Managing Bronchial Asthma in Children

Asthma is a chronic inflammatory condition in which the airways narrow and swell, and produce extra mucus. This can make breathing difficult and trigger coughing, wheezing and shortness of breath. One in five Singaporean children suffers from bronchial asthma.

Asthma is a chronic condition and cannot be cured, however its symptoms can be controlled. In many children, symptoms do improve with age. Frequency and intensity of asthma symptoms vary over time, so it is important to work with the doctor to track your child’s signs and symptoms and adjust treatment where needed.

Asthma symptoms vary from child to child. Common symptoms include:

• Cough
• Shortness of breath or difficulty in breathing
• Chest tightness, discomfort or pain
• Wheezing

Very young children may present with seemingly harmless symptoms of tiredness, irritability, persistent crying or changes in mood.

Childhood asthma is caused by the interaction of a genetic tendency for asthma with the environment. A family history of any allergic diseases such as bronchial asthma, allergic rhinitis, food allergy, atopic dermatitis increases the risk of a child developing bronchial asthma. The following environmental factors may also contribute to this risk:

• Contracting some types of airway infections at a very young age
• Exposure to environmental factors, such as cigarette smoke, traffic pollution and smoke haze
• Sensitisation to environmental allergens such as house dust mites

Triggers that result in asthma attacks may differ in each child. Some common triggers include:

• Viral infections, such as the common cold
• Environmental allergens, such as dust mites, pollen, animal dander and mould
• Changes in temperature or humidity
• Irritants in the air, including traffic pollutants, cigarette smoke, and smoke haze
• Exercise, especially in children with uncontrolled asthma
• Negative reactions to medications such as painkillers such as aspirin, NSAIDS
• Strong emotions and stress

Bronchial asthma is a chronic disease and long-term treatment and follow up is necessary for good symptom control and optimal lung function and health outcomes. In addition, several childhood conditions have similar symptoms, and it is important to confirm the diagnosis of bronchial asthma before starting treatment.

The following tests may be helpful in the evaluation of and to confirm the diagnosis of asthma:

• Tests to measure lung function
• Fractional Exhaled Nitric Oxide (FeNO)
• Allergy testing
• Exercise challenge test for exercise induced asthma
• Chest X-Ray
• Additional tests may be needed to rule out other possible causes e.g., blood tests, induced sputum test

Treatment usually involves learning to recognize your triggers, taking steps to avoid them and tracking symptoms to make sure daily asthma medications are keeping symptoms under control. Long-term preventers or controller medication use are key in preventing asthma flare ups.

There are two main types of asthma medications:

Preventers/ Controllers: These work slowly to control the chronic inflammation, by making airways less sensitive to triggers. Use these medicines/inhalers daily unless instructed to stop by the doctor – this is important in the control of asthma. Examples of preventers include steroid inhalers, combination inhalers and oral anti-leukotrienes.

Relievers: These work rapidly to open the airway, providing quick relief of asthma symptoms. They should only be used when needed. Examples of relievers include Salbutamol inhalers and certain combination inhalers.

The written asthma action plan outlines in writing when to take certain medications or when to increase or decrease the dose of your medications based on your symptoms. Follow your written asthma action plan and check in with the doctor when in doubt.

Signs of an asthma flare up include:

• Worsening of shortness of breath or wheezing
• Persistent coughing
• Inability to feed well, sleep or play

Consult the doctor if your child:

• Has persistent breathlessness and cough despite activating the written asthma action plan
• Is unable to feed and take fluids well
• Is unable to speak in complete sentences
• Is drowsy, lethargic or irritable and difficult to calm

Though bronchial asthma is a chronic disease, symptoms can be controlled and most children achieve a normal quality of life. Understanding the disease, active participation in the care plan, compliance with the prescribed medications and regular review is key to successful treatment of the condition.

• If you think your child has asthma– Treating asthma early may prevent long-term lung damage and help prevent the condition from worsening over time.
  
  
• To monitor your child’s asthma and keep it under good control– Good long-term control allows your child to participate in all activities as desired and have a good quality of life. Good control of asthma can prevent a life-threatening asthma flare-up and optimize future lung function outcomes.
  
  
• If the asthma flare-up cannot be controlled with the written asthma action plan– An early review by the doctor may be lifesaving in a severe flare up.
  
  
• To review your treatment– Asthma is a chronic disease and symptoms often change over time. Regular reviews are necessary to make any needed treatment adjustments.
  
  
• If there is any doubt and concerns – It is important to clarify any health concerns to ensure accurate diagnosis, appropriate treatment plans and optimal health outcomes.

Many parents worry about their children falling ill with SARS-CoV-2 (the virus that causes COVID-19). This is especially a concern if the child has bronchial asthma. Current studies suggest that children with asthma are not at increased risk of catching COVID-19 infections nor at risk of more severe COVID-19 disease. Keeping asthma well controlled is important for the prevention of severe COVID-19 disease in asthma.

To reduce the risk of flare of asthma or COVID-19 disease in children, parents must ensure the following:

• Keep to the prescribed medications for allergic rhinitis and asthma and use these according to your written action plans. Adherence to the use of prescribed controller medications will help reduce the risk of an asthma attack being triggered by any respiratory virus, including COVID-19 virus

• Keep to your scheduled follow up appointments as recommended by the doctor as this is important for good monitoring of and control of disease.

• Engage with your doctors early in case of uncertainty or concerns. Respiratory symptoms associated with COVID-19 as described may be very similar to asthma symptoms.

• Be on schedule with recommended childhood vaccinations including COVID-19 and influenza vaccines.

• Comply with the locally prescribed measures for prevention of COVID-19 disease including use of face masks and or face shields, social distancing and hand hygiene.
   

As the COVID-19 pandemic evolves and new information is rapidly made available, prevention and treatment recommendations may change. Please reach out to your doctor early for any questions or concerns.

This article was contributed by Dr Jenny Tang, AIA Preferred Provider, and Consultant Paediatrician with a special interest in Asthma, Lung, Sleep and Allergy.  To request an appointment with Dr Jenny Tang, please click here.

1. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention, 2020. Available from: www.ginasthma.org
2. British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN). British guideline on the management of asthma - a national clinical guideline. 2019. https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/
3. National Asthma Council Australia. The Australian Asthma Handbook, version 2.1. National Asthma Council Australia, Melbourne, 2020. Available from: www.asthmahandbook.org.au
4. Asthma – Optimising long term management with inhaled corticosteroid. ACE Clinical Guidance 15^th Oct 2020. https://www.ace-hta.gov.sg/healthcare-professionals/ace-clinical-guidances-(acgs)