Asthma in children under 5: Understand symptoms, medications and treatment plans.By Mayo Clinic Staff
Asthma is ongoing (chronic) inflammation of airways in the lungs. This inflammation makes the airways vulnerable to episodes of difficult breathing (asthma attacks). Common triggers include allergies, colds and exercise. Asthma is managed by controlling inflammation with drugs, avoiding triggers when possible and using medications to treat asthma attacks.
Diagnosing and managing asthma in children under age 5 can be difficult. In infants and young children, the primary symptoms of asthma — wheezing and coughing — may be caused by other conditions. Also, standard diagnostic tests used to measure how well someone is breathing cannot be used easily or accurately with children under age 5. Some treatments available to older children for managing asthma are not recommended for infants and preschool children.
For these reasons, the management of asthma in children under 5 requires careful and relatively frequent monitoring. You can help minimize asthma symptoms by following a written asthma action plan you develop with your child's doctor to monitor symptoms and adjust treatment as necessary.
Common asthma signs and symptoms in children under 5 include:
- Wheezing, a high-pitched, whistle-like sound when exhaling
- Trouble breathing or shortness of breath
- A tight, uncomfortable feeling in the chest
The severity and patterns of symptoms may vary:
- Worsening of symptoms at night
- Short periods of coughing and wheezing between periods of time with no symptoms
- Frequent or chronic symptoms with episodes of worse wheezing and coughing
- Seasonal changes based on prevalent infections or allergy triggers
Asthma symptoms may be triggered or worsened by certain events:
- Colds or other respiratory infections
- Allergy-causing agents (allergens), such as dust, pet dander or pollen
- Activity or exercise
- In infants, feeding
- Exposure to cigarette smoke or other airborne irritants
- Strong emotional reactions, such as crying or laughing
- Gastrointestinal reflux
- Changes or extremes in weather
Severe asthma attacks can be life-threatening and require emergency room treatment. Signs and symptoms of an asthma emergency in children under age 5 include:
- Gasping for air
- Breathing in so hard that the abdomen is sucked under the ribs
- Trouble speaking because of restricted breathing
Diagnosis of asthma in children under age 5 can be challenging. The primary symptoms may indicate other conditions. With older children a doctor can use a breathing test that measures how well the lungs work, but these tests are not useful with younger children, who may have trouble following instructions and breathing exactly as directed.
If your child under age 5 has symptoms that might indicate asthma, your doctor or asthma specialist will likely use several pieces of information to make a diagnosis.
Your doctor will likely ask a number of questions, such as the following:
- Is there a family history of asthma?
- How often do symptoms occur?
- Does coughing wake your child at night?
- Do the symptoms accompany a cold or are they unrelated to colds?
- How often do episodes of breathing difficulty occur?
- How long do they last?
- Has your child needed emergency care for breathing difficulties?
- Does your child have any known pollen, dust, pet or food allergies?
- Is your child exposed to cigarette smoke or other airborne irritants?
Other tests may include the following:
- Blood test. Your doctor can measure the levels of certain white blood cells that may be elevated in response to infections.
- Chest X-ray. A chest X-ray may reveal changes in the lung when asthma is moderate to severe. It may also be used to rule out other conditions.
- Allergy test. A skin or a blood test may indicate if your child is allergic to a suspected or likely allergen.
If your doctor suspects your child has asthma, he or she will likely prescribe a trial treatment. If your child has relatively mild and infrequent symptoms, he or she may take a short-acting drug. If breathing improves in the time and manner expected for that treatment, the improved breathing would support a diagnosis of asthma.
If the symptoms are more regular or severe, your doctor will likely begin a drug for long-term management. Improvement during the next four to six weeks would support a diagnosis and lay the groundwork for an ongoing treatment plan.
It's important for you to keep track of your child's symptoms during a treatment trial and to follow instructions carefully. If you have followed the instructions and there is no improvement within the trial period, your doctor will likely consider another diagnosis.
The treatment goals for young children with asthma are to:
- Treat inflammation in the airways, usually with daily medication, to prevent asthma attacks
- Use short-acting drugs to treat asthma attacks
- Avoid or minimize the effect of asthma triggers
- Maintain normal activity levels
Your doctor will use a stepwise approach for treating your child's asthma. The goal is overall management with a minimum number of asthma attacks that require short-term treatment.
This means that initially the type or dosage of treatment may be increased until the asthma is stable. When it is stable for a period of time, your doctor may then step down the treatment, so that your child takes the minimum drug treatment needed to remain stable. If your doctor determines at some point that your child is using a short-acting drug too often, then the long-term treatment will be stepped up to a higher dose or additional medication.
This stepwise approach may result in changes up or down over time, depending on each child's response to treatment and overall growth and development, as well as on seasonal changes or changes in activity levels.
Medications for long-term control
Long-term control, or maintenance, medications are usually taken daily. Types of long-term control medications include the following:
- Inhaled corticosteroids are the most commonly used long-term asthma control drugs for children under age 5, as well as the preferred treatment according to the National Asthma Education and Prevention guidelines. Easily administered inhaled corticosteroids available to infants and preschool children include budesonide (Pulmicort Flexhaler, Pulmicort Respules), fluticasone (Flovent HFA) and beclomethasone (Qvar).
- Leukotriene modifiers may be added to a treatment plan when an inhaled corticosteroid treatment alone does not result in stable asthma management. The drug montelukast (Singulair) is approved in a chewable tablet form for children age 2 to 6 and in a granular form that can be added to pureed food for children as young as 1.
- Long-acting beta agonist is an inhaled drug that can be added to a corticosteroid treatment regimen. The drug salmeterol is a long-acting beta agonist combined with an inhaled corticosteroid as a single-dose inhaled medication (Advair HFA).
- Cromolyn is an inhaled drug that blocks inflammatory events and may be used as an add-on treatment with inhaled corticosteroids. There is less evidence of the effectiveness of this treatment than the for the other long-term control drugs appropriated for young children.
- Oral corticosteroids are used only when asthma management cannot be controlled with other treatments.
These medications — called short-acting bronchodilators — provide immediate relief of asthma symptoms, and effects last four to six hours. Short-acting bronchodilators for asthma include albuterol (ProAir HFA, Ventolin HFA, others) and levalbuterol (Xopenex HFA).
For children with mild, intermittent asthma symptoms, the short-acting medication may be the only treatment needed.
For young children who have persistent asthma and use long-term control drugs, the short-acting drug is used as a quick-relief, or rescue, medication to treat asthma attacks. It may also be used to prevent asthma symptoms triggered by exercise.
Overuse of short-acting medications usually indicates that the long-term control treatment plan needs to be revised.
Medication delivery devices
Most asthma medications are given with a device called a metered dose inhaler that requires a correctly timed deep breath to get medications to the lungs. Attachments for metered dose inhalers and other devices can make it easier for children under age 5 to get an appropriate dose. These devices include:
- Valved holding chamber with mask. A valved holding chamber with a face mask can be attached to a metered dose inhaler. The chamber allows a child to inhale the medication and doesn't allow exhaling into the device. The mask enables your child to take six normal breaths to get the same dosage as inhaling a single large puff of medication.
- Nebulizer. A nebulizer turns medications into a fine mist your child breathes in through a face mask. Young children often need to use a nebulizer because it's difficult or impossible for them to use other inhaler devices.
You can best manage your child's asthma by following these tips.
Create an action plan
Your doctor can help you create a written action plan that you can use at home and share with other family member, friends, preschool teachers and sitters. A thorough plan includes such things as the following:
- Your child's name and age
- Physician and emergency contact information
- The type, dose and timing of long-term medications
- The type and dose of rescue medication
- A list of common asthma triggers for your child and tips for avoiding them
- A system for rating normal breathing, moderate symptoms and severe symptoms
- Instructions for what to do when symptoms occur and when to use rescue medication
Monitor and record
Keep a record of your child's symptoms and treatment schedule to share with your child's doctor. These records can help your doctor determine if the long-term control treatment plan is effective and make adjustments to the plan. Keep appointments as recommend by your doctor to review records and adjust your action plan as necessary. Information you record should include:
- The time, duration and circumstances of an asthma attack
- Treatment responses to asthma attacks
- Medication side effects
- Changes in your child's symptoms
- Changes in activity levels or sleep patterns
Control asthma triggers
Depending on the triggers for your child's asthma, make adjustments at home, as well as in child care facilities and other environments, to minimize your child's exposure to triggers. These may include:
- Cleaning thoroughly to control dust and pet dander
- Checking pollen count reports
- Removing cleaning products or other household products that may be an irritant
- Administering allergy medicine as directed by your doctor
- Teaching your child hand washing and other habits to minimize colds
- Teaching your child to understand and avoid triggers
Sept. 20, 2016
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- Adkinson NF, et al. Management of asthma in infants and children. In: Middleton's Allergy: Principles and Practice. 8th ed. Philadelphia, Pa.: Saunders Elsevier; 2014. http://www.clinicalkey.com. Accessed Aug. 3, 2016.
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- Spacers and valved holding chambers (VHCs) for use with metered dose inhalers (MDIs). American Academy of Allergy, Asthma & Immunology. https://www.aaaai.org/conditions-and-treatments/library/asthma-library/spacers-asthma. Accessed Aug. 4, 2016.