Five Questions to Ask About Pediatric Asthma

Asthma is a chronic disease that impacts a person's airways. According to 2021 statistics from the Centers for Disease Control and Prevention (CDC), 6.5 percent of children in the United States have asthma. In Arkansas, 20 percent of children have asthma.  

Many children are taken to an emergency room when they first experience an asthma attack, which causes coughing, shortness of breath and other symptoms. As the only children's hospital in the state and a regional leader in asthma care, Arkansas Children's Hospital (ACH) in Little Rock and Arkansas Children's Northwest in Springdale provide expert care in recognizing and treating pediatric asthma.  

“Kids are not just small adults. Along with asthma, there can be a mix of children with other issues with similar symptoms, like bronchiolitis and viral-induced episodes, all those types of illnesses that kids can present with. So having pediatric care leads to faster and more accurate diagnoses,” said Robbie Pesek, M.D., medical director for asthma at ACH and an associate professor of allergy, immunology and pediatrics at the University of Arkansas for Medical Sciences. “In my experience, a pediatrician can quickly recognize a child coming into the emergency room or hospital for asthma and say, ‘Hey, we probably need to get this patient back into clinic with their provider because we’re worried they have asthma and we need to figure out ways to prevent this from happening again.’ And yes, others can do it. But our recognition of it and ability to coordinate that care sets us apart and allows us to intervene earlier and better for these kids.”  

Children who visit ACH or ACNW have access to allergy and pulmonary specialists and more specialty services if they have other conditions that impact their asthma.  

For the past seven years, ACH's Asthma Program has focused on improving the quality of care for pediatric asthma patients in the hospital, at home and in the community. It's led by Dr. Pesek, Coordinator Kim Cobb, a registered respiratory therapist, and other respiratory therapists and pulmonologists. The program ensures children receive follow-up care from a provider following an ER visit or hospital admission at ACH, coordinating care with pediatricians across the state within the Arkansas Children's Care Network.  

"We've provided education to providers on campus, specialists, respiratory therapists across the state, school nurses, parents and families on how to better recognize and manage asthma," Dr. Pesek said. "Research is an important part of our program and our most recent efforts are trying to develop a 'trigger reduction program' where we can either go into people's homes or use telemedicine to help educate patients about asthma, but also identify things in their home environment that could be triggers for their asthma that we can help them remove, and hopefully make their kids healthier."  

Arkansas is one of 23 states with a stock albuterol law, allowing schools to carry emergency supplies of inhalers with the medicine albuterol to relieve asthma attacks. The ACH Asthma Program has partnered with the Little Rock School District and others to help create generic action plans for schools to recognize an asthma attack and administer albuterol.  

Dr. Pesek said it’s important for parents and caregivers to work with their asthma specialist before the school year to create an asthma action plan for their child to give to the school so they can quickly intervene if an asthma attack happens.  

Dr. Pesek discussed the following five questions parents should ask about asthma:  

1. What is asthma and its typical symptoms?  

Asthma is a chronic, inflammatory disease of the lungs. It impacts the airways, or breathing tubes, in the lungs. A child with asthma has sensitive airways which overreact to things they breathe in. These triggers cause the airways to become swollen and narrow, making it hard to breathe.   

Its two main features are:  

• Inflammation (swelling) in the airways  
• Muscle tightness around the airways  
  
  

The following are common asthma symptoms:  

• Cough; can include waking up at night coughing, with exercise or movement or changes in mood, like extreme crying or excitement  
• Wheezing  
• Shortness of breath  
  
  

"We may see more exercise-induced symptoms in older kids as they compete more in sports and outdoors," Dr. Pesek said. "For younger kids, it can just be coughing. Coughing at night is a key symptom. When kids get upset, that can trigger coughing as well."  

Even when a child is not having asthma symptoms, swelling in the airways is still there. It means a child could have an asthma attack at any time.  

While asthma is a chronic disease, many children treated properly during their childhood can be weaned off their medications over time.  

2. How is it treated and managed?  

There are three primary ways to treat asthma:  

1. Rescue medication: An inhaler, typically with albuterol, is used to relax airway muscles and provide fast relief for asthma attacks.  
2. Controller medications: An inhaler with corticosteroids, an anti-inflammatory medication, which reduces airway swelling. It can prevent symptoms and asthma attacks.  
3. Combination medication: These medications are used as a controller and rescue medication.  
   
   

Some inhalers have combination medications to combat severe asthma. Biologics, or monoclonal antibodies, is a newer therapy for severe cases and is available at ACH.  

Managing asthma varies depending on the number of symptoms a child has daily. Dr. Pesek said they typically follow the "rule of twos": If a child has symptoms more than two days a week, uses rescue medication more than twice a week or wakes up at night more than twice a month from asthma-related symptoms, their treatment needs to be adjusted.  

Acute asthma attacks that require systemic steroids, like prednisone, or lead to a trip to the ER or a medical provider should not occur more than once per year. If these occur more frequently, a family should reach out to their provider to discuss adjusting their treatment plan. 

3. What does an asthma attack look like?  

There are variations of asthma attacks from mild to severe.  

Children can have a worsening cough that causes them to be unable to catch their breath, coughing to the point of vomiting or developing signs of respiratory distress and are unable to breathe.  

“Younger kids will sometimes use what are called accessory muscles, so they’re breathing so hard you can see their ribcage and belly going in and out,” Dr. Pesek said.  

While uncommon, thanks to advances in treatment of acute asthma attacks, children can still die from delayed recognition and assistance during an asthma attack.  

4. How is it diagnosed?  

Besides documenting a history of potential asthma symptoms, experts will examine the rest of a child's medical history. For example, if they have a history of eczema, food allergies or relatives with asthma, they are more likely to be diagnosed with asthma.  

For children five or older, a medical expert can perform a breathing test called a pulmonary function test that measures how air flows through an airway. The child breathes in deep and breathes out forcefully over a period of time, allowing doctors to measure the pattern of air movement. The test will reveal if there's an obstruction or if the airway is inflamed, indicating asthma.  

Breathing tests are typically administered every six months to reassess symptoms.  

Doctors do not typically diagnose a child with asthma before the age of 2, because symptoms can sometimes mirror other issues in younger children, like a viral trigger of wheezing. However, if parents suspect their child could have asthma, they should make an appointment.  

"It's technically true that you can't do the breathing tests to diagnose asthma until you're around 5 to 7 years of age. But if you're aware of the condition and know symptoms to look for, we'll see kids much younger than that with asthma," Dr. Pesek said.  

5. What are some common asthma triggers?

Several ordinary household items and natural triggers can cause asthma attacks. Reducing or removing allergens, irritants or non-allergic triggers can help, or using an inhaler will help reduce symptoms. Some common triggers include:  

• Outdoor allergies, like pollen  
• Animal dander (flakes of skin)  
• Cockroach droppings  
• Dust mites  
• Foods 
• Mold  
• Tobacco smoke, vaping, e-cigarettes  
• Pollution from a car exhaust, construction dust, smog  
• Strong smells, like cleaning products, perfumes, candles, air fresheners 
• Wood burning smoke from grills, fireplaces, outdoor fires  
  
  

There are also several non-allergic triggers, including colds and infections, exercise, weather changes and strong emotions, like crying or laughing.  

It's important for children to be healthy to help reduce symptoms of some of these triggers. That includes being at a healthy weight for their age, having a balanced diet, getting good sleep and exercising.  

*This article was written by the Arkansas Children’s content team and medically reviewed by Robbie Pesek, M.D.