Asthma in Children

Respiratory illnesses are the most commonly occurring acute and chronic illnesses in childhood. Of these, asthma accounts for the majority of episodes of both types of illnesses. Recent data indicate that asthma affects approximately 4.8 million children. It also accounts for high rates of hospitalization among children. By having an understanding of the mechanisms that underlie symptoms of asthma, the nurse will be able to assist children and their parents to follow prescribed treatment plans and better manage symptoms.

The Expert Panel Report 2 (1998) currently defines asthma in the following way.

…a chronic inflammatory disorder of the airways characterized by recurrent episodes of wheezing, breathlessness, chest tightness and coughing. Episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. Inflammation involves many cells and cellular elements including mast cells, eosinophils, T lymphocytes, macrophages, neutrophils and epithelial cells. The inflammation that occurs also causes increased bronchial hyperresponsiveness to a variety of stimuli.

Physiologic research has identified the following evidence related to airway changes in asthma.

1. Mast cells, eosinophils, epithelial cells, macrophages, and activated T cells influence airway function through secretion of specific mediators that act either directly on the airways or indirectly through neural mechanisms.
   
2. TH2 cells (a subpopulation of T lymphocytes) may release selective cytokines that regulate allergic inflammation.
   
3. Other airway cells including fibroblasts, endothelial and epithelial cells also contribute to inflammation through cytokine and chemokine release.
   
4. Other airway cells including fibroblasts, endothelial and epithelial cells also contribute to inflammation through cytokine and chemokine release.
   
5. Airway smooth muscle tone, mucus secretion and characteristic structural changes, associated with chronic asthma, are influenced by cell derived mediators.
   
6. In childhood asthma, there is often evidence of atrophy or the genetic susceptibility to produce IgE antibodies that become activated when they encounter specific antigens. The allergens that trigger IgE production in children include common environmental substances such as house dust mites, animal proteins and fungi. (Expert Panel Report 2,1998)

The manifestations of these physiological changes are the symptoms commonly associated with asthma including wheezing, complaints of breathlessness, chest tightness, coughing, and increased mucus production. These symptoms occur in children. It is important to remember, however, that children will not articulate their symptoms in the same ways that adult patients do.

Children also will often have improvement in their symptoms as they grow. This is partially due to the fact that their lungs are still developing. Lung growth is not complete in children until later, in the school age years. This physical growth allows for better expansion of the airways.

The presenting symptoms of asthma in children often depend on the child’s age and specific medical history. Infants and younger children will often develop asthma symptoms when they have a viral illness such as an upper airway infection. Sinus infections can also trigger asthma symptoms. These illnesses trigger asthma symptoms, because the infection irritates the epithelial lining of the airways and receptors are more exposed to noxious stimuli.

In addition to these presentations, older children may develop symptoms when they exercise or engage in sports activities. The symptoms can develop in activities occurring in either indoor or outdoor settings.

Children may also develop symptoms as a result of exposure to allergens. Common allergens that precipitate symptoms are the dust mite, pet dander, mold, and some foods. Irritant substances in the environment such as cigarette smoke or fragrances also provoke symptoms.

Children born prematurely and treated for respiratory distress are at a high risk for asthma because of residual airway damage. A family history of asthma or airway disease also increases the likelihood of asthma in children.

Data have also indicated that children who live in inner-city environments have a higher risk of morbidity from asthma. Three factors contribute to this: 1) higher incidence of exposure to cigarette smoke, other indoor allergens and motor vehicle exhaust, 2) psychological problems of children and their caretakers, and 3) problems in accessing appropriate medical care and follow-up.

Asthma is accurately diagnosed by obtaining an accurate history of symptoms, performing a physical exam, and administering specific diagnostic testing. Each area will be discussed.

An accurate history includes information about the child’s symptoms, lifestyle, and environment. Question the primary caregiver for infants and preverbal children. When children become verbal, ask them questions phrased appropriate to their developmental level. The following chart lists developmentally appropriate and pertinent questions.

 In addition to the data obtained from these questions get specific information about cultural beliefs that could influence treatment. For example, many parents follow the prescribed treatment regimen for an acute episode of asthma; however, when the acute illness has subsided, these same parents may use more traditional “folk remedies” as standard treatments. The parents do not understand the etiology of asthma and the need for continuing the prescribed regimen. Rather, they rely on culturally based beliefs about health and illness. Many cultures believe that the acute episode is the only time the child has asthma. Information about cultural beliefs and treatments assist the nurse to optimize compliance with a prescribed treatment regimen.

It is important to use developmentally appropriate approaches when examining a child. Moreover, specific components of the respiratory exam must be included, i.e. the child’s color, respiratory rate, accessory muscle use with breathing, sound of the voice, and general activity level. The following are changes that occur in these signs with asthma symptoms are:

The extent of the physical exam depends on the child’s presenting symptoms. If the child is in acute distress, the exam should be brief and focused on the acute symptoms and treatment. When a child presents with chronic symptoms, the exam can be more detailed and incorporate more components

The respiratory physical exam data the nurse can assist in collecting includes the following:

 Data from the history and physical are communicated to the practitioner/physician to determine the need for further diagnostic work.

The diagnostic testing indicated for children presenting with asthma symptoms depends on the age of the child and the factors already discussed. Allergy testing to identify specific triggers, a chest x-ray, and pulmonary function testing may be indicated when the child presents with chronic symptoms If the child presents with an acute episode, testing is delayed until the acute episode is resolved. A chest x-ray is performed to rule out other causes for symptoms, particularly pneumonia.

Pulmonary function testing is performed to measure specific changes that occur in lung volumes before and after use of an inhaled short acting bronchodilator. This testing cannot always be performed reliably on younger children, however. Another measure that can be assessed in children is change in peak expiratory flow. This measure will change prior to the onset of other symptoms, such as wheezing. Children can learn to use a peak flow meter and assist in recording the changes noted.

Once a diagnosis of asthma is established, it is classified according to severity before treatment. The severity classifications defined by the Expert Panel Report 2 (1998) place a patient into one of four categories depending on overall symptoms, nighttime symptoms and lung function. The following chart indicates the classification based on symptoms and nighttime symptoms. These categories are used to classify childhood asthma.

 In any of these categories, there can be wide variability of symptoms and the child’s classification can change over time. The classification assists the physician in prescribing medications to treat symptoms.

Asthma management involves multiple approaches. Medications are used, peak expiratory flow monitoring is taught, and environmental changes may be recommended. A key component for children is to teach them how to manage their symptoms themselves. This includes teaching the child about symptoms, medications and other self-care strategies that can be incorporated into their lifestyle. The goal of management is to assist children so they are able to engage in developmentally appropriate activities without triggering asthma symptoms.

Medications are used to prevent and control asthma symptoms. Medications are used to reduce the inflammation that limits airflow, increases mucus production and causes coughing. Medications are considered long-term control and quick relief resource medications. Long-term medications are taken on a daily basis to attain control of persistent symptoms. Quick relief or rescue medications are taken to give prompt relief of acute symptoms or breakthrough episodes. The following chart outlines specific information about medications used in treatment of asthma. Remember that medications are always prescribed based on the individual child’s needs.

In children, the medications prescribed are based on the classification of asthma that the child is determined to have. The National Asthma Education and Prevention Program (2002) have recently developed a stepwise approach for management of symptoms of asthma in children, based on age. This approach outlines recommendations of preferred and alternative medication treatments for each classification of asthma.

The stepwise approach also suggests that the treatment plan be reviewed every six months to determine if the child is ready to have medications reduced. Conversely, if the child continues to have difficulty, then the regimen originally prescribed requires review.

Medications are only one component of a treatment plan for children with asthma. After medications are prescribed, the child and parents/caregivers must have an understanding of the medications including the action, methods of taking the medication, possible interactions with other medications the child takes, and or foods the child eats. Additionally, a daily schedule for taking medications is necessary to maintain compliance.

If the child attends school, it may be necessary to have information available to the school nurse or health aide about the child’s symptoms and treatment plan. These issues will be discussed further.

The nurse can be instrumental in assisting the child and parents achieve an understanding of asthma and its management. Once a definitive diagnosis of asthma is established in a child, the nurse can organize a teaching plan the family can implement to avoid and alleviate the child’s symptoms.

Educating the family cannot be achieved in one encounter. Rather, it should be done each time a child is seen for asthma management.

To teach the family, begin by explaining the differences between the functioning of normal airways and what occurs when asthma symptoms develop. Use varied approaches. The family can be given information verbally or reading material to review when they are at home can be used. If the latter approach is used, tell the family to write down any questions they have and bring them with them on a subsequent visit.

When teaching the child, a developmentally appropriate approach is essential. Additionally, there are a variety of educational materials available from the American Lung Association for children with asthma, their website is

www.lungusa.org/asthma/. This website has specific information that parents can forward to the child’s school so that teachers and school officials understand the child’s needs. Patient education materials are available in Spanish.

The Allergy and Asthma Network Mothers of Asthmatics, website www.aanma.org, also has beneficial information. This organization was founded by the mother of a child with asthma and allows parents to post questions to a nurse who is the mother of two children with asthma. Questions are answered from a professional perspective.

After the family and child learn about differences between normal airways and changes in asthma, teach them about the medications that have been prescribed. Include teaching how the medications work to relieve the child’s symptoms. Be sure everyone understands two factors: 1) the schedule for taking medications, and 2) the difference between any long-term control and quick relief rescue medications prescribed. Usually, long-term control medications are those that are prescribed to decrease inflammation. These will not afford quick relief of breakthrough symptoms.

When the child is school age, the goal is usually to have the child take medication before going to school or after coming home, to reduce interruptions in his daily routine away from home. Children should understand what to do if symptoms occur at school. Rescue medication should accompany the child to school.

Another important component is to be sure everyone understands any potential food-drug or drug-drug interactions; include any over the counter medications the child may use. Be sure the child knows appropriate liquids to drink when taking the medication to decrease the possibility of food and drug interactions that might effect the rate medication is metabolized.

When the child is using inhaled medications, he needs to understand how to use the medication delivery device. Younger children benefit from using spacer devices with metered dose inhalers (MDI). As the child grows and is able to coordinate breathing and using a MDI, the spacer device can be eliminated. Since MDI’s use different propellants, the child may experience some effects as the medication is inhaled.

If the inhaled medication is administered as passive nebulization, the child should learn to use a mouthpiece or facemask for treatments. The child and parents need information about cleaning this type of equipment.

Finally, the need for medication monitoring must be emphasized. Because medications doses are based on weight, routine follow-up is needed as children grow and gain weight. A child in good control on a specific asthma medication regimen should have medication doses re-assessed at least annually.

The child and parents need information about monitoring symptoms that indicate adequate control. They also need information about when symptoms indicate the child is having difficulty. Usually this means teaching the child and parents how to do peak flow monitoring, which measures forced expiration after taking a deep breath. The major advantage of teaching this method of symptom monitoring is that a better understanding of what affects the child’s asthma can be obtained. Changes in peak flow will occur well before acute symptoms of an exacerbation do. When the child and parents are able to do appropriate peak flow monitoring, they often are able to avoid unnecessary emergency room trips. It also allows the child to gain mastery and understanding of his/her symptoms. Typically, a diary of peak flow is kept and brought to regular visits with the clinician managing the asthma regimen.

Another very important component of asthma treatment and management is knowing whether certain factors in the home or external environment precipitate symptoms of asthma. This information is solicited when getting the history as discussed earlier. When environmental factors are identified that affect the child, the nurse can assist the family to identify ways to eliminate the trigger.

Within the home environment, the typical triggers are the dust mite, mold, animal dander and cigarette smoke. The dust mite is present in bedding, upholstery and carpeting even when regular cleaning is performed. Helpful information for parents includes assisting them to identify whether they need to remove certain items from the child’s room or try alternate methods of cleaning. Damp dusting items that the child uses frequently often removes many potential triggers from an object.

Parents may need information about specific filters for the ventilation system present in their home. Filtering the air can often remove mold, animal dander and other triggers.

When smokers are present in the child’s environment, they should be encouraged to quit or if unwilling to quit, to smoke outside the home. Additionally, knowing they may be hurting their child’s health sometimes stimulates a parent to stop. The nurse can assist the parent to find stop smoking methods.

Parents and children often ask about appropriate activities and sports. When they see peers engaging in sports, children will want to participate. The child with asthma, who has adequate control, can engage in many activities with peers, although sometimes it is necessary for the child to gradually incorporate an activity into his/her lifestyle while medication regimens are being adjusted. Having asthma does not mean that activities cannot be pursued. Rather, the child should be encouraged to participate without exacerbating symptoms. Swimming is often recommended. Outdoor sports may sometimes require appropriate medication adjustment.

The child should be encouraged to engage in age appropriate activities to foster achievement of developmental milestones. With careful assessment and planning, the nurse can assist the child and family to participate alongside peers.

The nursing role of educator can have a significant impact on the quality of life of a child with Asthma and their family. Effective teaching of etiology, compliance with treatment and symptom management also has the potential to prevent emergency room visits and hospitalizations.

Bearison, D.; Minian, N.; Granowetter, L. (2002) Medical management of asthma and folk medicine in a Hispanic community. Journal of Pediatric Psychology 27(4): 385-392.

Divertie, V. (2002) Strategies to Promote Medication Adherence in Children with Asthma. MCN The American Journal of Maternal-Child Nursing 27 (1): 10 – 18.

Expert Panel Report 2 (1998) Guidelines for the Diagnosis and Management of Asthma. National Heart Lung and Blood Institute, NIH, Bethesda, Md.

Expert Panel Report 2 (2002) Guidelines for the Diagnosis and Management of Asthma – Update on Selected Topics 2002. National Heart, Lung and Blood Institute, NIH, Bethesda, Md.

McMullen, A., Yoos, H., Kitzman, H. (2002) Peak Flow Meters in Childhood Asthma: Parent Report of Use and Perceived Usefulness. Journal of Pediatric Health Care. 16 (2): 67 – 72.

Strunk, R. (2002) Defining Asthma in the Preschool Child. Pediatrics. 109 (2) 357 – 361.