Treating asthma in children under 5

Asthma is ongoing swelling of airways in the lungs. This swelling, also known as inflammation, makes the airways prone to bouts of difficult breathing. These are called asthma attacks. Common triggers include allergies, colds and exercise. Asthma can be managed with treatments and lifestyle changes. Medicines can control inflammation or treat asthma attacks. And some attacks can be prevented by staying away from triggers when you can.

Healthcare professionals can find and treat asthma in children under age 5, but it may take time. In infants and young children, the main symptoms of asthma are coughing and a high-pitched whistling sound made while breathing out. This sound is called wheezing. These symptoms may be caused by other conditions. Also, standard tests that measure how well someone breathes cannot be used easily or accurately with children under age 5. What's more, some asthma treatments available to older children are not recommended for infants and preschool children.

For these reasons, your child's healthcare team needs to track your little one's asthma closely to manage the condition. You'll also work with the care team to make a written action plan. This helps you and other people in your child's life know what to do when your child has asthma symptoms.

Common asthma symptoms in children under 5 include:

• Coughing.
• Wheezing.
• Trouble breathing or shortness of breath.
• A tight, uncomfortable feeling in the chest.

The seriousness and patterns of symptoms may vary:

• Symptoms that become worse at night or in the early morning.
• Short periods of coughing and wheezing between periods of time with no symptoms.
• Frequent or ongoing symptoms with bouts of worse wheezing and coughing.
• Seasonal changes based on common infections or allergy triggers.

Asthma symptoms may be triggered or made worse by certain events:

• Colds or other respiratory infections.
• Things that cause allergies, such as dust, pet dander or pollen.
• Activity or exercise.
• In babies, feeding.
• Exposure to cigarette smoke or other irritants in the air.
• Strong emotional reactions, such as crying or laughing.
• Stomach acid that flows back up into the tube that connects the stomach to the mouth, a condition called gastroesophageal reflux.
• Changes or extremes in weather.

Severe asthma attacks can be life-threatening. These need to be treated in the emergency room. Symptoms of an asthma emergency in children under age 5 include:

• Gasping for air.
• Breathing in so hard that the stomach area is sucked under the ribs.
• Trouble speaking because of restricted breathing.
• Irregular rapid breathing.
• Flaring nostrils.
• Chest pulling in with each breath.

It can be a challenge to find out whether a child under age 5 has asthma. The main symptoms can overlap with other conditions. With older children, a healthcare professional can use a breathing test that measures how well the lungs work. But this type of test is not useful with younger children. That's because they may have trouble following instructions and breathing as they're told.

For those reasons, your child's healthcare professional likely will use many pieces of information to figure out whether your child's symptoms are caused by asthma.

Your child's healthcare professional likely will ask you many questions, such as the following:

• Is there a family history of asthma?
• How often does your child have symptoms?
• Does coughing wake your child at night?
• Do the symptoms happen along with a cold? Or do they happen without a cold?
• Have the symptoms kept your child from going to school or doing other activities?
• How often do bouts of breathing trouble happen? And how long do they last?
• Has your child needed emergency care for breathing trouble?
• Does your child have any known pollen, dust, pet or food allergies?
• Is your child exposed to cigarette smoke or other irritants in the air?

Other tests may include the following:

• Blood test. This can measure the levels of certain white blood cells that may be higher in response to infections.
• Chest X-ray. This may reveal changes in the lungs when asthma is moderate to severe. It also may be used to find out if other treatable conditions are the cause of your child's symptoms.
• Allergy test. A skin or a blood test may indicate if your child has an allergy.

Asthma medicine likely will be prescribed if your child's healthcare professional thinks your child might have asthma. This is called a trial treatment. If the medicine improves breathing, that makes it more likely that your child has asthma. Children with somewhat mild and infrequent symptoms may take medicine with effects that last a short time. This is known as quick-relief or "rescue" medicine. It's also called a short-acting bronchodilator.

If your child's symptoms are more regular or serious, your child likely will need medicine that's taken regularly to control symptoms and prevent asthma attacks. Improvement during the next 4 to 6 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. Follow your healthcare professional's instructions carefully too. If your child's symptoms don't get better during the trial, your child's healthcare professional likely will look for other treatable causes.

The treatment goals for young children with asthma are to:

• Treat inflammation in the airways, most often with daily medicine, to prevent asthma attacks. This also is called long-term treatment.
• Use quick-relief medicine to treat asthma attacks.
• Stay away from or lessen the effect of asthma triggers.
• Help children stay as active as usual.

Your child's healthcare professional adjusts your child's long-term treatment over time. At first, the amount of medicine may be raised, also called stepped up. This is done until the asthma is under control for a time. Then the amount of medicine is lowered, also called stepped down. This common treatment plan is called the stepwise approach. The goal is to find the right balance of medicine. It involves taking the least amount of daily medicine possible to keep asthma under control. It also means needing as few quick-relief treatments for asthma attacks as possible.

If your child needs to use quick-relief medicine too often, the long-term treatment likely will be stepped up. Or another medicine may be added.

Medicine gets stepped up or down depending on the response to treatment and each child's overall growth and development. It also depends on seasonal changes or changes in activity levels.

Long-term control medicines usually are taken daily to prevent asthma symptoms. You also might hear them called maintenance medicines. Types of long-term control medicines include the following:

• Inhaled corticosteroids. These medicines are breathed in to treat the airway inflammation that leads to asthma symptoms. They're the most effective and important type of long-term control medicine for children. Inhaled corticosteroids for infants and preschool children include budesonide (Pulmicort Flexhaler, Pulmicort Respules), fluticasone (Flovent HFA) and beclomethasone (Qvar Redihaler).

• Leukotriene modifiers. These medicines taken by mouth block the effects of immune system chemicals that lead to asthma symptoms. A leukotriene modifier may be added to a treatment plan if an inhaled corticosteroid alone does not control asthma well enough. The medicine montelukast (Singulair) is approved in a chewable tablet form for children ages 2 to 6. It's approved in a granular form that can be added to pureed food for children as young as 1.

  Rarely, montelukast has been linked to mental reactions. These include agitation, aggression, hallucinations, depression and suicidal thinking. Get medical help right away if your child has any unusual reactions.

• Long-acting beta agonist. This type of medicine is breathed in to relax muscles in the airways that carry air to the lungs. A long-acting beta agonist is not used by itself due to a risk of serious asthma attacks. Instead, it can be added to an inhaled corticosteroid treatment if the steroid alone doesn't help enough. A common long-acting beta agonist approved for children 4 years and older is salmeterol (Serevent).
• Long-acting beta agonist and an inhaled corticosteroid. These two medicines can be combined to treat small children with serious, persistent asthma. For example, salmeterol plus fluticasone (Advair Diskus) is approved for children 4 years and older.
• Cromolyn. This medicine is breathed in to ease inflammation in the lungs. It can be used by itself or as an add-on treatment with inhaled corticosteroids. There is not as much research as to how well it works compared with the other long-term control medicines for young children.
• Oral corticosteroids. These medicines taken by mouth help ease lung inflammation. They're used only when asthma can't be controlled with other treatments.

These medicines can relieve asthma symptoms right away, and the effects last 4 to 6 hours. Quick-relief medicines for asthma include albuterol (ProAir HFA, Ventolin HFA, others) and levalbuterol (Xopenex HFA).

For children with mild, occasional asthma symptoms, this type of medicine may be the only treatment that is needed.

For young children who have ongoing asthma and use long-term control medicines, quick-relief medicine is used to treat asthma attacks. It also may be used to prevent asthma symptoms triggered by exercise.

Overuse of quick-relief medicines usually means that a healthcare professional needs to change the long-term control treatment plan.

Most asthma medicines are given with a device called a metered dose inhaler. A correctly timed deep breath is needed to get medicines into the lungs. Attachments for metered dose inhalers and other devices can make it easier for children under age 5 to get the right amount of medicine. These devices include:

• Valved holding chamber with face mask. This can be attached to a metered dose inhaler. The chamber helps a child breathe in the medicine. The mask lets the child take six breaths to get the same amount of medicine the child would get by breathing in a single large puff of medicine.
• Nebulizer. This device turns medicines into a fine mist. Your child breathes the mist in through a face mask. Young children often need to use a nebulizer because it's hard or not possible for them to use other inhaler devices.

You can best manage your child's asthma with these tips.

Your child's healthcare team can help you make a written asthma action plan. You can use the plan at home and share it with other family members, friends, preschool teachers and babysitters. A thorough plan includes such things as the following:

• Your child's name and age.
• Healthcare professional and emergency contact information.
• The type, dose and timing of long-term medicines.
• The type and dose of rescue medicine.
• A list of common asthma triggers for your child and tips to help stay away from them.
• A system for rating typical breathing, moderate symptoms and serious symptoms.
• Instructions for what to do when symptoms happen and when to use rescue medicine.

Keep a record of your child's symptoms and treatment schedule. Share it with your child's healthcare team. These records can help your child's care team decide whether the long-term control treatment plan works well. The care team can change the plan as needed. Keep all checkups that your healthcare professional recommends too. Information you record should include:

• The time and length and of an asthma attack, along with what happened right before it.
• Treatment responses to asthma attacks.
• Medicine side effects.
• Changes in your child's symptoms.
• Changes in activity levels or sleep patterns.

Work with your child's healthcare team to learn what things trigger your child's asthma attacks. Then help your little one stay away from these triggers as much as possible. You may need to make changes at home and other places your child often goes, such as child care centers. Depending on your child's triggers, you may need to make changes such as:

• Clean thoroughly to control dust and pet dander.
• Check daily pollen count reports.
• Remove cleaning products or other household products that may irritate your child's airways.
• Give your child allergy medicine as directed by the healthcare team.

It also can help to teach your child hand-washing and other habits to help prevent colds. Once kids are old enough, you also can teach them to understand and stay away from their asthma triggers.