With the cold and flu season underway, many children are coming down with fevers, runny noses and sore throats. Some may even develop a recurring cough. But during this peak time for infection-related illnesses such as bronchitis, that cough that persists for weeks or months may signal something else less obvious – childhood asthma.
Infections, followed by allergens, are the leading triggers - or factors - that cause an asthma attack in children. The opposite is true for adults. So what may be assumed is a cough associated with bronchitis can actually be the first sign of a child’s asthma, and possibly the only sign of an asthmatic state.
The frequent cough may also indicate that the child’s asthma is becoming worse or is not being controlled correctly. As a result, these children do not receive the proper asthma treatment. They may be wrongly prescribed antibiotics, which are ineffective for viral infections including bronchitis. This can lead to overexposure to antibiotics, increasing their resistance to the medication.
“Seven out of 10 times the chronic recurring cough is due to asthma,” said Dr. Reddivalam Sudhakar, medical director of pulmonology at Children’s Hospital Central California in Madera. “Triggers of asthma include infection, allergies, pollution, exercise and stress. Upper respiratory tract infections are the most important triggering factor for asthma flare-ups in children during the fall and winter months.”
Other potential causes of a chronic recurring cough include sinus disease, allergic rhinitis, cystic fibrosis, tuberculosis, Valley fever and whooping cough (pertussis). In some cases, often with a toddler, a foreign body such as food or a toy lodges deep into the child’s lung or airway. The child may be believed to have asthma and is prescribed medication accordingly. Meanwhile, the object remains inside the body, posing a potential risk to the young patient’s health.
To avoid a wrong diagnosis, Children’s Hospital’s board certified pediatric pulmonologists encourage area physicians to refer families who have children with a chronic cough to their practice – especially if those affected have not responded to conventional treatments after several weeks. Equipped with state-of-the-art pulmonary function testing, bronchoscopy and sleep labs, Children’s pulmonology experts can effectively measure the function of the child’s lungs and diagnose and treat complex respiratory conditions, including asthma.
Over the past 15 years, improved medications combined with increased education and awareness has enhanced asthma patients’ quality of life. Despite these efforts, uncontrolled childhood asthma is a significant issue in the United States. Among pediatric patients with asthma seen in primary care for any reason, the prevalence of uncontrolled asthma is 46 percent. Asthma is also the third major cause of hospitalization in American children under age 15. Children with asthma miss an average of seven school days a year and more than a third play limited sports.
But it doesn’t have to be this way.
“No child needs to suffer from the effects of asthma,” said Dr. Sudhakar, noting the Central Valley’s significant asthma rate. “Asthma can be 100 percent controlled with medication but it has to be done properly.”
What is Asthma?
The most common chronic childhood disease, asthma is a disease in which the lungs’ airways become blocked or narrowed temporarily, causing shortness of breath, difficulty breathing, wheezing, chest tightness and other symptoms. Because children have narrow airways, the condition can be very serious for them, particularly those under age 5. If asthma becomes severe, emergency treatment may be needed to restore normal breathing.
In the U.S., asthma occurs in about 5 million children, with about 200,000 hospitalized each year. Although the illness can occur in people of any age, even infants, about half of all asthma cases develop before age 10, and nearly 80 percent of patients exhibit symptoms before they are 5 years old.
Various factors may trigger asthma. Triggers vary from person to person but the following are some of the most common:
- Infections: Rhinoviruses, which cause most common colds.
- Allergens: Foods such as eggs, cow’s milk, wheat, soybean products, and peanuts, as well as pollen, house dust mites, molds and animal hair.
- Pollution: Tobacco smoke – including “secondhand” smoke – smog, cotton defoliants, pesticides, aerosol sprays, perfume, and automobile exhaust and paint fumes.
- Exercise: Exercise – especially in cold air. A form of asthma called exercise-induced asthma is triggered by physical activity, with symptoms sometimes not appearing until after several minutes of sustained exercise. Other physical activities include laughing, crying, holding one's breath and hyperventilating.
- Stress: Stress and anxiety can cause shortness of breath, potentially exacerbating asthma symptoms.
Making the Diagnosis
Children’s Hospital pulmonologists use various diagnostic and therapeutic tools in their pulmonary function testing, bronchoscopy and sleep labs to determine and treat pediatric pulmonary conditions ranging from chronic recurring cough and asthma to sleep apnea. Their multidisciplinary approach involves working with the infant’s, child’s or teenager’s other caregivers to deliver the best possible care.
Pulmonary function testing lab: Pulmonary function tests measure how well the patients’ lungs work. Pulmonologists use lung function tests to help diagnose conditions, check the extent of damage caused by a condition, and assess how well treatments are working. Lung function tests at Children’s include the following breathing tests:
- Spirometry: Measures how much air is breathed in and out, and how fast air is blown out.
- Lung volume measurement: Measures how much air remains in the lungs after breathing out fully.
- Lung diffusion capacity: Measures how well oxygen passes from the lungs to the bloodstream.
A cardiopulmonary exercise test may also be performed to measure how well the child’s lungs and heart work while exercising on a treadmill or bicycle.
If it’s still unclear after multiple tests whether a child has asthma, Children’s uses the methacholine challenge test to make the final determination. This test involves the child inhaling the medication, methacholine, in increasing doses to produce a change in the pulmonary function test results.
Bronchoscopy lab: Bronchoscopy is a procedure to visualize the inside of the airways for diagnostic and therapeutic purposes. With a bronchoscope inserted into the patient’s airways, usually through the nose or mouth, the practitioner examines the airways for foreign bodies, bleeding, tumors, inflammation and other abnormalities. Specimens may be taken from inside the lungs. With the child under anesthesia, Children’s pulmonologists and pediatric surgeons perform bronchoscopies in the hospital’s surgery suite using flexible optical fiber instruments with real-time video equipment. They have scopes in different sizes, making it easier to treat children of all ages, from one-day-old to age 21.
Sleep lab: Specializing in identifying pediatric respiratory-based sleep disorders, experienced respiratory care practitioners in the pulmonology practice’s sleep services at Children’s collect and analyze hours of sleep data captured in the hospital’s two private bedroom suites. The pediatric pulmonology specialists read the scored data – in conjunction with the patient’s medical history and physical examination – for assessment, interpretation and subsequent medical plan.
Other tests that Children’s pulmonologists may use to diagnose conditions – including those previously mentioned associated with a recurring cough – are low-dose computed tomography scans, chest X-rays, and allergy, blood and DNA tests.
Once asthma is diagnosed, the next steps are to limit or remove the child’s known triggers and to begin the patient on a customized, low-dose medication treatment plan to control symptoms. Adhering to the National Institute of Health “step” guidelines, Children’s pulmonology specialists “step up” the patient’s medication dose and frequency if the asthma becomes worse. When the asthma is controlled, the medication is “stepped down.” Children’s asthma patients are monitored every three to four months to ensure their medication is working properly.
Asthma medications may be inhaled or in pill form, and are composed of two types – quick-relief and long-term control. Quick relief medications relieve immediate symptoms of an asthma attack. Long-term control medications do not provide relief right away but over time help reduce the frequency and severity of attacks. Children’s emphasizes the importance of asthma patients taking the long-term control medication daily, whether or not they are experiencing symptoms.
“We often see children with asthma who don’t do this because they feel fine,” said Dr. Sudhakar. “But when we test their lung function, it is below where it should be. When these children come into contact with one of their triggers, their asthma attack could be worse than if they had been taking their medication regularly. If asthma patients take their medication consistently they can prevent asthma mortality by 100 percent.”
In addition, Children’s recommends asthmatic patients take the quick reliever medication 15 minutes prior to engaging in sports or exercise.
Acknowledging some parents’ concerns regarding steroid-based, long-term control medications, Dr. Sudhakar pointed out that only about 15 percent of the medication is inhaled into the lungs. “There are actually few side effects,” he said. “The benefits far outweigh any risks. Parents should talk to their child’s doctor about their concerns and learn as much as they can about asthma and its treatment.”
Leading an Active Life
Asthma is a chronic childhood disease that sometimes goes undetected or is mistaken for another condition. The earlier the condition is diagnosed, the faster the child can get the proper treatment. “This will give the child the best chance of controlling their asthma and the opportunity to lead a normal, healthy and happy life,” said Dr. Sudhakar.