mild asthma—may result in changes to the airways that speed up and make worse the natural decrease in lung function that occurs as we age.³

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Author:	Maria G. Essig, MS, ELS	Last Updated: March 20, 2009
Medical Review:	Michael J. Sexton, MD - Pediatrics Harold S. Nelson, MD - Allergy and Immunology
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