Asthma: treatment and prevention

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If a child continues to have frequent attacks, and/or regular symptoms, it may be that they are not being treated appropriately, and you should seek medical advice.

In treating asthma, the first principle is to prevent attacks from occurring. If acute attacks do occur, the aim of treatment is to minimise their severity and duration.

From a treatment point of view, children with asthma can be grouped into one of three clinical categories:

1.   Episodic asthma

Most children with asthma fall into this group. These are children who have symptoms several times a year, almost always in association with a cold or viral infection. They may wheeze or cough for a few days, and respond quite rapidly to treatment. In between attacks, they are in good health, with no symptoms of asthma at all and enjoy an unrestricted lifestyle. These children usually only need to be treated for their acute attacks – in between attacks they normally do not need to take any asthma medications.

2.   Persistent asthma

These youngsters will also have a number of acute attacks each year, usually more frequent than those in the first group, but may also have symptoms in between attacks. They may have an intermittent cough, or a wheeze triggered by exercise. Children in this group are usually given medication on a regular daily basis, in order to prevent acute attacks from occurring.

3.   Chronic asthma

This is the smallest group of children with asthma. Their symptoms are often ongoing, and they need to take several medications a day.

Asthma medications

Asthma medications come in different forms:

• Solutions to be inhaled as a mist from a hand-held inhaler (metered dose inhaler or puffer, best used with a spacer device), or occasionally from a nebuliser driven by a pump. The inhaler with a spacer device is just as effective and much more convenient.
• Dry powders to be inhaled from a hand-held inhaler (spinhaler or rotahaler).
• Liquids, tablets or sprinkles to be swallowed.

Combinations of medicines are often necessary. Inhaled medicines are far more effective than those swallowed. More of the drug reaches the lungs, where it acts on the airways, and very little reaches the bloodstream.

Medicines taken by mouth are absorbed into the bloodstream and may sometimes cause unwanted side effects such as a fast heart rate or irritability. Most children over the age of two years can be taught to use a spacer or inhaler of some kind.

Asthma medications can be divided into relievers, used to treat and relieve the symptoms of asthma, and preventers, used to prevent acute attacks from occurring. Some children take both these classes of medication. Your doctor will tell you the most appropriate medications for your child to take.

Relievers

• Beta-2 agonists such as salbutamol (Ventolin, Respolin), terbutaline (Bricanyl), fenoterol (Berotec): these are the most commonly used drugs for the treatment of acute symptoms of asthma.
• Prednisolone (a steroid) is also often given early in an acute attack to by minimise the acute inflammation and thereby reduce the swelling of the lining of the air passages.

New and more powerful drugs for the treatment of asthma are introduced from time to time and are especially useful for children with severe asthma who are under the care of a specialist.

Preventers

Drugs used to prevent asthma are seen as increasingly important. They act either to reduce the effects of inflammation, which is the main underlying cause of the disease, or to minimise the effects of some of the cells in the airways which contribute to the inflammatory response. Preventive medications need to be taken regularly every day. The drugs used for prevention include:

• Inhaled steroids such as beclomethasone (Becotide, Aldecin, Becloforte), budesonide (Pulmicort) and fluticasone (Flixotide, Tilade). These can be inhaled and used to prevent attacks.
• Steroid tablets or mixtures (prednisolone), which can also be given by mouth to prevent attacks. One of the important advances in asthma management has been the introduction of inhaled steroids. In normal doses, these have virtually no side effects, and certainly none of the problems that are associated with the long-term use of steroids taken by mouth.
• Sodium cromoglycate (Intal). This is inhaled on a regular basis, irrespective of whether the child has symptoms or not.

Antibiotics have no place in the treatment of asthma, even though they may sometimes be prescribed (incorrectly). There is a misconception that because an attack of asthma is often precipitated by an upper respiratory tract infection, that antibiotics are useful in shortening the infection, and thus the duration of asthma symptoms. However, the majority of infections that trigger acute asthma are viral in nature, and antibiotics will not affect them at all.

Other forms of management

Drugs form the mainstay of the modern treatment of asthma. Most other forms of treatment are unproven and have a limited place, if any, in the treatment of asthma in children. While allergens probably have a role in the triggering of asthma attacks, there is very little evidence that desensitisation (a series of injections designed to make the child less allergic to certain substances) makes any difference either to the frequency or the severity of attacks. Physiotherapy may occasionally have a role to play for some children with asthma, but generally your child is better off being encouraged to participate in regular exercise and sporting activities.

Prevention

Consideration should be given to factors which may trigger attacks of asthma. Cigarette smoke should be avoided. Exposure to animals that cause symptoms (often household pets) should be minimised or avoided, and your child may be better with non-allergenic bedding if they are affected by goosedown or feathers. In some selected cases, carpets may need to be removed to minimise dust and decrease exposure to the common house dust mite.

These measures should be balanced with the need to minimise drastic changes to your child’s and your family’s living conditions. Change in environment of any significant degree may not be indicated in children with mild or minimal symptoms.

Some of these precipitating factors can and should be avoided. However, the mainstay of management of asthma is pharmacological – the appropriate use of medications to prevent and treat symptoms.

Understanding asthma management

It is very important that both you and your child understand very clearly how best to manage asthma. If your child has frequent attacks, or if symptoms prevent them from playing sport, sleeping at night, or feeling healthy, then it is likely that they are being undertreated. Your doctor should be made aware of this, so that treatment can be changed as necessary.

It is a good idea to keep in regular touch with your child’s doctor to make sure that symptoms are monitored closely and that treatment is optimal. Ensure that you and your child understand how to take the asthma medication – how much, how often, and the correct way to use the inhaler. If you are not sure, ask your doctor. The use of inhalers, in particular, needs to be explained carefully, and demonstrated several times.

Children with asthma are not always good at judging the severity of their symptoms. Often they say they feel fine even though their asthma is poorly controlled.

It is important that you let the school know about your child’s asthma. Sport and exercise should be encouraged, not limited and avoided. Children may benefit from taking their asthma medication just before exercise to prevent a wheeze or a cough from occurring during sport.

Asthma medicines are generally very safe, especially those that are inhaled. Children generally get into trouble because they do not take enough asthma medication, rather than because they take too much. If you feel that your child is experiencing side effects from medications, you should report this to your doctor so that changes can be considered. It is very important not to stop the medicine without letting your doctor know.

There should be an asthma management plan for every child with asthma. You and your child should know what triggers asthma symptoms, what medications they take and how they work. They should also know what to do if the symptoms get worse, and what to do in an emergency if there is not the expected response to the drugs that are usually taken.

Remember that most children with asthma can lead perfectly normal lives. The aim of treatment is to prevent attacks from occurring in the first place, and if they do occur, to treat them aggressively. If you have any questions about your child’s asthma, make sure you ask your doctor. And make sure you have an asthma action plan for your child.

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