For the parent of an asthmatic child: A brief review

Asthma is a common medical condition with high morbidity and mortality specifically when managed incorrectly. The prevalence of asthma in the pediatric population is anywhere from ten to twenty percent in some populations and up to greater than twenty percent in others.  Asthma can be difficult to manage, especially with problems of non compliance to medication administration. This is of grave concern to pediatricians, as a sudden asthma attack can possibly result in death!

Pediatric clinic visits for asthmatic care follow-up can seem very over-whelming to a teenager who simply wants to fit in at school. It can also seem over-whelming to parents, specifically those who are younger in age or who have not dealt with other children affected by asthma. There is a resistance to adhere to medications due to the fear of side effects. There is also incorrect usage of medications when multiple medications are prescribed by the pediatrician. Asthma can seem complex to families and the short clinic visit with your child’s pediatrician may not be enough for the full clarification needed. The purpose of this article is to help clarify a few common concerns.

Firstly, it is very important for parents to recognize that no two children with asthma have the same symptoms or the same frequency of asthma attacks. Some asthmatics are never hospitalized for the duration of their lifetime while others may have one or two hospitalizations. The most severe asthmatics may be hospitalized on a near monthly basis. Some asthmatics are well controlled solely on an albuterol inhaler for symptomatic episodes. Others may need one or more controller medications to be used on a daily basis, in addition to their albuterol inhaler for symptomatic episodes.  Generally asthmatics need extra follow-up visits with their pediatricians outside of the yearly well checks for an older child. Very severe asthmatics may even need to see a pediatric pulmonologist. The need for the intervention of a specialist will be determined by your child’s pediatrician.

During your child’s visit, the pediatrician will ask questions about the frequency of symptoms (cough or wheeze) and the frequency of nighttime awakenings due to cough. He/she will also ask about symptoms related to sports and outdoor allergies. Based on the answers, your child will be classified as an intermittent asthmatic, or a persistent asthmatic. Persistent asthmatics are further classified as mild, moderate or severe persistent asthmatics. The medications recommended by the pediatrician are based on this classification.

Albuterol is a symptomatic medication, and should be administered only when your child is experiencing symptoms such as cough, wheezing or shortness of breath. An older child may indicate that they are having “chest tightness” in the absence of any significant cough or wheezing. Albuterol should be administered in this case as well. One indication where albuterol is administered in the absence of symptoms is in the case of the child with exercise-induced asthma. It is found that an albuterol treatment approximately half an hour prior to the onset of an exercise regimen, as well as a warm up period prior to onset of more strenuous activity are both very helpful in this particular scenario.

One concern of parents of asthmatics is the possible side effects of asthma medications, particularly steroids. Steroid use for asthma management can be broken down into short course and long course steroid treatments. Short course steroids are typically oral (given by mouth) and are generally given for a seven to ten day period. Oral steroids are more potent and carry a higher (but still relatively small) likelihood of resulting side effects. Longer course steroids are typically inhaled (i.e. given as a metered dose inhaler similar to albuterol). Inhaled steroids are less likely than oral steroids to result in any side effects however; more persistent asthmatics may be on inhaled steroids on a daily basis for several years.  The side effects which could possibly be seen from steroid use include but are not limited to: 1) decreased linear growth, 2) oral candidiasis (also known as thrush, a condition more often seen in newborn babies or persons with immunodeficiencies) , 3)tooth discoloration, to name a few. The latter two are seen primarily with inhaled steroids and can be totally avoided by instructing child to rinse mouth thoroughly after steroid inhalation. Stunted growth is rarely seen and if it does become evident, your child may be referred to an endocrinologist (hormone doctor). The benefits of a short course therapy or long-term steroid inhalation therapy generally greatly outweigh the possible risks. One has to keep in mind that any severe asthma attack could result in death. It is also imperative to understand that each asthma exacerbation in a hospitalized setting carries with it an increased risk of morbidity and mortality related to this chronic illness.