Find out why experts say it's time for a rethink. A brief history of asthma. Medically reviewed by Debra Sullivan, Ph. Asthma is ancient More recent developments Modern perspectives Takeaway Asthma is a chronic disease of the airways with links to the immune system.
Asthma is ancient. Share on Pinterest Hippocrates was the first to links asthma symptoms to environmental triggers. More recent developments. Share on Pinterest The over-prescription of bronchodilators led to an epidemic of asthma deaths in the s. Modern perspectives on asthma. Exposure to air pollutants may amplify risk for depression in healthy individuals. Costs associated with obesity may account for 3. Related Coverage. Chronic obstructive pulmonary disease COPD. Medically reviewed by Judith Marcin, M.
Is chest pain a symptom of asthma? Medically reviewed by Elaine K. Luo, M. Infants and toddlers have much smaller airways than older children and adults. In fact, their airways are so small that even small amounts of swelling of the lining of the airways caused by viral infections, tightened airways, or increased amounts of mucus can block the flow of air making breathing extremely difficult for the infant or young child.
The first episodes of asthma in young children are often triggered by viral respiratory infections. These young children cannot tell their parents that they are having trouble breathing. As a result, infants or young children with viral respiratory infections should be monitored for the signs and symptoms of asthma discussed below.
Children are at a higher risk for wheezing in the first years of life if they are born prematurely; if their mother smoked during pregnancy; if they have a family history of asthma or allergies; or they have a personal history of eczema.
Infants and children who wheeze once often wheeze again. Young children who have wheezed before should be carefully monitored for symptoms and signs of asthma when they have respiratory viral illnesses. Look for other asthma symptoms such as those listed here in addition to the increase in respiratory rate. Asthma symptoms can quickly develop into a serious medical condition, especially in infants and toddlers. Parents may not be aware that asthma symptoms are becoming serious, possibly leading to a medical emergency.
If your child demonstrates any of the symptoms listed below, seek medical treatment immediately! Do other illnesses or conditions have the same symptoms as asthma in very young children? Newborns, infants, and toddlers can exhibit asthma-like symptoms of wheezing, coughing, and difficulty breathing with a number of different diseases, illnesses, or conditions. These include:.
Your pediatrician or an asthma specialist can assess your child to determine the underlying cause of the asthma- like symptoms. Toddlers and preschool aged children often continue to be fairly active in spite of increasing chest tightness or difficulty breathing. Diagnosing asthma in very young children is difficult. Since they are not able to communicate, they cannot describe how they are feeling.
To help your pediatrician make a correct diagnosis, you must be able to provide information as follows:. Pulmonary lung function tests are routinely used in older children and adults to help confirm an asthma diagnosis but these tests are very hard to do with young children. In addition, blood tests, allergy testing, and x-rays may be done to gather additional information. Using all this data, your physician then can make the best diagnosis. Sometimes parents are referred to a pediatric allergist or pulmonologist lung specialist for specialized testing or treatment.
Babies and toddlers can take most asthma medications prescribed for older children and adults. The dosage, of course, is lower and the way the medication is given is different. In general, inhaled medications are preferred for asthma treatment because they act more rapidly to reduce symptoms and produce fewer side effects.
Medications to treat asthma symptoms in infants and toddlers are often given in a tasty liquid form, by using a nebulizer with a facemask, or by using an inhaler with a spacer and facemask. Nebulizer treatments take about 10 minutes and are usually given several times each day until symptoms decrease. Nebulized medications are given to infants and young children using a facemask. Although some small children are initially apprehensive, with parental reassurance, the majority of children rapidly become accustomed to this form of medication delivery.
The particle size of the medication is very small and is affected by side stream air resulting in very little actually being inhaled by the infant or small child. Some toddlers and preschoolers are able to use an inhaler containing asthma medication with a spacer and mask attachment. A spacer is a small tube or chamber that holds the medication released by the inhaler fitted into it.
They found improvement in most asthma control measures for both controllers. However, the Asthma Control Questionnaire scores, spirometric values, and inflammatory biomarkers exhaled nitric oxide, eNO improved significantly more with fluticasone than with montelukast therapy.
In a randomized, double-blind parallel study, three treatment regimes were compared over a treatment period of 48 weeks [ ]. Fluticasone monotherapy was superior to montelukast for asthma control days and for all other control outcomes FEV 1 , maximum bronchodilator response, bronchial hyperresponsiveness, and eNO.
The GINA guidelines advocate other possibilities for controller medication [ 1 ]. Sustained release theophylline in steps 3 and 4 as treatment options and anti-IgE antibody omalizumab in step 5.
Theophyllines have long been known as bronchodilators and low dose therapy may have anti-inflammatory properties. The addition of low-dose theophylline to moderate-dose ICS, in asthmatic adults, is more effective in patients with severe asthma than increasing the dose of ICS to the maximum tolerated dose [ ].
Subsequent withdrawal of theophylline causes a loss of asthma control in adult patients with severe asthma [ ]. In smoking adult patients who became refractory to steroids, theophylline is effective when added to a dose of ICS, shown to be ineffective as monotherapy [ ].
However, most European guidelines do not advise the use of theophylline because of the toxic side effects and drug interactions. Omalizumab is an expensive therapeutic option and has the inconvenience that it needs to be administered subcutaneously in hospital, under supervision.
It is a therapeutic option in step 5 for therapy resistant asthma, after the exclusion of all other possibilities, following the stringent work-up for this specific group as mentioned above [ ]. Omalizumab has been shown to reduce exacerbations, reduce the dosage of inhaled and oral steroids, and improve asthma related QoL [ , ].
Moreover, safety has been demonstrated in studies with 1-year duration [ ]. Yet, substantial numbers of children have higher levels [ ]. Guidelines for asthma diagnosis and treatment have been in use for at least two decades.
Most countries in the Western world have their own guidelines or use an internationally accepted guideline such as the GINA guideline or the British Guideline on the Management of Asthma [ 1 , ].
The latter guideline has the advantage that the level of evidence for each step is mentioned. A portion of the standard medication steps are based on little or no evidence. This may be due to the lack of efficacy of drugs, such as in preschool children, where it is impossible to predict the phenotype, benefitting from a certain drug. Another reason is a lack of studies that support decision making.
The latter is the case in steps 4 and 5 of the GINA guideline. A single study supports the choice to step up low-dose ICS therapy in a child with uncontrolled asthma [ ].
The dosage montelukast depended on the age of the child. Study follow-up time was 16 weeks. They observed clinically significant improvement in almost all children.
However, many children had a best response to montelukast or ICS step-up. This indicates that one may have to test which drug of choice is needed in the individual patient, if step-up is from low to moderate dose of ICS, it is required in uncontrolled asthma.
Most children appear to benefit from the addition of LABA, but many children benefit from doubling the dose of ICS and benefit from the addition of montelukast. Adherence to guidelines, by health care professionals, remains suboptimal. In 18 Primary Health Care Centres in Stockholm, Sweden, medical records from children with asthma were selected and investigated [ ].
The medical records were searched for documentation of the most important indicators of quality, as stipulated in the Swedish national guideline, that is, tobacco smoke, spirometry, pharmacological treatment, patient education, and inhalation technique.
The authors conclude that the adherence by healthcare professionals to guidelines for asthma is poor and that there is considerable room for improvement. The implementation of pharmacological treatment appeared to be better than nonpharmacological measures, such as documented education, demonstration of inhalation technique.
In this study the presence of an asthma nurse was not associated with improvement of most non-pharmacological measures [ ]. Patients who reported having visited the asthma nurse during the previous year, had more knowledge but similar asthma control and quality of life, compared to patients who reported no visit.
Spirometry was more readily performed in children consulting the asthma nurse. We showed, in a three-armed randomised open study, that the quality of care provided by an asthma nurse was similar, compared to care given by a paediatrician or general practitioner [ ].
In contrast to other studies, we showed that access to an asthma nurse improves asthma control, knowledge, and QoL [ , ]. In a recent Canadian study on adherence to paediatric asthma guidelines in an emergency department, the authors collected information from healthcare professionals regarding their knowledge, attitudes, and use of a care pathway, for acute childhood asthma [ ]. The authors concluded that the majority of healthcare professionals had a positive attitude toward the pathway.
Knowledge gaps and the balance between standardization and individualization of care were thought to be key elements in explaining suboptimal adherence. However, despite the positive attitude towards the pathway, both studies show suboptimal adherence to guidelines [ , ].
This is in agreement with many clinical practices. Suboptimal adherence to guidelines is generally the result of a lack of implementation strategies after publication of the guideline. It is well known that it is difficult to introduce new evidence and guidelines into routine clinical practice.
In an overview, Grol and Grimshaw discuss different approaches for transferring evidence into practice [ ]. In their overview, they state that plans for change should be based on characteristics of the evidence or guideline itself, barriers and facilitators of change. Changes in clinical practice are only partly within the control of physicians.
The patient, the organisation of care processes, resources, leadership, and political environment also play an important role [ ].
Grol and Grimshaw advise interactive and continuous education, including discussion of evidence, local consensus, feedback on performance, and making personal and group learning plans. Asthma is one of the most chronic disorders in children. The prevalence of asthma has increased during the last decades but seems to have reached a plateau. The burden of asthma is considerable.
It influences quality of life, may prevent children from participating in sports and play, may hamper social contacts, and may cause school absence and hamper career development. Asthma begins in early life. There appear to be different phenotypes. However, up to now, this still needs to be confirmed. For therapeutic purposes these phenotypes may offer a practical approach in daily clinical life.
Multiple trigger wheezing is far more likely to respond to treatment with an inhaled steroid than episodic viral wheeze. In many school-aged children, the management of asthma with occasional bronchodilator use and low- or moderate-dose inhaled corticosteroid is uncomplicated.
However, problematic severe asthma is seen in a small subpopulation of asthmatic school children. This is a heterogeneous group that requires a specific and stringent work-up. The group consists of children with an incorrect diagnosis of asthma, children with asthma in addition to another disease, children with difficult asthma, and children with therapy resistant asthma. Inhaled corticosteroid treatment is the cornerstone of preschool wheeze and asthma therapy in school children.
The evidence for these steps is limited. Only one study suggests starting with the addition of LABA because this appeared to be effective in most children, but many children benefit from a doubling of the ICS dosage and benefit from the addition of montelukast. This suggests that clinicians should try to individualize therapy. A further improvement in asthma care may be achieved through improvement of adherence to guidelines by health care professionals.
Therefore, implementation plans should be developed, which contain interactive and continuous education, including discussion of evidence, local consensus, feedback on performance and the making of personal and group learning plans.
National Center for Biotechnology Information , U. Journal List Scientifica Cairo v. Scientifica Cairo. Published online Dec Wim M.
Author information Article notes Copyright and License information Disclaimer. Received Aug 5; Accepted Sep This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
This article has been cited by other articles in PMC. Abstract Many children suffer from recurrent coughing, wheezing and chest tightness. Introduction Asthma is a chronic disorder of the bronchial tree, characterized by completely or partially reversible airway obstruction, which may improve spontaneously or may subside only after specific therapy.
This paper focuses on paediatric asthma and its treatment. Epidemiology Although much has been written about the epidemiology of asthma in children, published data are heterogeneous because a uniform definition and uniform methods of data gathering are often lacking. Phenotypes in Preschool Wheezing Wheezing disorders in childhood are common and vary widely in clinical presentation and disease course. Table 1 Characteristics of episodic viral wheeze and of multiple trigger wheeze.
Episodic viral wheeze Multiple trigger wheeze Definition Wheezing during discrete time periods, often in association with clinical evidence of a viral cold Wheezing that shows discrete exacerbations but also symptoms between episodes Triggers Viral infections Viral infections, tobacco smoke, allergen exposure, mist exposure, crying, and exercise Possible underlying factors Preexistent impaired lung function, tobacco smoke exposure, prematurity, and atopy Eosinophilic inflammation?
Open in a separate window. Predicting Asthma amongst Wheezing Preschool Children Periods of viral-induced wheezing, cough, and chest tightness occur in many children and currently it remains difficult, if not impossible, to identify which child is at risk of developing asthma later in life. Table 2 Modified asthma predictive index [ 20 ].
Table 3 Differential diagnosis of asthma at school age. The Burden of Childhood Asthma Childhood asthma is common in the Western world and underdiagnosed in minority populations in Europe and the United states. Asthma Control The goal of asthma therapy in children is to achieve asthma control by optimizing lung function, reducing day and night time symptoms, reducing limitations in daytime activities and the need for reliever treatment, and by reducing asthma exacerbations [ 79 ].
Table 4 Assessment of control for children from 6 years of age, according to the GINA guidelines [ 1 ]. Problematic Severe Asthma The majority of children with asthma are easy to manage with occasional bronchodilator use or a low or moderate dose of ICS. Incorrect Diagnosis of Asthma Asthma may be mimicked by other diseases such as dysfunctional breathing hyperventilation or vocal cord dysfunction, VCD , malformations of the airway anatomy such as a tracheal malacia, or vascular anomalies such as a vascular ring.
Asthma plus Another Disease Asthma itself may be mild or moderate, but comorbidities such as those mentioned above may also be present. Therapy Resistant Asthma Once all has been checked, what remains is classified as severe therapy resistant asthma. Nonpharmacological Measures A number of nonpharmacological measures to improve symptoms and disease outcome should be discussed with the parents. Tobacco Smoke Environmental tobacco smoke induces wheezing in the preschool child.
Allergen Exposure There is no evidence that avoidance of allergens improves symptoms in children with viral wheeze. Pharmacological Management The pathogenesis of recurrent wheezing, coughing, chest tightness, and breathlessness at preschool age is heterogeneous.
Table 5 GINA guidelines for children of 5 years and younger. Leukotriene modifier Low-dose inhaled corticosteroid plus Leukotriene modifier. Leukotriene modifier: leukotriene receptor agonist. Bronchodilators 5. Control Medication 5. Inhaled Corticosteroids The results of therapeutic studies are conflicting. Environmental control If step-up treatment is being considered for poor symptom, first check inhaler technique, check adherence, and confirm that symptoms are due to asthma.
Montelukast Montelukast is a leukotriene receptor agonist that is approved for the treatment of preschool children older than 5 months of age. Guidelines Guidelines for asthma diagnosis and treatment have been in use for at least two decades. Conclusion Asthma is one of the most chronic disorders in children. References 1. GINA report. The asthma epidemic. New England Journal of Medicine.
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Chadwick S.
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