An Active Lifestyle for Asthmatic Children
By Dr. Harold Kim, MD, FRCPC, Kitchener, ON
Asthma is the most common chronic illness in children and is one of the most frequent reasons for hospitalizations. The increase in the number of asthmatic children has followed the overall increase in other allergic conditions in the western world. Most children with asthma have ongoing lung inflammation with periods of worsening or exacerbations over time. Most asthma experts believe that the control of the ongoing inflammation will lead to fewer asthma exacerbations, better asthma control and a more normal life for these children.
The first step in helping asthmatic children is for the child and their parents to gain a good understanding of the underlying disease processes of asthma. We know that the majority of asthmatics do not really appreciate the mechanisms of the disease or how asthma should be managed. Most asthmatic children are allergic. Approximately 70-80% have at least one allergy identified when they have allergy skin tests completed. In many cases, these allergens are inhaled and lead to the chronic inflammation in the lungs that is the hallmark of asthma. In addition, the inflammation of asthma can worsen during exacerbations after exposure to viral respiratory infections, irritant exposure (e.g. smoke) or high levels of allergen exposure. Some surveys have estimated that over 50% of asthmatic children have had at least one severe asthma attack in the previous year. The frequency of asthma exacerbations varies over the year. For example, Canadian studies have shown that the most predictable time for severe asthma attacks is in late September. This time may be worse because viral infections increase soon after children return to school after Labour Day. Currently, we feel that prevention of these exacerbations is a key in contributing to a normal quality of life for the patient and their families.
Asthmatic children should be prepared for the common causes of asthma exacerbations. Although most children must attend school, we can be ready in other ways for these predictable times when asthma worsens. With regards to this "September Spike" in asthma, I feel that nearly all asthmatics should be taking maintenance asthma medications such as inhaled steroids daily from early September through the fall. This approach to therapy should prevent many severe asthma attacks caused by viral infections in children. As well, the child's identified allergens and exposure to smoke should be avoided. For children with worsening asthma during exercise, a relief inhaler can be taken about 20 minutes before exercise to prevent flares of asthma. Importantly, all asthmatics should have a written asthma action plan on how to deal with these exacerbations. Their health practitioners, including certified asthma educators, can provide these action plans.
Asthma actions plans should incorporate a definition of good asthma control. We feel that good asthma control means that a child with asthma is having no exacerbations, has a normal activity level, is not missing school, has no night time symptoms and requires their rescue bronchodilator infrequently. All of these criteria for good asthma control are very important, but for children it is particularly important that there is a normal activity level and school attendance is nearly perfect. Many asthmatics accept poor control and do not realize that a normal life is often quite easily achieved. For example, many asthmatic children will sit out physical education class at school or avoid sporting activities because they do not realize that their asthma could be well controlled. In fact, many world-class athletes with asthma have won Olympic medals. Asthmatic children should be encouraged to participate in physical activities for better overall health and fitness. Although obesity is not likely a cause of asthma, it is likely that children who are inactive will have an increased chance of becoming overweight. If obesity occurs, then the child is at risk of worsening asthma and developing other medical problems such as heart disease or diabetes. Often, children may miss days or even weeks of school because their asthma is flaring. These patients often do not realize there are safe and effective medications available that could improve their asthma control and prevent missed school days or sporting activities.
The mainstay of asthma therapy is inhaled corticosteroid (e.g. Flovent, Pulmicort, QVAR) medications. Over the last few decades, these effective and safe medications have revolutionized asthma care and have led to a dramatic improvement in the quality of life of asthmatics. Not only have these medications decreased the number of people dying from asthma, but also have improved all aspects of asthma control. Even very young children can take these medications to decrease the inflammation in the airways. This reduction in inflammation is essential for asthma to truly improve. The relief bronchodilator inhalers (e.g. Ventolin, Oxeze) should always be available for breakthrough symptoms. If these medications are not adequately controlling symptoms, then leukotriene antagonists (e.g. Singulair) or long acting beta agonists (e.g. Oxeze, Salmeterol) can be added onto the inhaled steroid medication. Also, there are some recent studies that show that leukotriene antagonists may prevent episodes of viral-induced asthma. There are new convenient combination inhalers available that contain both the inhaled corticosteroid and the long acting beta agonist (e.g. Advair, Symbicort). Regular use of the maintenance medications will prevent many asthma exacerbations and often lead to normal life for children with asthma.
In conclusion, children with asthma can lead active and productive lives. Our understanding of the causes and mechanisms of this disease have dramatically improved. With this understanding, have come several new and effective treatments. Now, we are able to control asthma with these modern therapies so that most asthmatic children can lead normal lives.
from Allergy & Asthma News, Issue 3 2005