Childhood Asthma
Asthma is also the most common cause of emergency-room visits in many pediatric centers. Pediatric asthma accounts for one in every four asthma admissions in innercity hospitals and produces more in-hospital days than any other childhood illness.
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- One-third of the children who develop asthma do so before their third birthday, and nearly three-fourths of all asthmatic children start to wheeze before they enter the first grade. Age of onset is an important factor, as children who develop asthma in infancy or early childhood are less likely to outgrow it.
- The sex distribution also varies with age: asthmatic boys out- number girls in early childhood, and in later childhood. the sex ratio is about equal, and in adolescence, females outnumber males by a three-to-two margin.
The Wheezing Infant
The most important asthma triggers in infancy are colds and viral infections. The first one or two episodes of a wheezing illness are likely to be called bronchitis or bronchiolitis by the family doctor or pediatrician. However, any child who experiences three or more episodes of a wheezy-type illness probably has asthma.
- Unfortunately, the correct diagnosis is often delayed, as doctors are unwilling to use the term asthma regarding a young child and his or her family.
- Doctors instead label it bronchitis or bronchiolitis, as the word asthma implies that the child may have a chronic disease that may last several years or even a lifetime.
- This hesitancy to label a wheezing youngster as a child with asthma is not unique to America or India Dr. L. Hey of Tyneside, England, found that 11 percent of all children in his town had bouts of bronchospasm characteristic of asthma, yet only one in three of these children was given appropriate asthma medicines.
- Only one in every ten victims was aware that they had asthma. The point here is that any reluctance by doctors to use the term asthma leads to inappropriate and poor care. I fully concur with Dr. Hey’s observations.
- In the past eighteen years, I have seen scores of children who have been coughing and wheezing for several years, yet the possibility of their having asthma has never been brought up Many parents are shocked when the diagnosis of asthma is mentioned.
- Their doctors have told the family that their child is only “bronchial,” a misnomer that leads to total undertreatment of a very treatable condition. In summary, any infant or child who has three or more episodes of wheezy bronchitis probably has asthma.
The diagnosis is almost a certainty if the child coughs or wheezes during sleep or exercise.
The Bad Rsv Virus
I mentioned that many infants are born with a genetic trait that makes them more likely to develop asthma. For this trait to become active, the infant must be infected with certain viruses. One such virus, RSV, or respiratory syncytial virus, is the most asthmatic of all childhood viruses.
- RSV causes a very severe wheezing-like illness of infancy, called bronchiolitis, which may not respond to anti-wheeze medicines, and RSV victims often require hospitalization when infections reach epidemic levels in late winter and early spring.
- What makes this infection so important is that nearly half of all infants who get RSV bronchiolitis eventually develop full-blown asthma. Recent studies have shown that many RSV victims make an allergic or IgE antibody to the virus itself.
- Years ago scientists recognized the asthmatic potential of RSV and initiated trials with an RSV vaccine. The early results of these trials were both disappointing and tragic, as many vaccinated infants developed severe RSV infection when they were exposed to natural RSV, and a few even died from overwhelming RSV infection.
- RSV vaccine trials were promptly abandoned. Two additional factors that may increase the overall risk of developing asthma in childhood are repeated bouts of croup and exposure to general anesthesia.
- Dr. Douglas Johnstone of Rochester, New York, has reported that children who are subjected to general anesthesia at a young age have a much greater chance of developing asthma.
- This paper was of particular interest to me, because my son, who developed asthma at age four, underwent a rather difficult hernia repair at age two that required nearly two hours of general anesthesia.
Asthma In Middle Childhood
While asthma that begins in infancy is more likely to be the non-allergic type, asthma that starts after age three is usually the allergic form of asthma. The best time for a person to develop asthma is between ages four and ten, as mid-childhood asthma is often the easiest type of asthma to treat and has the best prognosis or outlook.
- Children who develop allergic asthma between ages four and ten often lack a strong family history of asthma and have normal breathing tests between attacks. Many go on to develop hay fever in their teenage years.
- Do children outgrow their childhood asthma? Unfortunately, the answer is no. While many can go into permanent or partial remission, most adults with a past history of childhood asthma still have a “twitchy lung.” This means that, like myself, they may wheeze when they get a bad chest cold or exercise in cold air.
- In one English study, two-thirds of three hundred childhood asthmatics were still symptomatic at age twenty-one. The natural course of a child’s allergic asthma often parallels that of an asthmatic parent.
- Many children with allergic asthma can and do become symptom-free, but sometimes asthma reappears in adulthood. Just why asthma recurs in some people and not others is not well understood.
- The children with the poorest outlook are those with a strong family history of asthma, eczema, and asthma that started in infancy. When asthma begins in early adolescence, the outlook is likewise not so rosy, as this asthma is more likely to be the nonallergic type with less chance of remission.
Adolescent onset asthma can be very severe and difficult to control. The risk of developing severe asthma, nasal polyps, and aspirin allergy is increased in this age group.
Psychological Factors
Do psychological factors play a role in childhood asthma? In most cases, they do not. Stress or tension is just one more asthma trigger, like cold air or exercise. Many of my patients even wheeze when they laugh too much. However, asthma can be an incapacitating illness for a small percentage of children.
- This type of asthma can cause denial, anger, guilt, and a host of other responses that lead to profound problems for the entire family. Dr. Clifton Furukawa, of Seattle, Washington, has aptly depicted the family with multiple psychosocial problems due to severe asthma.
- Dr. Furukawa states that severe asthma in one member of the family leads to a great deal of overprotection by all family members. This can cause the entire family structure to become very rigid. No family members can deal with or resolve their problems.
- The sick asthmatic child becomes a substitute solution for all conflicts and assumes the role of a holy or godlike person. Strange as it may seem, this family is most at peace when the child is amid an asthma relapse.
This family eventually self-destructs: school loss increases; family trips and school vacation plans are repeatedly canceled; and, when both parents work, income is lost. Outside social contact ceases as parents are unable to transfer responsibility to any babysitter.
- These families require intense, continuous psychological support to avoid destruction. In some instances, the only salvation for such a family is to admit the child with asthma to a residential asthma-care center, allowing the family to return to a more normal lifestyle and rebuild the collapsed family structure.
- Fortunately, cases of this sort are quite rare, as severe malignant asthma affects less than 1 percent of all children with asthma. What are the effects of asthma on a more typical family with an asthmatic child? National Jewish Hospital in Denver has recently surveyed several hundred patients and families affected by asthma.
- From across the United States. These families averaged ten office or clinic visits per year. The afflicted children averaged eight to fifteen lost school days per year.
- Half the parents reported that asthma caused depression in their children, and four out of ten parents felt that their children were overly concerned about becoming ill. Nearly one-third experienced guilt feelings after an asthmatic attack.
Strained relationships were common, and the more severe the asthma, the more strained the relationships between family members.
The School And Asthma
Children with asthma are frequently subjected to ridicule, scorn, and neglect in the school setting. In 1983 the American College of Allergy and Immunology (ACAI) established a school committee to study this problem.
- One of the major goals of this committee was to determine the scope of the problem by surveying ACAI physician members. Their survey found very widespread absenteeism, poor school performance, and an unwillingness of many schools to permit students to take their medications during school hours.
- Students had unjustly received poor grades in physical education or were entirely excluded from gym or sports due to a complete lack of understanding of their asthma by physical education instructors or team coaches.
- Chaired by Dr. Warren Richards from Los Angeles, this committee developed guidelines and handouts aimed at improving the communication between doctors and school personnel and educating teachers, gym instructors, school nurses, coaches, and administrators about asthma.
- The general guidelines set forth by the ACAI for allergic and asthmatic children in a school setting are outlined as follows:
Program Goals
1. The asthmatic and allergic child should
- Be provided with an equal opportunity for a normal learning experience and not be made to feel sickly or different from other students
- Be allowed to participate in all physical activities up to his or her physical capacity
- Be able to attend school on a regular basis and not be absent without just cause
2. The physical education instructors should
- Be provided with education detailing the telltale signs and symptoms of asthma and allergic conditions
- Permit and encourage the child to participate in regular physical activities whenever possible
- Notify the parents if the child cannot fully participate in gym and should not allow the child to stop taking gym classes unless so directed by a doctor
- Allow for a reduction in outdoor activities during cold weather or periods of air pollution and excuse the student from classes if he or she has significant symptoms
- Attempt to determine the child’s physical limitations and encourage the child to function within those limits
- Not force the child to exceed her or his limitations (for example, should not force the child to run laps on a cold day) when activity is not tolerated and should encourage warmup activities and exercises
- Be familiar with exercises that are best tolerated by children with asthma
- Allow the child to set his or her pace on a daily basis
- Permit the child to take the prescribed asthma drugs before or during exercise with no inconvenience
3. The school nurse should
- Become familiar with the signs, symptoms, and medical management of patients with asthma and should know about asthma medicines and their side effects
- Assume the responsibility for educating teachers and physical education instructors about allergies and asthma and should maintain up-to-date medical files and quickly communicate with parents or the child’s doctor when they detect worsening asthma that is interfering with the child’s attendance or school performance
- Take responsibility to minimize the exposure to allergens or irritants in the child’s classroom and ensure that the child follows specially prescribed diets
- Allow the child to use asthma medicines and to self-medicate when fully authorized by parents and the physician
- Be prepared to handle a child with an acute allergic reaction or an acute asthma attack
- Talk with cafeteria workers about food allergens and make them aware of the hazards of hidden food ingredients such as peanuts
- Organize an annual in-service workshop with teachers on school health problems in which the need for interaction with physicians should also be stressed
- Draft an asthma management program approved by the school physician and include regular peak flow monitoring as an integral part of any such program
- Stay in close contact with physical education instructors to ensure fair grading for students with allergies, particularly those with asthma
4. The classroom teacher should
- Be provided with information and educated about asthma and the side effects of asthma medications
- Inform the school nurse and parents if the child has a significant deterioration in performance or develops behavioral problems
- Keep the classroom relatively dust free and do not allow furry or feathered animals in the child’s environment
- Be prepared to handle an acute asthma attack
- Allow the child extra time to make up missed work or examinations
- Treat the student as a normal human being and provide a normal learning experience
- Be aware that asthma is a very treatable condition
- Minimize chalk dust exposure by using a wet cloth or sponge, not an eraser, to clean blackboards
5. The school administrators should
- ensure that the student has a safe environment, free of allergens and air pollutants; whenever possible, new school construction and maintenance projects should be done during vacation periods.
- After school hours be sure that the school nurse maintains up-to-date medical records and provides in-service education classes for all other school personnel
- Allow asthmatic students to be bused, especially on colder winter days when walking to and from school may trigger an asthma attack
- Not allow any discrimination on the part of physical education instructors or classroom teachers that would interfere with the child’s learning experience As children spend a large part of their lives in a classroom, school personnel can have a dramatic effect on the treatment of asthma.
While they should never diagnose or provide primary medical care to students, they have an obligation to provide proper environmental controls and appropriate guidelines on the emergency use of medication.
- AAFA has recently developed an Asthma Action Card that outlines the patient’s basic allergies and common asthma triggers and lists a prevention and medication plan that utilizes peak flow readings.
- These cards allow the physician and the family to provide clear, concise information on triggers, prevention, and emergency treatment. Many school nurses in the National Association of School Nurses, a professional organization dedicated to improving awareness in the school of student health problems, believe that the size of the asthma and allergy population in schools is increasing.
- In one survey in Los Alamitos, California, nearly 20 percent of students were thought to have health problems related to asthma and allergies. Another school nurse survey by the National Asthma and Allergy Network (NAAN) uncovered a significant need for improving the health and educational process of children with asthma and allergies.
- Responders indicated that children experienced some degree of embarrassment surrounding the use of asthma medications. Many schools lacked full-time nurses, and only a few schools had a peak flow monitoring program.
- Physicians need to educate parents, students, educators, and teachers that the increased use of medication by a student with asthma indicates the need to adjust the treatment plan.
- The NAAN report pointed out that schools must allow children with asthma to have access to medications, receive appropriate medical assistance during a relapse, and have freedom from embarrassment generated by the need for medications.
When The Student Leaves Home
When the asthmatic student leaves home for the first time to go to a boarding school or college, special steps need to be taken to build a solid foundation for the student’s self-management of asthma.
- A departing student who will be independent for the first time should have a sound grasp of the fundamentals of asthma and should know how and when to use medications and how to seek additional care for acute relapsing asthma.
- The student’s physician or asthma doctor should prepare a summary of the student’s medical history and current list of medications that will allow school doctors who are unfamiliar with the student’s medical background to follow similar treatment programs.
- The student’s doctor can also write a letter to school housing authorities requesting nonallergic bedding, nonsmoking roommates, and an air-conditioned dormitory. Many prep schools and colleges are situated in remote, rural areas where competent asthma care may not be readily available.
- The student should be encouraged to communicate by phone with parents or doctors during an asthma crisis. As many college students tend to neglect their medications and environmental controls during their first semester, I usually schedule a brief follow-up visit during a vacation period to make sure they are following their treatment program.
- Many parents, including myself, have felt school dorms and apartments to be potential dust bins, yet they often contain little carpeting and upholstered furniture, the major reservoirs of house dust mites.
- Sometimes the first semester at college is one of dramatic improvement for dust mites or pet-sensitive patients who leave a dusty home where animals were kept.
- I have many patients who were able to stop all asthma medications once they left for school but experienced a severe relapse when they returned home for a holiday break. Reexposure to a family homestead infested with house dust mites and animals is usually the cause of such relapses
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