Dr. Amanda Striegl, a pulmonologist, and Marijo Ratcliffe, a nurse practitioner in the Pulmonary Division at Seattle Children’s, address questions about pediatric asthma management.
Thank you to Dr. Wendy Sue Swanson, a pediatrician at The Everett Clinic in Mill Creek, a member of Children’s medical staff and author of the Seattle Mama Doc blog, for submitting these questions.
Q: Can you explain the difference between a preschooler wheezing and a 10-year-old wheezing?
A: Viral illnesses cause wheeze in many more preschoolers than school-age children because it takes less inflammation and mucus to restrict their smaller airways. When a school-age child wheezes, they tend to have true multitrigger asthma that can be brought on by virus, allergy, cold air, etc. About a third of children under age 3 will wheeze at least once with a cold, but only a third of that subset will go on to have asthma.
The toddlers who are most likely to have persistent wheeze because of asthma are those with allergies in infancy (eczema and food sensitivities) or those whose mom has asthma.
Q: At what age do you stop calling a wheeze reactive airway disease and start calling it asthma?
A: We avoid the term reactive airway disease, or RAD, because it gives a message to families, schools and others that it‘s not asthma when, in fact, the medications and the appropriate response during illness are exactly the same.
There’s no specific age or number of wheezing episodes that determines when a child really has asthma. It’s based on the clinical picture. If a 1-year old is very allergic (has eczema and wheezes in response to the cat or dust in addition to colds), we call it asthma. Likewise, if an older child is short of breath with exercise and colds, we call it asthma.
Young children who wheeze only with viruses and respond to asthma medications often change over time and can weather their colds without medications by age 5 or 6.
This is when you see a steep drop in the viral wheeze/reactive airways phenotype that is replaced by multitrigger wheeze or true asthma. See a graph of wheezing phenotypes by age (PDF).
Q: Can we safely give steroids to young children with frequent wheezing?
A: Daily inhaled steroids are the best and safest therapy for any child with frequent or more severe asthma symptoms. Many parents are uncomfortable with steroids, but may not realize that children may have reduced steroid exposure if inhaled rather than oral steroids are used, due to both the actual volume given and the fact that the oral steroid is systemically absorbed.
An intermittent, high-dose inhaled corticosteroid (ICS) regimen can be trialed in wheezy toddlers who have needed oral steroids to see if it reduces the severity of flares. If toddlers wheeze with colds but don’t need oral steroids very often, we just use intermittent albuterol.
The same is true for older children with asthma who only have trouble with viral illnesses one or two times per year or with exercise one or two times per week. See graphs comparing a daily low dose and intermittent high doses (PDF).
Q: Some children tolerate persistent asthma symptoms during childhood. What’s the real risk of those children’s underdiscovered symptoms?
A: If a child and parent become used to a false normal, they’re less likely to intervene aggressively when needed. The biggest risk is that the child is always one step closer to that severe exacerbation that lands them in the hospital – or even the intensive care unit (ICU) – than a child with totally normal airways.
Q: What’s the most common mistake you see with children referred from primary care?
A: We often see poor drug delivery technique or incorrect use of inhalers. It‘s surprisingly common to meet children who don’t use a spacer with their inhaler or who use it incorrectly. Nebulized drugs also need attention to technique; a common mistake is giving them without a mask so that much of the drug is wasted into the air near the face. Correcting technique can be the biggest impact we have on control.
It’s also surprisingly common to see families using their rescue albuterol daily and their daily controller steroid intermittently because they were confused. It can help to ask families to bring their medications or have pictures on hand to make sure families know the names of the medications and when to use them.
Q: When starting an ICS for a persistent wheezer, what’s the best way to determine the starting dose?
A: The best reference is the National Heart, Lung and Blood Institute (NHLBI) asthma guidelines for severity of symptoms (PDF).
Q: At what interval do you recommend seeing the child back in the office? What should we focus on during visits?
A: See them back in four to eight weeks – sooner in severe cases.
Check and recheck spacer technique, especially if control is poor. Don’t change a medication plan without being confident they’re actually using the medications as you had intended. Ask how many times they forget to take them in a typical week and whether refills are obtained on time. It’s important to know what is actually being given before ramping up treatment rather than making assumptions.
Q: At what age do you typically say that children on chronic medications can carry and self-administer their metered-dose inhalers (MDIs) or medications?
A: Not usually until age 10 – and only after they demonstrate in clinic. The child must also be able to tell time.
Q: Side effects are a big concern for some parents. What’s the easiest way to summarize the risks of daily ICS for a child with persistent asthma?
A: The use of medium to high-dose inhaled steroids over years can slow linear growth in asthmatic children, with greater effect in girls. Although research shows that speed of growth resumes after stopping ICS, children treated with ICS were, on average, half an inch to one inch shorter than their untreated peers when measured as young adults.1
You can tell parents how high or low their child’s exposure is considered based on dose and length of time taking the medication, and tell them how much of a concern it is. It’s also important to point out that frequent use of oral steroids and chronic untreated illness can similarly affect growth and delay puberty.
Q: What is important to discuss with parents with respect to triggers and environmental conditions?
A: We often overlook and undereducate about environmental triggers. In particular, dust mites cause symptoms, and it’s easy to intervene by using pillow and mattress covers and washing bedding in hot water. There’s also a tendency to be too forgiving with pets. If the child can’t breathe and needs increasing therapy, the cat needs to go!
The Master Home Environmentalist Program conducts free home environmental assessments for Seattle residents and provides a Home Environmental Assessment List that families can use.
- Kelly HW, Sternberg AL, Lescher R, Fuhlbrigge AL, Williams P, Zeiger RS, Raissy HH, Van Natta ML, Tonascia J, Strunk RC; CAMP Research Group. Effect of inhaled glucocorticoids in childhood on adult height. N Engl J Med 2012 Sep 6;367(10):904-912.