Pediatric Asthma

What is Pediatric Asthma?

Pediatric asthma is a condition involving limited airflow and consistent breathing problems in children. These issues can include wheezing, coughing, shortness of breath, and a tight feeling in the chest. Asthma commonly begins in children, with almost half of all newborns wheezing during their first year of life, with many going on to have persistent symptoms by the time they are six years old. Factors like genetics and the environment contribute to how common and severe asthma can be, and patients often have overly sensitive and inflamed airways. Asthma’s degree of seriousness can vary from irregular symptoms to life-threatening breathing problems, making thorough diagnosis important.

Typically, there are two distinct groups of children with asthma-like symptoms and wheezing. One group’s symptoms are usually sporadic, often triggered by viruses, which they tend to outgrow. The other group typically develops symptoms later in life, often alongside a family history of asthma and allergies, thus having a higher risk of having persistent asthma later on. Efforts have been made to predict what children are likely to have long-term asthma by categorizing common traits, identifying genetic risks, and developing prediction tools. However, these methods have limited practical use at present.

Spirometry, a type of lung function test, is crucial for definite diagnosis, alongside assessing the response after bronchodilator therapy. This test helps detect various lung problems in children, which could include blocked airways, restrictive lung disease, chest wall issues, respiratory muscle weaknesses and problems with gas exchange. While most discussions about asthma triggers focus on airborne agents, a broad range of factors can set off or exacerbate asthma. These can include respiratory infections, exposure to allergens, environmental irritants, physical activity, hormonal changes, certain medications, and mental stress. The approach to controlling asthma involves educating patients and caregivers, keeping track of symptoms, and having access to quick-relief medications and controller medicines depending on the disease’s severity.

What Causes Pediatric Asthma?

Asthma is a condition that is influenced by a mix of genetic and environmental factors. There are many different genes that can play a role in someone developing asthma, or in how severe their asthma is or how well they respond to treatment. Scientists think that ‘epigenetics’, or changes in how genes work due to things in the environment, might help explain some of this.

Some studies have found certain genes that could be linked to asthma. For example, genes called ORMDL3 and GSDMB, which are on chromosome 17, have been linked to asthma in children. Other genes that have been associated with asthma include IL33, IL1R1, and PYHIN1, which are mainly found in people of African descent. Another gene that could be involved in asthma is one that is associated with a molecule called thymic stromal lymphopoietin (TSLP). This molecule is involved in inflammation, which is a key part of asthma.

Other parts of the genome that have been linked to a risk of asthma include HLA-DQA1, TLR1, IL6R, ZPBP2, and GSDMA. An interesting point is that identical twins don’t always both get asthma, which suggests that environmental factors, and not just genes, are important. Furthermore, the effects of certain gene versions can differ depending on what environmental exposures a person has had. This complexity is why genetic testing for asthma isn’t currently very useful.

There are many risk factors for developing asthma, which can occur at any point in a person’s life, including before they are born. Important asthma risk factors include being genetically prone to overreact to environmental allergens, being born prematurely, being exposed to smoke during pregnancy, and maternal vitamin D deficiency. However, it’s currently not clear how much we can reduce these risks or the long-term impact on asthma development.

The Copenhagen Prospective Studies on Asthma in Childhood (COPSAC2010) has found that children born to mothers who ate lots of omega-3 fats are less likely to develop asthma in the first three years of life compared to those whose mothers ate lots of omega-6 fats. Other research suggests that vitamins E and C and zinc might protect against asthma, and giving pregnant women vitamin C might reduce the harm of smoking on their babies’ lungs.

Risk factors for asthma during infancy and childhood include being male, having unusual lung function at birth, being exposed to allergens, obesity, and starting puberty early. Reports also suggest that exposure to certain bacteria and allergens within the first year of life could lower the risk of asthma, whereas exposure later on could increase it. Some studies suggest there might be a link between use of certain medications and asthma, but more research is needed. Lastly, smoking and exposure to second-hand smoke are both risk factors for developing asthma.

Risk Factors and Frequency for Pediatric Asthma

Asthma is the main reason for school absences and hospitalizations among children, making it a common diagnosis in many U.S. children’s hospitals. The U.S. Centers for Disease Control and Prevention (CDC) states that over 6 million children in the U.S. suffer from asthma. This condition tends to become more common as children grow, with a rate of 1.9% in kids aged 0 to 4, and 7.7% in kids and teenagers aged 5 to 14. It is more prevalent in boys below 20, but in adults, women are more affected.

• Among infants, 20% have wheezing problems due to upper respiratory tract infections, but the good news is that 60% will outgrow it by age 6.
• Asthma is more common in Black individuals (10.1%) than in Whites (8.1%).
• Hispanics typically have a lower prevalence rate of 6.4%, but those from Puerto Rico have a higher rate of 12.8%.
• Minorities and people living in poverty have the highest number of asthma cases and the highest rates of asthma-related health problems and deaths.

In a global context, the Global Burden of Disease report indicates that asthma contributes to around 420,000 deaths annually. These numbers reflect a similar trend in the U.S., where asthma-related death rates have consistently decreased. At present, the rate is 9.86 per million, down from 15.09 per million in 2001. Nevertheless, the death rate for Black patients from asthma remains significantly higher than for White patients. As per the CDC, between 1999 to 2016, the asthma death rates for adults aged 55 to 64 were 16.32 per million people, for females 9.95 per million, for those who were not Hispanic or Latino 9.39 per million, and remarkably higher figures, 25.60 per million, for Black patients.

Signs and Symptoms of Pediatric Asthma

When it comes to diagnosing asthma in kids, doctors focus on key details such as symptoms, their frequency, and what might trigger them. They also look out for any known risk factors for asthma. Once a kid has been diagnosed with asthma, during check-ups, the doctor pays attention to how often and how severe the symptoms have been, any recent visits to the emergency room or hospital stays, use of daily control and quick-relief inhalers, and discusses the correct way to use an inhaler.

The most common symptoms of asthma in kids are coughing and wheezing. Sometimes, the only symptom might just be a cough. If a kid is coughing a lot, especially at night or if certain things like cold air or exercise trigger it, a doctor might suspect asthma. Persistent coughing after catching a cold can also suggest asthma. Kids who are not doing well in school or seem overly tired during the day might be having their sleep disrupted by asthma symptoms. As kids get older, they might also report feeling breathless or experiencing chest tightness.

When a kid is not showing any asthma symptoms, the physical check-up might seem perfectly normal. But, the doctor might find other signs during the examination like a runny nose, less airflow when breathing or wheezing, swollen nasal lining, extra skin folds under the lower eyelids, clear line across the nose, tender areas around the sinuses, dark circles under the eyes, bad breath, skin conditions like eczema or atopic dermatitis, and nasal polyps (swelling of the nasal lining). In adolescents and adults, nasal polyps can be linked with asthma worsened by aspirin. But in kids, nasal polyps can be a sign to check for a condition called cystic fibrosis. The presence of features like changes in the fingertips (digital clubbing), widened chest, wheezing over particular regions, skin rash, or a harsh, high-pitched sound when inhaling (stridor) might suggest other illnesses or conditions that occur alongside asthma.

During an asthma attack, the kid might breathe rapidly, not get enough oxygen, wheezing could worsen, the phase of breathing out might be longer, and muscles used for breathing could be overworked. Other signs can include flared nostrils, tiring easily, not being able to talk in full sentences, or making a grunting noise. A child who first shows increased effort to breathe but then seems to go back to normal, seems lethargic, or does not have wheezing anymore might be at a critical risk of a serious respiratory issue. Significant changes in alertness, lethargy, not responding, bluish skin color, or strangely “silent” lungs can all be serious signs indicating possible respiratory collapse.

Testing for Pediatric Asthma

If you or your child have occasional or ongoing symptoms similar to asthma, coupled with wheezing sounds when breathing, you might suspect asthma. To be sure, doctors need to rule out other possibilities and confirm that your airflow varies over time, which they can usually observe through a breathing test called spirometry.

In this test, patients are asked to take a deep breath and then breathe out forcefully into a device known as a spirometer. The device measures how much air you can breathe out in one second (FEV1) and the total amount of air you can breathe out forcefully after taking the deepest breath possible (FVC). If your FEV1 is less than 80% of what it should be, and your FEV1/FVC ratio is less than 0.85 (or 85%), this suggests you have asthma.

Doctors recommend that all children should take the spirometry test both before and after using a medication that helps open up the airways, known as a bronchodilator. This is because some children may show a significant improvement to their FEV1 after taking the medication, even if their initial FEV1 was normal. If your FEV1 improves 12% or more after using a bronchodilator, this is a significant sign of asthma, but this threshold was established using adult studies. Some experts argue that an 8% or more increase might be more appropriate for children.

Diagnosing asthma in children under 5 can be challenging. Doctors need to look for a consistent pattern of asthma-like symptoms and consider the child’s family history of asthma, as well as findings from a physical examination. Guidelines from the Global Initiative for Asthma list several signs that could indicate asthma in young children, including a recurring cough that gets worse at night, coughing or shortness of breath around trigger factors (like exposure to smoke), reduced activity levels in comparison to peers, history of allergies, improvement in symptoms with an inhaled steroid, or reversibility of symptoms with a fast-acting inhaler.

Allergy tests can be helpful to develop strategies to reduce exposure to potential triggers like furry pets, mold, cockroaches, or dust mites, particularly for older children.

Another useful test for diagnosing asthma is bronchoprovocation, which involves inducing asthma attacks via cold air, inhaled methacholine or physical exercise, followed by a spirometry test. This test typically applies to those with suspected asthma but normal spirometry, or patients with unusual symptoms or a cough only.

In some patients with asthma, the inflammation in the airways increases the levels of nitric oxide in the breath, known as fractional exhaled nitric oxide (FENO). The exact role of FENO in diagnosing and managing asthma remains unclear.

The doctor may order additional tests if the initial treatment does not provide the expected relief, or if they suspect another underlying condition. For instance, a chest X-ray may be necessary if symptoms persist despite treatment, or a stool sample test could be ordered if the child also presents symptoms of malnutrition or chronic diarrhea.

During a severe asthma attack, also known as an acute exacerbation, an immediate medical assessment is crucial, including checking vital signs and oxygen levels, observing breathing patterns, anxiety levels, consciousness, and use of accessory muscles for breathing.

While the peak flow test alone is not enough to diagnose asthma, it can help monitor the severity of asthma. However, this test can be difficult for young children to perform accurately.

In acute asthma attacks, a chest X-ray is needed if there’s chest pain, high fever, symptoms getting worse despite treatment, or if the patient is critically ill. In such situations, extra lab tests might be carried out, but these should not delay the start of treatment.

Treatment Options for Pediatric Asthma

In plain terms, treating childhood asthma begins by evaluating how severe the symptoms are, how frequently they happen, and the chances of them recurring in the future. For children under 5, there’s also an assessment of their risk of developing long-lasting asthma. This involves looking at how often asthma symptoms disrupt the child’s day or night and how often they need certain medications, like short-acting β-agonists (SABAs), to manage these symptoms. Doctors also keep track of how often these symptoms interfere with a child’s daily activities. And for children above the age of 5, breathing tests (spirometry) are conducted. Also, the incidence of asthma attacks requiring certain medications (glucocorticoids) in the previous year informs the likelihood of future asthma attacks.

For patients already on long-term treatment, healthcare providers assess the level of symptom control instead of severity. This control assessment often involves using spirometry tests and monitoring medication usage together. If the diagnosis or level of management is unclear, a test called Fractional exhaled Nitric Oxide (FENO) may be conducted.

Non-drug strategies for managing asthma involve educating the patient and caregivers. Personalized one-on-one education provided by the patient’s main healthcare professional has reported high effectiveness. It’s been observed that it reduces asthma attacks and hospital visits. Healthcare providers should give patients and caregivers education about what asthma is, its symptoms, triggers, and how to avoid them.

Inhaler technique and understanding the different types of asthma medications are vitally important. Healthcare professionals should identify any barriers to medication adherence and work with patients to overcome these. This cooperation increases the chances of patients adhering to their medication regimen.

Medication for childhood asthma involves a step-by-step process, as put forth by the Global Initiative for Asthma (GINA) for children under the age of 5. This happens in a series of steps, from 1 through 6. This process begins with the use of a particular type of medication (SABA) in cases of wheezing. If a child needs to use SABA more than twice a week for one month, they move up to step 2. Then, a therapy that combines daily low-dose inhaled corticosteroid (ICS) and SABA is initiated for at least three months. If the symptoms continue to persist after this stage, then further steps are taken. These steps upward are based on how well the prescribed treatment works.

It’s also important for patients with asthma to have an asthma action plan. This is a personalized plan for managing asthma – it states what to do during normal periods, flare-ups, and serious attacks. Healthcare providers create this plan based on the patient’s symptoms or peak flow readings, dividing it into the green, yellow, and red zones. The green zone indicates that the patient is symptom-free and their peak flows are 80% or better than their personal best. The yellow zone describes when symptoms start to show up and the red zone signifies severe shortness of breath and inability to perform everyday activities.

Treatment for acute asthma attacks depends on a variety of factors, such as the severity and whether the patient has any risk factors for a fatal asthma attack.

Overall, treating childhood asthma involves a combination of assessing symptom severity and frequency, patient education, pharmacological treatments following a stepwise process, an asthma plan, and managing acute exacerbations.

What else can Pediatric Asthma be?

When trying to diagnose asthma in young kids (12 or under), doctors have to exclude many other conditions that might look similar. These conditions can be grouped into four categories:

Upper Airway Diseases:

• Allergies affecting the nose and sinuses

Blockages in the Large Airways:

• A foreign object that has been inhaled
• Rings of blood vessels or webs in the voice box that shouldn’t be there
• Abnormal softness of the voice box or windpipe
• Swelling of lymph nodes
• A growth or mass
• Inflamed epiglottis, a flap of tissue at the base of the tongue
• Conditions that cause problems with the vocal cords

Blockages in the Small Airways:

• Viral infections causing inflammation of the airways, such as bronchiolitis
• Cystic fibrosis, a genetic disorder affecting the lungs
• Conditions affecting movement of the tiny hairs in the airway (ciliary dyskinesia)
• Damage to the lungs in premature babies, called bronchopulmonary dysplasia

Other Possible Causes:

• Heart failure resulting in congestion
• Acid reflux disease
• Allergic reactions causing anaphylaxis
• Swelling of the deep layers of the skin, called angioedema
• Chronic lung disease, more commonly seen in adults
• Blood clots in the lung
• Recurrent choking or aspiration
• Weak immune function
• Fluid in the lungs
• Enlarged heart, termed cardiomegaly
• Unusual lung infections, such as Mycoplasma pneumonia

By carefully considering all these possibilities and performing necessary tests, doctors can correctly diagnose whether a child has asthma or some other condition.

What to expect with Pediatric Asthma

The patterns of asthma in childhood can be good indicators of outcomes in the long run. It’s usually more favorable when asthma comes and goes in episodes, as perennial asthma from childhood tends to continue into adulthood with ongoing symptoms and slight impairment to lung function. Studies indicate that 30% to 70% of kids with asthma show significant improvement or even become symptom-free by early adulthood. Yet, almost three-quarters of adolescents with asthma and wheezing carry their symptoms into adulthood.

Several factors are linked to ongoing asthma, like being predisposed to allergic diseases, diminished lung function, and having overly reactive airways. Exposure and reaction to indoor allergens can triple these risks.

Effective management of asthma is essential for predicting long-term outcomes. The main aims include lessening future asthma attacks, preventing obstructed lung growth in kids, conserving lung functionality, and minimizing the negative side effects of medication. Various elements like having a history of intense asthma attacks in the previous year, poor adherence to asthma medication, incorrect usage of inhalers, decreased lung function, smoking or vaping, heightened FENO levels (a marker of inflammation in your lungs), and a higher number of certain white blood cells in the blood can all lead to an increased risk of further asthma attacks and a worse prognosis.

Possible Complications When Diagnosed with Pediatric Asthma

Asthma can lead to various complications, whether from the condition itself, the medications used for treatment, or medical procedures performed. Let’s break down some of these potential complications:

Complications Directly Related to Asthma:

• Pneumonia
• Interruptions in school attendance and sports activities
• Lung remodeling, which refers to changes in the structure and functionality of the lungs
• Poor sleep and fatigue
• Severe cases can lead to death

Complications due to Endotracheal Intubation (a medical procedure where a tube is placed in the windpipe through the mouth or nose):

• Low blood pressure (Hypotension)
• Pneumothorax (air leaks into the space between the chest wall and the lungs)
• Muscle disease (Myopathy)
• Pneumomediastinum (air in the middle of the chest)
• Pneumoperitoneum (air or gas in the abdominal cavity)
• Subcutaneous emphysema (air bubbles under the skin)
• Chances of foreign substances entering the respiratory tract (Aspiration)
• Narrowing of the airway below the vocal cords (Subglottic stenosis)
• Infections
• Gastrointestinal bleeding due to stress ulcers

Complications due to Medications:

• Mental health issues like agitation, depression, insomnia, and suicidal thoughts linked to the use of montelukast, a Leukotriene receptor antagonist (LTRA)
• Hoarseness (Dysphonia) and mouth fungal infection (Oral candidiasis) linked to Inhaled corticosteroids (ICS)
• Rare instances of weak adrenal function (Adrenal insufficiency) related to ICS
• Small decrease in growth speed in children due to ICS
• Eye conditions like Glaucoma, cataracts, and also high blood sugar level (Hyperglycemia) due to Oral corticosteroids (OCS)
• Change in blood elements like reduced serum potassium, phosphate, magnesium and increased glucose is associated with Albuterol
• Stress-induced heart problem or takotsubo cardiomyopathy linked to the treatment of severe asthma

Preventing Pediatric Asthma

In managing asthma in kids, teaching both the child and their caregivers about the disease is key to preventing severe attacks and maintaining good health. This includes making sure they understand what can trigger an attack, recognizing when an asthma attack might be starting, and the importance of sticking to the treatment plan set out by their doctor.

Caregivers and patients should know the early signs of an asthma attack and how and when to get urgent medical help. Being taught the correct way to use inhalers and measuring devices, like peak flow meters, can make them more confident in dealing with asthma at home. It’s also important to discuss the possible side effects of asthma medicines so the caregivers can watch out for these and make wise choices about their child’s care.

Focusing on the importance of avoiding things like tobacco smoke, allergens, and pollution can help reduce the risk of an asthma attack. Creating a personalized ‘asthma action plan’ that fits the child’s needs and level of asthma control can give a clear plan for preventing and dealing with attacks and changing treatment as necessary. For an example of what an asthma action plan might look like, you can visit the CDC’s asthma action plan webpage.

Regular check-ups with healthcare professionals permit ongoing evaluation of symptom management and medication effectiveness and provide a chance to deal with any worries or fears. By combining complete patient tutoring, medication management, and personalized asthma action plans, doctors can give families the tools they need to manage childhood asthma effectively and improve long-term health.