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Asthma management in children age 5 and under

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The management of asthma in young children is tricky. Children are more difficult to properly diagnose, there is less research on the effectiveness of different treatment regimens, and it is more difficult to determine whether their symptoms are getting worse. Young children with exercise-induced asthma can be hard to manage because they are so spontaneously active. Nevertheless, great strides have been made in improving asthma treatment in infants and young children.

Diagnosis

It's estimated that up to 80% of children with asthma develop their first symptoms before age 5. That underscores the importance of early diagnosis and treatment. Many children under age 5 with asthma have NOT been properly diagnosed. Some children should receive asthma treatment, even if they do not yet have asthma in order to prevent it from developing (see below).

Diagnosis can be difficult -- other conditions that may have similar symptoms include bronchitis, pneumonia, gastroesophageal reflux, colds, and other conditions. Because wheezing and coughing can be due to these other conditions, it is important not to jump to the conclusion that the child has asthma and begin unnecessary long-term asthma therapy. A trial run of asthma medication may help determine whether asthma is the cause of wheezing, cough, or breathlessness.

Treating asthma attacks

Any child, regardless of age, who is having an asthma attack needs relief medicine to open the airways. The preferred treatment is a short-acting beta agonist. Small children are unlikely to be able to use an inhaler by itself properly. Therefore, they need to use either a nebulizer (which has a mask and hose connected to a machine that aerosolizes the medicine) or an inhaler with a mask-spacer attached to it. Some companies even make nebulizer masks with fun characters on them to make the experience a little more tolerable for small children.

Should my child use control medicine every day?

An expert panel organized by the National Institutes of Health recommended that long-term, daily control medication should be considered for children age 5 or under who:

  • Need their asthma symptoms treated with relief medication more than 2 times per week
  • Have asthma symptoms more than 2 nights per month
  • Have severe episodes fewer than 6 weeks apart

In addition, young children should be considered for daily control, whether or not they have been diagnosed with asthma, in order to prevent or delay the development of asthma. Children most likely to benefit are those who have had more than 3 episodes of wheezing in the past year (which lasted more than a day and disrupted the child's sleep) and if they have any of these risks for developing asthma:

  • Child has atopic dermatitis
  • A parent has or had asthma
  • Child wheezes when the child doesn't have a cold and has allergic rhinitis, or evidence of allergies on a blood test

Recommendations for asthma control in infants and young children can be found in the National Institutes of Health Expert Panel Executive Summary (Note: File requires Adobe Acrobat). A chart is on page 4 and dosing information is on page 6. This expert panel report is intended for physicians and written at a clinical level, but some parents may find the detailed information useful.

The safety of long-term medication use

Studies have investigated the impact of long-term inhaled steroid use on growth, bone mineral density, and other factors in children. While some unwanted effects have been seen, the evidence to date indicates that these effects tend to be uncommon and reversible.

Inhaled corticosteroids and growth in children is a common concern. However, several studies report only a slight effect (about half an inch) on children's growth, which may only be temporary. Other important points for patients to understand include:

  • When asthma is poorly controlled, growth may also be reduced.
  • Since short-term growth may vary, it is important not to be alarmed by short-term slowing of growth.
  • The best estimation of the effect of inhaled corticosteroid usage is a 1 cm (less than 1/2 inch) reduction in height.
  • The effect is generally apparent in the first several months, but it is not progressive.

If a child appears to be having a slow rate of growth, the benefits of continuing asthma medication should be weighed. It is likely the child will eventually reach a normal height. For children with persistent asthma, inhaled steroids are very effective and the benefit of preventing asthma attacks usually outweighs a risk of growth delay. Also, keep in mind that children who take control medicine need lower doses of relief medicine, and thus have fewer side effects from that.

Monitoring asthma in young children

Children age 5 and under are often unable to use a peak flow meter correctly. Therefore, it is largely up to the parents or care-givers to watch for signs that the child's asthma is growing worse. These include wheezing, coughing, skin on the neck and chest looking sucked in, and other signs of breathing difficulties. As children get older, they are better able to recognize when their condition is getting worse, and eventually will be able to use a peak flow meter with the parent's help.

It's a good idea to teach a child under 5 how to use a peak flow meter, just to get them into the habit of using it from an early age, but not to actually rely on the meter for monitoring the child's condition.

References

National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Rockville, MD. National Heart, Lung, and Blood Institute, US Dept of Health and Human Services; 2007. NIH publications 08-4051.

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