Childhood Asthma

Childhood Asthma: Causes, Symptoms, Treatment and Management

Asthma is the most common lung condition in children. Childhood asthma is a long-term condition that causes the inner lining of the airway to become inflamed and swollen and to produce excess mucus. It also makes the muscles around the airways tighten. When these things happen, our airways become narrower (called bronchoconstriction) and we find it more difficult to breathe air in and out of our lungs.

Childhood asthma affects about 1 in 11 children in the UK [1] – this amounts to about 1.1 million children [2] living with the condition. In the United States, 1 in 10 children have asthma.

People of any age can have asthma. However, symptoms most often appear for the first time in childhood and usually before the child’s fifth birthday. [3]

Your child’s asthma symptoms could improve as they get older. About half of children with asthma find that their symptoms disappear when they become teenagers. [4]

We don’t know exactly what causes asthma. It is likely a combination of environmental and genetic (inherited) factors [5]. Children are more likely to develop asthma if they:

Have eczema or an allergy
Have a close relative who has eczema or allergies
Are exposed to cigarette smoke (or if their mother was exposed to cigarette smoke when she was pregnant)
Are exposed to other environmental pollutants
Live in a low-income and poorly resourced community [6] – this might be partly because of damp, moldy housing, and pollution
Have a respiratory virus infection – at least half of children who need to go to hospital with respiratory syncytial virus (RSV) later develop asthma
Had a low weight at birth
Are overweight or have other health problems [5]

Certain triggers [7] make asthma symptoms worsen (flare up), commonly:

Respiratory infections – usually viral
Allergies – for example, allergies to house dust mites, pollen (i.e., hay fever), foods, cockroaches, fungal spores, animals, and pets could trigger allergy-induced asthma
Cigarette smoke
Pollution – such as car exhaust fumes and other irritants in the air
Weather extremes – hot, cold, damp, or stormy
Exercise
Stress and strong emotions, such as feeling very upset or excited

Triggers are personal and one or several of these factors could cause your child’s symptoms to flare up.

Symptoms of childhood asthma include: [7]

Coughing – especially if the cough is persistent or keeps coming back
Wheezing – this is a whistling sound when they breathe
Being short of breath
Chest tightness

Your child won’t necessarily have symptoms all the time – it depends how well or poorly controlled their asthma is, and whether they’re exposed to any triggers. Their symptoms may be worse at night (sometimes referred to as nocturnal asthma [8]), first thing in the morning when they awaken, or after exercise or bursts of energy.

What Are the Symptoms of Asthma in Children Under 5?

Coughing and wheezing are probably the easiest signs to recognize in children younger than 5 years old. If your baby or toddler is breathless, they might be breathing faster than usual or using their body to breathe (for example, lifting their shoulders up and down with each breath).

Children under 5 may not describe how they’re feeling in the same way as an older child or adult. For example, instead of saying their chest feels tight, they might say they have a tummy ache or you might notice they are rubbing their stomach or chest.

If you are concerned that your child may have asthma, you should take them to see a doctor, who will most likely:

Ask about their medical history – any symptoms and possible triggers you’ve noticed recently, and when they occurred
Ask if your child or any family members have eczema or allergies
Do a physical examination – in particular, they will listen to your child’s chest for any wheezing. Note that if they do not find a wheeze, it does not necessarily mean that your child does not have asthma.

If your child is under 5, they may be diagnosed with suspected asthma on the basis of one simple assessment. To be certain it’s asthma, though, you’ll have to wait until they’re old enough to do some coordinated breathing tests. [9]

Children between 5 and 16 years of age will be asked by their doctor to do one or more breathing tests:

Spirometry – your child is asked to blow into a mouthpiece as fast and for as long as they can to measure how well their lungs are working.
Bronchodilator reversibility (BDR) – if that first spirometry test suggests that your child is not exhaling (breathing out) very well, your doctor or asthma nurse will give them a one-off dose of bronchodilator medication. Two spirometry tests – one before and one after the medication – will measure for any improvement. A positive BDR test confirms an asthma diagnosis.
Fractional exhaled nitric oxide (FeNO) – measures the level of inflammation in your child’s airways.
Peak expiratory flow (PEF) monitoring – your child blows into a small tube to measure how fast they can breathe out. If PEF changes a lot from day to day, that can indicate a diagnosis of asthma.

Don’t worry if your young child doesn’t have the hand-to-breath coordination to do these tests – they can try again every six to 12 months.a reviews with your nurse or doctor. It is a great opportunity to talk about your symptoms and treatment, and decide whether any changes are needed.

There are three main types of inhalers used to treat asthma in children: [10]

Reliever or rescue (bronchodilator) inhaler – use these occasionally to relieve your child’s symptoms when they happen. They are quick acting, within about three minutes.
Preventer (anti-inflammatory) inhaler – use these every day to prevent your child having symptoms.
Combination inhaler – these contain two types of medicine, one of which is an inhaled corticosteroid. Your doctor will tell you if this needs to be used daily or as needed.

Inhalers deliver the medicine as a spray or powder directly to where it is needed – the airways. Most children have well-controlled asthma if they use their inhaler(s) correctly. Connecting a spacer to the inhaler (when appropriate) or using a nebulizer device can make it easier to use – especially for babies and young children.

Depending on how old they are, children with difficult-to-control asthma may also need to take a daily tablet or switch to a different inhaler.

Further specialist add-on treatments for children with severe asthma include theophylline (smooth muscle relaxant used in some global locations, ex-US [10], steroid tablets [11], and biological medications. [12]

Asthma Treatment for Children

Children under 5

If symptoms are mild and occasional, your doctor may take a “watch and wait” approach to see if there is a pattern to their symptoms. For example, do they only appear after a cold then go away?
Add a reliever inhaler to use if the symptoms occur.
If the symptoms persist, prescribe a trial of a daily preventer inhaler, then stop. If your child’s symptoms return within four weeks, it is likely they have asthma. In this case, they will be asked to start taking the daily preventer again and use a reliever inhaler as required.
Add a daily LTRA tablet (or syrup) for extra prevention if needed.
If symptoms are severe or persist after all the above steps have been taken, they will be referred to a specialist.

Children ages 5 to 16

Prescribe a reliever inhaler as needed.
Add a daily preventer inhaler if needed.Add a daily preventer leukotriene receptor antagonists (LTRA) tablet if needed.
If symptoms persist, stop the LTRA and change to a long-acting preventer inhaler.
If symptoms persist, change to a combination inhaler (both preventer and reliever).
Refer to a specialist if necessary.

How Can You Manage and Keep Childhood Asthma Under Control?

Use and follow your child’s Asthma Management Plan. Share it with teachers, carers, and close family members.
Establish a daily routine for taking preventer medicine – it will help you and your child to remember.
Refill prescriptions for inhalers before they expire.
Make sure your child has access to their reliever inhaler at all times and knows where it is.
Take your child for a review with their doctor or asthma nurse at least once a year.
Regularly check that your child’s inhaler (and spacer) technique is correct. See your asthma nurse or doctor for a reminder if you are unsure.
Monitor your child’s symptoms and keep a symptoms/reliever diary.
Record peak flow measurements regularly at home, if necessary.
Know what triggers your child’s symptoms and avoid these.
If you or anyone in your household smokes, quit.
Encourage your child to exercise, eat a good diet, and get enough sleep.
Know what to do if symptoms worsen and, if they do, act early.
When they are old enough, teach your child about asthma so that they understand how to manage their symptoms.
See your doctor or nurse if your child needs to use their reliever more than three times a week.

Information and Support

You will find a wealth of further information about allergies and asthma on our website, and we hope you will explore it. Below are some recent articles. You can also get in touch with us – we would love to hear from you!

2024 recommendations for asthma monitoring in children: A PeARL document endorsed by APAPARI, EAACI, INTERASMA, REG, and WAO.
A paper co-authored by GAAPP President, Tonya Winders, was published in June 2020 JACI and outlines the international unmet needs in pediatric asthma. Read the paper here.
“A Worldwide Charter for All Children With Asthma” can be found here.
“Asthma: Working Together with your Health Care Team Guide” can be found here.

References

England N. NHS England» Childhood asthma. England.nhs.uk. Published 2020. Accessed April 22, 2024. https://www.england.nhs.uk/childhood-asthma/.
Types of asthma. Asthma + Lung UK. Published November 30, 2022. Accessed April 22, 2024. https://www.asthmaandlung.org.uk/conditions/asthma/types-asthma#-childhood-asthma.
Asthma Symptoms, Diagnosis, Management & Treatment. Aaaai.org. Published 2024. Accessed April 22, 2024. https://www.aaaai.org/conditions-treatments/asthma/asthma-overview.
UHBlog. Half of Kids With Severe Asthma May Grow Out of It. Uhhospitals.org. Published December 17, 2020. Accessed April 22, 2024. https://www.uhhospitals.org/blog/articles/2020/12/half-of-kids-with-severe-asthma-may-grow-out-of-it.
‌Asthma in Children. Hopkinsmedicine.org. Published May 12, 2022. Accessed April 22, 2024. https://www.hopkinsmedicine.org/health/conditions-and-diseases/asthma/asthma-in-children.
Children’s asthma rates linked with neighborhood characteristics, race, ethnicity. News. Published June 9, 2022. Accessed April 22, 2024. https://www.hsph.harvard.edu/news/hsph-in-the-news/childrens-asthma-rates-linked-with-neighborhood-characteristics-race-ethnicity/.
Health. Asthma in children. Vic.gov.au. Published 2023. Accessed April 22, 2024. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/asthma-in-children#triggers-for-asthma-in-children.
Nocturnal Asthma. Sleep Foundation. Published February 4, 2021. Accessed April 22, 2024. https://www.sleepfoundation.org/sleep-related-breathing-disorders/asthma-and-sleep.
Childhood asthma: Make a plan to control attacks-Childhood asthma – Diagnosis & treatment – Mayo Clinic. Mayo Clinic. Published 2023. Accessed April 22, 2024. https://www.mayoclinic.org/diseases-conditions/childhood-asthma/diagnosis-treatment/drc-20351513.
Theophylline (Oral Route) Proper Use – Mayo Clinic. Mayoclinic.org. Published 2024. Accessed April 22, 2024. https://www.mayoclinic.org/drugs-supplements/theophylline-oral-route/proper-use/drg-20073599.
What asthma means for kids under 5. Mayo Clinic. Published 2023. Accessed April 22, 2024. https://www.mayoclinic.org/diseases-conditions/childhood-asthma/in-depth/asthma-in-children/art-20044376.
Bacharier LB, Jackson DJ. Biologics in the treatment of asthma in children and adolescents. The journal of allergy and clinical immunology/Journal of allergy and clinical immunology/The journal of allergy and clinical immunology. 2023;151(3):581-589. doi:https://doi.org/10.1016/j.jaci.2023.01.002.