Wheeze season: Childhood asthma's September peak

Every September in Halifax, a fundamental change occurs in the respiratory health of children.

Asthma returns.

Asthma is the most common chronic disease of childhood. In Canada, as many as 15 per cent of children may have asthma. It is a very seasonal entity in kids; each summer, asthma presentations fall off until August, which is the slowest month of all. Then we hit September, asthma's busiest month, probably because of autumn allergens and back-to-school viruses. There are peaks and valleys over the next 11 months, usually associated with cold and flu seasons, but September, the month of the official end of summer, marks both the beginning and the peak of the season of pediatric wheeze.

So with asthma season upon us, I thought I would share the three messages that I try to communicate each time I see an asthmatic child in the emergency department.

1. Relax: It just isn't that dangerous

"TV asthma" goes like this: the is child rushed to the hospital in a screaming ambulance where grave but good-looking health-care workers struggle to keep him breathing. Fortunately, this is mostly myth. In reality, childhood asthma is simply not a particularly dangerous disease.

According to Statistics Canada, an average of just under three children die each year in Canada as a result of asthma. The death of any child is a tragedy, and we need always to learn from asthma mortality. But death rates from other causes in childhood are overwhelmingly more frequent. Relative to the other hazards, childhood asthma is simply not a dangerous disease.

For example, in 2004, 250 Canadian children died in accidents. That's nearly 100 accident deaths for every death due to asthma. Allowing for the difference in populations (any child can have an accident, but only asthmatics can die from asthma), asthmatic children have nearly 10 times the risk of mortality due to accident than mortality due to asthma. Their breathing may be what parents focus on, but that trampoline, ATV or swimming pool is the real risk. How many of us lie awake at night worrying about whether we have fastened the kiddie gate at the top of the stairs? Frankly, more of us should.

Instead, some parents are afraid to let their asthmatic children play hockey, or go camping, or visit grandparents who smoke, all out of fear of causing a dangerous asthma attack. My advice in most cases: lighten up folks put your child into organized sport, teach her independence, and grant her the gift of an extended family, even if they do smoke. With rare exceptions (and these can usually be identified by your doctor) asthmatic children will have minor, irritating symptoms which might interrupt their day, but which will not put them at significant risk. Asthmatic children should be confident social jocks, not reclusive couch potatoes, and as a physician, I am willing to put up with some mild wheezing after the game to get that. Stealing important parts of a childhood to prevent an illness that has such low risks seems to me to be a poor bargain. Let your kid be a kid! Just treat the asthma properly.

In case, by the way, you thought that I just said it was okay to smoke? Or that you could ignore mild asthma symptoms? I didn't. More on that below.

2. An ounce of prevention

Parents and physicians are often quite concerned when a child has an asthma "attack," but that little nagging cough between attacks well, you can't treat every little thing, can you?

Actually, with asthma, yes, you can.

Asthma is a disease of the tubes; it is caused by inflammation in the smaller airways in the lungs, which plugs up air flow. There are lots of these small tubes; as a result, it is only when about half of these are blocked that your child starts to cough, and even more have to be blocked before he starts to work harder to move air.

So what does this mean? It means that by the time your child has mild symptoms, he has extensively involved lungs. Conversely, if your child looks well, that doesn't mean that the asthma has "gone."

It makes sense, in other words, to treat with preventative drugs long after the symptoms of asthma have resolved, because the "real" disease (the inflammation in the airways) might still be active, just silent.

'Asthmatics are at greater risk for obesity, poor fitness and poor school performance' Brett Taylor

What happens with mild untreated asthma? Well, that cough after recess might simply persist. Or it might develop into an attack that mucks up her day and your night, stealing sport or school or social interaction in the process. Also, a year from now, your kid might not be as willing to play sports; asthmatics with poor control are known to self-select away from exercise because it makes the wheeze more apparent. After all, if running made you feel sick, would you willingly persist?

Note that I am not saying that you should stop the exercise. Asthmatics are at greater risk for obesity, poor fitness and further, because their symptoms keep them awake at night and sometimes home during the day, poor school performance. Together, this means a risk of poor body image. These are important lifelong problems and each has substantial health risks. Building your child's physical confidence through sport helps inoculate against them. Preventing and treating "mild" asthma symptoms is key.

From an emergency pediatrician's perspective, then, many people have asthma management backwards. We get all worked up about acute asthma attacks, which are virtually always safe events, then forget about prevention and the management of the mild day-to-day symptoms, thus setting the child up for long-term risks.

Essentially, effective asthma management is much less about acute asthma attacks and much more about an ounce of prevention.

Rescue medications for asthma are those that work immediately. An example is inhaled salbutamol (such as Ventolin), usually provided in the form of a (blue) puffer, which relaxes the muscle spasm around the irritated airway. Dexamethasone (Decadron) is another rescue med given orally during acute attacks; it markedly reduces airway inflammation within hours. Combined, these medications improve symptoms quickly. But they are rescue drugs and should only occasionally be necessary. In fact, daily use actually has risks. Using rescue puffers on a daily basis is an indication of poor control.

Inhaled steroids like fluticasone (Flovent an orange puffer) are safe, effective medications that prevent asthma attacks. Like the steroid creams used to treat some rashes, these work by reducing airway inflammation. Correct use of inhaled steroids results in fewer attacks and hospitalizations, less nighttime cough, more time at school or on the soccer pitch. But these medications have to be taken on a regular basis for a number of weeks to have significant benefits.

It is important to use preventative medications properly. The idea that you can use inhaled steroids for only a week or two until the symptoms get better is fundamentally flawed; these are preventative, not rescue, drugs. Using inhaled steroids for less than four to six weeks does very little; appropriate use of these meds is often for months at a time.

Another preventative medication is montelukast (Singulair). This is a safe drug that is effective for a smaller subgroup of asthmatics. Since inhaled steroids treat the vast majority of asthmatic children very well, addition of these other agents should probably be left to asthma specialists. If your child isn't responding to inhaled steroids, someone experienced should re-evaluate the diagnosis carefully.

3. Control the triggers where possible

Asthma isn't an allergy, nor an infection, nor a disease caused by chemical irritants. Rather, asthma is part of a larger syndrome called atopy, in which the skin and mucous membranes tend to become inflamed more easily, and to stay inflamed longer. The triggers that cause the inflammation change from patient to patient, and from age to age. Asthmatic toddlers are generally triggered by viruses (parents will come in saying that their child "only wheezes with colds"), while older children who have had the chance to develop allergies may find that their asthma is triggered by aeroallergens like pollens or pet dander. Certain chemicals and cold, dry air tend to affect nearly all asthmatics to some extent.

Toddlers are often sick with viral illness in the winter, and this often frustrates asthmatic parents. Appropriate immunization helps. Don't let urban myth frighten you on this immunizations are safe and generally quite effective. Whooping cough and influenza cause substantial illness, often lasting weeks or even months, and vaccination will reduce the risk to an asthmatic child. Unfortunately, there are many viruses for which effective vaccines are not available. For these children, common-sense measures, like good hygiene at daycare, prevail. Ultimately, proper use of preventative medication is often the best anyone can do.

Common allergens include pets, house dust mite and plants, among others. If your child's asthma is not easy to control, referral to an allergy specialist might be appropriate. It isn't necessary to automatically eliminate family pets again, unless there is some demonstrated benefit to the child, why should we steal this important part of childhood? But if a reasonable regime of medication doesn't provide good asthma control, the child should get tested to see if Fido or Sylvester is part of the problem.

The biggest issue in managing triggers, however, is cigarette smoke. Studies in many settings by many researchers show that childhood asthma symptoms are worsened by exposure to cigarette smoke, that puffer medications are less effective in the presence of cigarette smoke, and that asthmatic children raised in smoking households have worse lungs as adults. If you can't quit, step outside and close the door behind you before you light up your cancer stick.

'You must ban smoking from your house. Period.' Brett Taylor

What about your smoking grandparents? Well, there are 168 hours in a week; if your child visits smoking relatives once a week fortwo hours, that means that he can be smoke-free for 99 per cent of his life if there is no smoke at home or daycare. Your home is your responsibility. Clean that air up.

None of the excuses are valid. Having only one or two cigarettes a day, smoking only when the kids aren't home, smoking by an open window all these are magical thinking. In order to properly treat your child's asthma, youmust ban smoking from your house. Period.

Bottom line:

So these are the three messages: don't be frightened, use preventative medications properly, and control your child's triggers. Plug your asthmatic child into sports, and make sure that fear isn't needlessly stealing important parts of your kid's childhood away. Pay attention to small symptoms and be picky about giving preventative medications. If things aren't working, see an asthma specialist and consider testing for allergies.

If, during high-risk seasons, your child takes her preventative puffer and you are careful about environmental control, you will probably find that you are in charge of the asthma instead of the other way around.

Help is widely available (Google theCanadian Lung Association, for example) and the costs involved in treating asthma are not high. So maybe this is the final message: don't be disheartened. This isn't rocket science. You can do this.

Brett Taylor is an associate professor of pediatrics and emergency medicine at Dalhousie University. He works as an emergency paediatrician and researcher at the IWK Health Centre in Halifax. He is in the process of obtaining a Masters in Health Informatics, also through Dalhousie. His website for parents is available at www.thevirtualpediatrician.com.