ASTHMA IN THE UNDER FIVES

Asthma affects one in seven children in the UK. About 30 per cent of under fives have had at least one attack of wheezing. This means that millions of parents have been told that their child has asthma and have seen for themselves what asthma can do. Most of the time asthma is mild and easily controlled by medicines, but sometimes children have attacks that can be frightening and very distressing. Most young children outgrow their asthma by school age.

For parents it is always worrying to see their child suffer, no matter how mild the asthma may be. The National Asthma Campaign receives many thousands of enquiries from worried parents who are keen to know more about asthma and to do the best thing for their child. What follows will help you to understand and control your child's asthma by following a management plan.

Describing asthma

Lungs have hundreds of tiny tubes called airways that carry air in and out. Children with asthma have airways that are extra sensitive to substances which irritate (trigger) them. Although they vary from child to child, triggers such as colds, cigarette smoke or pollen can cause the airways to become narrower as the surrounding muscles tighten.

The lining swells and produces a sticky mucus which narrows the airway even more. This often, though not always, causes a wheezing noise when they breathe. Children with asthma may cough a lot because their airways are irritable and because they produce a lot of mucus (phlegm).

Some children with asthma may also have other related conditions such as eczema, hayfever (allergic rhinitis) and itchy, streaming eyes (conjunctivitis). It is important to make sure that doctors take an overall view, so always remind them of your child's other conditions.

The cause of asthma

The tendency to develop allergies, including allergic asthma, often runs in the family, but there are probably a number of other things that cause children to develop asthma. It is known, for instance, that smoking during pregnancy increases the likelihood of childhood asthma and that children with asthma whose parents smoke will have more severe symptoms. In the first few years of life asthma consists mainly of acute attacks with colds. It occurs in response to virus infections and is usually unrelated to allergies. On the other hand, at school age most asthma occurs in children who have some sort of allergy. There is no evidence that traffic pollution causes asthma to develop in previously healthy individuals.

How asthma is diagnosed

The typical symptoms of asthma in young children are wheezing and/or troublesome coughing, particularly at night, with colds or with exercise. It is the pattern and severity of symptoms over time which shows whether a child has asthma or not. Children benefit once everyone knows they have asthma because they will then receive regular monitoring and proper treatment.

You can help by recording how your child's symptoms are and when they happen. Children tend to develop their own pattern and severity of symptoms.

Your doctor or nurse may ask you to fill in a symptom chart to provide a clear picture of the asthma. Charts are especially useful when asthma is diagnosed for the first time and, later on, if the asthma or the treatments change. Once you are familiar with the pattern and severity of your child's asthma, there is no need to fill in the chart every day.

Charts often ask you to record:

• the type of symptom: cough or wheeze
• the time of symptom: day or night
• the severity: by using a simple score
• the need for extra reliever

Using a simple scoring system, the doctor or nurse can see from the chart the pattern and severity of your child's asthma. Using this information the doctor or nurse can decide which treatments to recommend and develop a management plan that suits your child.

Asthma can get worse gradually, over a few days or very suddenly, such as after a cold. Children can have bad day-to-day symptoms, separate attacks or both. After good treatment with a preventer the day-to-day symptoms are better and need only occasional reliever, but attacks may still occur.

It is important to note that for many young children, a dry, irritating cough may be the only symptom of asthma, even though most people think that wheezing is the only asthma symptom. Healthy children rarely cough, except with a bad cold.

Children under two are most likely to suffer from the type of asthma which is set off by virus infections such as colds and a runny nose.

Spotting asthma in very young children can still be difficult because:

• at least 30 per cent of all children will have wheezing during their first five years of life. Most of these children will never have breathing problems again so doctors may not want to use the term 'asthma'
• doctors describe asthma in a number of ways: wheezing, wheezy bronchitis, chesty coughs, colds that move to the chest
• it is not easy to measure how well a young child's lungs are working because the device that is normally used for school children and adults (the peak flow meter) can only be used by children who are over six years old

It may take several visits to the doctor to get to the bottom of your child's breathing problems.

Different degrees of asthma

Doctors often use the words 'mild', 'moderate' and 'severe' to describe asthma. Below are some guidelines explaining what they mean.

Mild

Coughs and/or wheezes, but plays happily and feeds well; sleep is undisturbed by symptoms.

Moderate

Waking at night; can't run around and play without wheeze or cough.

Severe

Too restless to sleep; unwilling to play at all; too breathless to talk or feed; or (if very severe) lips going blue.

Modern asthma medicines

Unfortunately there is no cure for asthma yet. The aim of modern management is to reduce children's symptoms, and allow them to lead full and active lives, unaffected by their asthma. Avoiding the things which make the asthma worse and using asthma medicines are the main ways we can achieve this.

Almost all asthma medicines these days are given by some form of inhaler, even to very small babies. There are two main types of asthma medicine:

Preventers

Preventers protect the lining of the airways and make thein less likely to narrow when triggered. They do not bring immediate relief from symptoms. Preventers are usually reconunended if a child needs to use a reliever more than once a day on a regular basis.

Preventers must be taken regularly, even if your child is well. They take about 14 days to become fully effective, but sodium cromoglycate can take longer. Once the symptoms are under control, your doctor may suggest reducing (stepping down) the treatment to a lower level.

There are two types of preventer therapy. Sodium cromoglycate (eg Intal and Cromogen) comes in white and red inhalers respectively. The steroids beclomethasone (Becotide or Beclazone are two examples) and budesonide (Pulmicort) are in brown inhalers. The newer steroid, fluticasone (Flixotide), comes in inhalers of different shades of orange according to the strength. Because they are normally in haled through a spacer and are prescribed at a low dose these steroids do not cause side-effects and have no effect on growth.

Relievers

Relievers make breathing easier by relaxing the tiny muscles surrounding the narrowed airways and allowing them to open up. They are mostly used after symptoms appear. They may also give brief protection against triggers such as exercise, if given just beforehand. Relievers are particularly important for treating asthma attacks.

The relievers, which usually come in blue inhalers, include salbutamol (eg Ventolin) and terbutahne (Bricanyl). lpratropium broniide (Atrovent) is a different type of reliever, most commonly used in the youngest age group.

It is worth noting that not all relievers work well for all children under one year old, and so doctors must use trial and error to find the one which works best.

Symptoms cannot always be prevented so it is necessary to have a reliever medicine to hand at all times.

Medicines have two names; the chemical name and the brand name (in brackets). Doctors may use either when they prescribe medicine for your child, but the pharmacist will always put the proper chemical name on the label.

Steroid tablets

A short course of steroid tablets (1-5 days) is sometimes needed to treat or prevent an attack, in addition to the preventers and relievers. The tablets are called prednisolone. They are like the steroids that your body makes naturally, but are very different to anabolic steroids. Your child should not experience side-effects from steroid tablets that are taken occasionally, except for possible temporary hyperactivity. For further information please read our 'Steroid treatment for asthma' booklet.

If your child shows any signs of developing chickenpox and has had a short course of steroid tablets in the last month, you should visit your doctor immediately.

Complementary treatments

Many people have suggested that complementary treatments have improved their asthma. Because complementary treatments have not undergone the same strict trials that medicines have, doctors will rarely recommend them.

Complementary treatments are often wrongly called 'alternative' treatments. There are no proven alternatives to modern medicines. If you decide to consult someone other than your doctor about your child's asthma, remember to continue giving your child the preventer and reliever medicines as agreed with your doctor.

Helping the medicines go down
Inhalers

Most asthma medicines are breathed in (inhaled). Because they go straight into the lungs they can be given in low doses and have the smallest possible side-effects. Even in infants, inhaled medicines are much more effective than the syrups which used to be prescribed.

There is a wide range of inhalers. Some are aerosols (puffers) which are like mini spray cans. These cannot be used for pre-school children without a spacer (see below). Sometimes, for children older than five years, dry powder devices are prescribed. These are good as a preventer treatment but they do not work as well when children are tight-chested and wheezy. An aerosol may still be needed for reliever therapy at such times.

Spacers

All young children should be prescribed a spacer to fit their aerosol puffer. Spacers are important because they make it possible to give very young children inhaled medicines, provided they are prescribed a face mask. Spacers make sure that the medicine reaches the lungs rather than landing on the throat or in the month. Never put more than one puff at a time int o the spacer. Wash it when it gets dirty and allow it to dry by standing it in a warm place (do not dry with a cloth).

There are several brands of spacer which fit different puffers, have a detachable mask and are available on prescription (including Volumatic and Nebuhaler). The Aerochamber is not available on prescription: details from Medic Aid (01243 267321).

Nebulisers

Very occasionally children need extra help to take their medication. They may be prescribed a nebuliser by a hospital consultant. These machines create a mist of medicine which the child breathes in. While they are very helpful for a small minority, most children are better off using a spacer which is quicker to use and much less bulky. For further information, please read our 'Spacers and nebulisers' booklet.

Using puffers and spacers

Getting your child to take inhaled medicine properly is the most important part of successful asthma management. Many parents find this can be difficult with young children. The following suggestions may help you to give your child the medicines they need.

• Make sure your doctor, practice nurse or pharmacist (chemist) shows you how to use the inhalers and spacers that you have been given. You should also be told how to keep them clean and when to replace them.
• Always give your child the medication using an aerosol puffer fitted with a spacer (unless your child has been prescribed a nebuliser by a hospital consultant).
• Introduce your child to the spacer and puffer as toys. Use them yourself (without firing the puffer) to demonstrate. Try putting stickers on the spacer to make it look more interesting and try to turn giving the medicine into a game.
• Giving your child the spacer or nebuliser treatment when asleep is always an option. This method is often successful for vigorous toddlers.
• If your child is in distress and you want to give the medication quickly, remember the treatment can still be inhaled even when the child is crying.

Asthma and daily life
Preventing the onset of asthma

There are no simple cures or methods of preventing the onset of asthma. In any case most of the youngest children who wheeze occasionally after colds will grow out of asthma.

Breast-feeding

Breast-feeding is often encouraged for a number of very good reasons. But even in families with a history of allergies, breast-feeding has not been shown to prevent the onset of asthma; at best there is a delay in the onset of symptoms. If artificial feeds are used then soya milk is no better than cow's milk. If your child has eczema or other definite allergies, you should consult your health visitor or dietician to discuss low-allergy weaning diets. It has to be said that these diets are rarely of any value for wheezing (see the 'Diet and asthma in babies' factsheet available from the National Asthma Campaign

Avoiding the triggers

Common colds
Some triggers are easier to avoid than others. For example, it is almost impossible to avoid colds and runny noses in young children. House dust can be very difficult to control and in the summer pollen is almost everywhere. All parents would like to take positive steps to help their child, but it can be very demoralizing trying to avoid the unavoidable. Therefore it is important to discuss any changes you plan to make in your lifestyle with your doctor or nurse first.

Below is a list of common triggers that cause asthma symptoms to develop in children.

Irritants
- Cigarette Smoke
One trigger which all children should avoid is cigarette smoke. This should be the priority of all parents.

Cigarette smoke is especially harmful to growing lungs and triggers asthma attacks. If planning another baby, parents should stop smoking during pregnancy too, to reduce the risk to the next child. For advice, help and support on giving up smoking call Quitline on 020-7487 3000.

Do not smoke in the home or anywhere around children. Be bold and ask others to do the same, and avoid smoky places. Join a campaign to promote smoke-free areas.

Allergies
- House-dust mites
House-dust mites are tiny creatures that live in our beds, carpets, soft furnishings and soft toys. About 60 per cent of all wheezy school children are allergic to house-dust mite droppings. Most pre-school children with asthma do not have known allergies to mites or other dust. Therefore it is worth weighing up carefully the costs and the benefits before adopting a strict regime of dust control, and only take steps if your child is very allergic to dust mites.

Dust control can reduce the number of house-dust mites, but it will not get rid of them altogether. A combination of the following measures may help: replace the bedroom carpet with vinyl; keep pets out; damp-dust once a week; don't put a child with asthma in the bottom bunk; put a special cover over the mattress, pillow and duvet and wash the linen at 60°C once a week; put soft toys in the freezer once every two weeks to kill the dust mites they harbour; and avoid feather and wool on bedding and pillows (see the 'Dust control' factsheet available from the National Asthma Campaign

- Pollen
Pollen can trigger asthma in older children. Again, few infants and very young children have this type of symptom unless they have other allergies or a farmily history of allergy.

It can be very difficult to avoid pollen at some times of the year. Children should not be stopped from playing outside, but playing in long grass or outside when the pollen count is high could cause problems. This might mean increasing the dose of preventer during the pollen season.

- Pets
Some children with asthma are allergic to furry animals and occasionally to birds.

Do not keep pets with fur or feathers if there is a family history of allergies or your child has asthma. It is much harder to get rid of a pet than never to have had one.

- Moulds
Tiny pollen-like particles are released into the air by mould which grows in almost any warm, damp area. They are common in damp places.

Remove mould in the house quickly and avoid condensation where possible. It is important to keep rooms well aired.

Activities
- Exercise and excitement
Exercise, laughing and excitement can trigger asthma. If this happens regularly then the asthma is not well-controlled and you should see your doctor.

It is very important for children with asthma to have fun and enjoy exercise. With proper asthma management this should not be a problem. For more information, please read the 'Exercise and asthma' booklet available from the National Asthma Campaign

- Cold air and asthma
Some children are sensitive to cold air and may cough or wheeze initially on going out. This should not mean they have to stay inside. A dose of reliever just before going out may be all that is needed.

Over-wrapping babies and keeping the bedroom too warm does not help wheezy young children and can be dangerous for other reasons.

Childcare and asthma

Many parents work or study when their children are young. Finding the right childcare can be difficult, especially for parents of children with asthma. There are a number of alternatives to try including childminders, nannies, day nurseries, playgroups and nursery schools. To stop your child's asthma getting worse while you are away watch out for triggers and make sure your childcare workers know what to do in an emergency. Think about the following:

• Will people be smoking around your child?
• Are there any pets to consider?
• Will your child's carers give your child medication if necessary? If so will they understand when and how to use it?
• Do your child's carers know how to recognise and deal with an emergency?
• Can they contact you quickly at all times?
• Is your child's carer properly registered with the local authority?

As with school children it is important to leave clear written instructions with carers. You can give a copy of your child's asthma management plan to your childcare worker. This will show them which medicines your child needs to take and when to give them, and what to do in an emergency.

Before your child starts school, check with the teacher and playground attendant that they know how to deal with your child's asthma. Contact the school nurse and make sure they have written instructions on a School Card and a School Asthma Policy. (For more information please contact the National Asthma Campaign

Asthma and sleep

It is not normal for children with asthma to wheeze and cough during the night; the presence of such symptoms means that the asthma is not under control. This can mean disturbed sleep for both child and parents. Sleeping problems can have a major eeect on the quality of life; children can become tired and listless during the day, and parents can become short-tempered and have difficulty coping. Every effort should therefore be made to get rid of night-time symptoms (as with all asthma symptoms) and to allow a normal sleeping pattern to develop. If night-time symptoms persist talk to your doctor or nurse, who may want to alter your chfld's asthma management plan.

What next?

All parents would like to know if their child will grow out of asthma, but no-one can predict the future. In general terms the younger the children are when they develop asthma, the more likely they are to grow out of it by the time they start school. Children who develop asthma later (aged three to five) or who have a strong family history of allergies, tend to experience asthma during their school careers, but may grow out of it by their teens. Of those children who still have asthma at the age of 14, the majority will carry a tendency towards asthma into adult life.

A cure for asthma?

At the time of writing there is no cure for asthma. Thanks to research this may change in the future. One thing is certain: the outlook for asthma research has never looked so good.

Researchers are tackling asthma from many different directions: pollution, allergies, infant asthma, cell biology, chemical structures and new medications are just a few. Not only are they looking for a cure, but they are also looking at ways to improve asthma care and the quality of life for children with asthma today.

Childhood asthma management plan

It is important that you know how to limit the effect asthma has on your child's life. This means learning how to recognise and avoid the triggers that set asthma off and how to control asthma symptoms once they occur. Most important is to know what to do when your child has an asthma attack. By stepping in early, severe attacks can usually be prevented.

This section is designed to be used together with your doctor or nurse. It will help you decide what to do in a number of different situations. This plan is only a guide. Your doctor or nurse may wish to change this plan to suit your child. Although this plan has four zones, your doctor or nurse may prefer to miss out Zone 2.

The National Asthma Campaign publishes a card, and the text here in booklet form, which help you record your child's asthma management plan. It also reminds you when to give your child the asthma medicines that have been prescribed.

Adjusting your child's treatment

Zone 1 - Your child seems fine, seldom coughing or wheezing.
Action - continue usual treatment
Zone 2 -Asthma gettinw worse or developing a cold (which you suspect may cause an attack); needs a reliever more than once a day; coughing or wheezing for the last day or so; waking with coughing or wheezing for the last night or so
Action -Increase inhaled preventer to (ask your doctor or nurse); give reliever, as needed; contact the doctor in the next few days
Zone 3 -Asthma much more severe; needs reliever every four hours; coughing all the time; too wheezy to run and play; waking each night with coughing or wheezing
Action -Give reliever, as needed; continue inhaled preventer; give steroid tablets, as directed; contact the doctor
Zone 4 -Severe asthma attack if any of these happens: Reliever lasts less than three hours; very distressed by wheezing or breathlessness; too breathless to feed or talk; lips boing blue
Action - Call for help (doctor/ambulance/or go to the nearest casualty department); give extra reliever, every few minutes if necessary, while wairing for help. Use spacer or nebuliser if available; give steroid tablets, as directed.

Be aware

During an asthma attack coughing, wheezing or breathlessness worsens quickly until breathing becomes difficult. Some children become too breathless to talk or feed during an attack. An attack can take anything from a few hours to a few days to develop and in young children it normally accompanies a cold. An asthma attack can be life-threatening and therefore needs to be taken seriously. It can be frightening, but knowing what to do can help you to stay calm and help your child.

Danger signs

Follow your child's own emergency plan if your child has any of these signs:

• Needs their reliever repeating before three hours
• Becomes very distressed by wheezing or breathlessness
• Is too breathless to feed or talk
• Becomes blue around the lips

The emergency plan will be along these lines:

• Call for help immediately. Call your doctor or an ambulance or take your child to the nearest hospital offering emergency care to children. Your plan will show you which is best in your area.
• Give your child their reliever treatment immediately. Repeat every five to ten minutes until their breathing improves or until help arrives.
• Give your child steroid tablets if they have been prescribed by your doctor
• Hold or sit your child in a comfortable upright position. Lying down is usually less comfortable

Do not be afraid to ask for help

If your child goes to hospital make sure your own doctor is kept informed and that your child has a follow-up appointment either at the hospital or with your own doctor.

Update the plan

• Because your child's asthma may change as time goes by, your doctor may need to change the plan accordingly. You should take your child to visit the doctor or nurse at least twice a year
• If your child is often in Zone 2 or 3, let your doctor know because the usual medicines may need to be increased or changed
• If your child is always in Zone 1, your doctor may wish to reduce (step down) the regular medicines
• We recommend that one month or so after starting the plan, you should review it with the doctor or nurse

National Asthma Campaign

The National Asthma Campaign is the only charity dealing exclusively with asthma and related allergy. It funds research into asthma and provides information to a host of people including doctors, nurses, people with asthma and their friends, teachers and employers.

The Campaign has a network of local branches around the UK. Each branch offers support to local people and raises money to help support the charity.

The National Asthma Campaign works to promote the interests of people with asthma; to raise the public's awareness of asthma; and to do everything in its power to ensure that no person with asthma suffers needlessly.

Who can help

Use your local health services; they are free and with regular visits and teamwork you have the best chance of controlling your asthma. If you would like additional information you may like to do the following:

• To speak to an asthma nurse call the Asthma Helpline on 0345 010203 between 9am and 9pm, Monday to Friday. Calls are charged at local rates.
• Subscribe to Asthma News, the National Asthma Campaign's quarterly magazine, by becoming a member.
• Contact your National Asthma Campaign local branch.
• If you are 12 or under you may like to join the junior Asthma Club.
• Write to the National Asthma Campaign at the following address:
  National Asthma Campaign
  Providence House
  Providence Place
  London
  N1 0NT