Asthma and Respiratory Conditions

Asthma in childhood develops when a child’s airways narrow excessively and become over-sensitive to certain triggers. When the inner surface of the airway swells and becomes inflamed, air has to pass through something like a narrow tube, and that is felt as cough, wheeze and breathlessness. Asthma is the best known of the respiratory conditions of childhood, and one of the situations that worry parents most.

This page explains how asthma develops in children, how it is separated from bronchiolitis and transient wheeze, what triggers the symptoms, what to do during an attack, and when a doctor must be consulted. Nothing here is a diagnosis or a treatment recommendation: your child’s breathing can only be assessed by a doctor, from the history, the examination and, where necessary, tests.

How asthma arises in children

Two things happen together in asthma. The inner surface of the airway becomes inflamed and swollen, and the tendency of those airways to open to their normal width disappears. The child who breathes easily in ordinary conditions then starts to struggle as soon as certain triggers appear.

The most common pattern is that the symptoms change across the childhood years and gradually settle. In small babies the sign may be wheeze alone; in older children a cough, particularly one that worsens at night or in the early morning, becomes the dominant complaint. By adolescence the picture usually improves considerably, but because the structure of the airways changes during this period, the symptoms may not disappear entirely.

This picture reaches into a child’s daily life. Broken night sleep, tiredness during the day, poor concentration at school and being unable to join in games with friends can all follow. Childhood asthma is not only a matter of breathing: it has to be considered alongside growth, sleep and school life too.

Telling asthma, bronchiolitis and transient wheeze apart

When a child wheezes, asthma is the first thing that comes to mind, yet the most common cause in babies and small children is bronchiolitis, a viral infection of the small airways. Bronchiolitis is common in the winter months and runs its course with wheeze, cough and a mild fever. Another pattern seen in children is transient wheeze during an infection, which often recurs in the spring.

Because these three look alike, the distinction is made through the examination and by following the course of the symptoms. Transient wheeze tends to settle, and the child is well in between episodes; in asthma the symptoms recur in a regular pattern, are linked to the seasons and are set off by exposures.

What triggers asthma in children?

• Upper respiratory infections are the most common trigger of attacks in children. A cold and the mucus that gathers in the throat increase the swelling in the lower airways and set off the wheeze.
• Allergens — house dust, pollen, animal dander, mould — can noticeably worsen symptoms in children who have an allergic background.
• Exercise may produce a cough or wheeze only after the activity, which can be a sign that asthma is not well controlled.
• Cold and dry air irritate the airways, and are among the common reasons symptoms increase in winter and in children playing outdoors.
• Smoke and strong smells — perfume, room sprays, cleaning products and dense smoke — act directly on the airways. Not smoking indoors is one of the most effective measures available here.

Monitoring asthma at home

Home monitoring has two sides: recording the symptoms and avoiding the triggers in the surroundings. A written record is far more useful than memory. Noting on which days the child coughs, how often sleep is interrupted and in which settings wheeze occurs lets the doctor see the picture far more clearly.

• Medicines are used only in the way the doctor has set out. If a spray is used regularly, correct technique directly affects how well it works, so it should be reviewed at every visit.
• Keeping the airways clear means reducing dust in the child’s room, washing bedding frequently, keeping pets out of the bedroom and ventilating regularly.
• In cold weather, covering the child’s mouth and nose with a scarf can reduce the way cold air acts as a trigger.
• You can observe the breathing yourself. The upper chest moving in and out too much, the shoulders lifting, a constant cough or a child who pauses for breath while speaking may all point to laboured breathing.
• During the school years, perfume, chalk dust and gym smells can also be triggers, so watch whether symptoms change when the classroom or seat changes.

What to do during an asthma attack

The defining features of an attack are that the child feels very tired and struggles to breathe. The order of priorities:

1. Move the child somewhere calm and quiet and have them sit up. Crying and running make breathing harder, and sitting the child up keeps the airway open.
2. Use the reliever medicine your doctor has prescribed, in the way you were taught. It acts directly on the airways and helps the child settle.
3. Slow the child down: breathing in through the nose and out slowly through the mouth helps the chest movements slow as well.
4. Make the surroundings easier: air the room, move people away and use a calm voice.
5. If there is no improvement, or if the warning signs below appear, do not wait: call 112 or go to the nearest emergency department immediately.

When to see a doctor

In these situations, call 112 or go to the nearest emergency department immediately:

• Breathing is clearly laboured, the child cannot speak, or the lips look pale or bluish.
• The wheeze is loud enough to hear from a distance, or the chest is pulling in between the ribs.

These situations need a doctor the same day:

• A cough keeps breaking the sleep, and the child looks tired, listless or unwell during the day.
• There is a cough that has lasted for several days without interruption and is getting worse each day.
• The symptoms have not settled within hours of the start of an attack, or attacks are becoming more frequent.
• Wheeze began during an infection and has continued after the infection has passed.

Common mistakes

1. Waiting until things are very bad before using the medicine. Following the schedule your doctor has set is the basic step that reduces the frequency of attacks.
2. Changing the dose on your own. Using a spray more often or less often can change how well it works, and that is a decision for the doctor.
3. Stopping treatment once your child feels better. Stopping the regular treatment when the symptoms disappear can bring them back shortly afterwards.
4. Treating cough medicine as the answer to a cough. Some cough preparations are not suitable for children and should not be used without the doctor’s advice.
5. Assuming asthma is temporary. Wheeze and night cough lasting a few weeks need following up and should not be ignored.

Common questions

Is there always a wheeze with asthma?

No. Wheeze is the most obvious sign in small babies, but in older children there may be a cough alone, particularly one that worsens at night. In some children the complaint is noticed only during exercise, so no wheeze does not mean no asthma.

Does my child need their asthma medicine every day?

Your doctor decides that. Some children use medicine only when symptoms appear, while for others medicines need to be taken regularly even when there is no cough or wheeze. This is not a distinction for a parent to make alone.

Can a child with asthma take part in sport?

Yes. Regular physical activity is beneficial for children with asthma too. How long the warm-up should be, what to do in cold air and what to do if symptoms appear during exercise are best planned with your doctor.

My child coughs at night. What should I do?

Note which days the cough occurs, how long it lasts and how often it breaks the sleep; that record helps the doctor a great deal. If the cough continues during the day or you notice laboured breathing, book an appointment.

How should an inhaler be used?

Correct technique directly affects how well the medicine works. Ask your doctor or nurse to show you which spacer to use, how to take the breath in and how to look after the mouth afterwards. Reviewing the technique at each appointment keeps the treatment on track.