Breathing Easy

More than four million kids in the U.S. have asthma, and its on the rise.
Fortunately, there are ways parents - and young patients - can control it.

By Julia Glass

I broke down in tears at the pediatrician's office for the first time my son had a bad cough. Alec was 18 months old, and one of my biggest fears, I explained, was that he would develop the asthma that killed my grandmother and plagued my younger sister from the time she was a toddler. My memories of those attacks - my sister's gasping for air, my mother's anxiety, the high-speed trip to the emergency room - are the most frightening of my childhood.

Asthma is the most common chronic disease among children; of the estimated 17.3 million people who now have it, slightly more than a quarter are under age 14. While hospitalization rates have dropped for most illnesses, they remain high for asthma - especially among patients under age five. Each year, some 200 asthmatic children die. And of the heels of every new drug developed to fight this disease, which is mainly caused by allergens, comes the discovery of new allergenic culprits, from mold to cockroaches.

Researches are trying to find out why asthma is on the rise. One of the most persuasive theories targets indoor air pollution - specifically the increasing amount of time we spend inside, the growing quantity of chemicals we're exposed to synthetic building materials, and the tighter construction of buildings that has occurred since the energy crunch of the 1970s (minimizing air circulation). But setting aside all the whys, the important fact remains that asthma, while chronic and incurable, is controllable. For so many parents, what seemed like a tragedy has become little more than a nuisance.

"Your doctor should give you nothing but the highest expectations," says Thomas Plaut, M.D., author of Children With Asthma: A Manual for Parents. Low expectations, he adds, are a self-fulfilling prophecy, passed from doctor to parent to child.

If your child is diagnosed with asthma, you'll need to wear a couple of hats: pharmacist,detective, troubleshooter. You'll be the one keeping the drugs straight, observing the ebb and the flow of symptoms, eradicating triggers and pointing your child toward a healthy, active future.

Knowing What You're Up Against

During an asthma attack, the lower airways of the lungs swell, while surrounding muscles tighten: excess mucus is also produced. Together, these changes reduce the capacity of the airways, making it difficult to breathe. As someone having an attack tries to force air out, he'll wheeze or cough.

A decade ago, doctors didn't know what caused these bronchospasms and treat only the symptoms. My sister's scenario was typical: A mad dash to the ER as soon as the wheezing started and a speedy dose of bronchodilators - adrenaline like drugs to open the airways. Doctors knew these episodes could be triggered by an allergic reaction, but only in the 1980s did they learn they were dealing with an inflammatory disease in which the lungs overreact to environmental substances such as dust mites, pollen or cat dander by summoning white blood cells to the area, leading to an attack. When it comes to defending the body from airborne invaders, the asthmatic immune system is over vigilant, like a bully itching for good fight. This is what your pediatrician means if she tells you your child has "twitchy airways."

This insight led to the use of anti-inflammatory drugs - mainly corticosteriods - as a first line of defense against asthma. These drugs actually help prevent attacks over the long term instead of just reversing them as they occur. The steroids used to treat asthma are not the bodybuilding variety taken by Terminator wannabes but are akin to those made by the adrenalin glands. Inhaled steroids work locally, within the lungs, and have very little effect on the rest of the body. Some studies have shown that, if taken continuously over several years, they may slightly inhibit linear growth in some children - but then, severe asthma stunts growth too.

How might you suspect that your infant or toddler has asthma? The most common early tip-off, says Dr. Plaut, is persistent coughing. Any cough - especially one that's short and nonproductive - lasting more than two weeks should alert a doctor to the possibility of asthma. Risk factors that influence the diagnosis of asthma include: family history (asthma or allergies in a parent or sibling increases a child's risk); any allergy-related condition diagnosed in early childhood (for example, eczema); parental smoking (not just because secondhand smoke triggers asthma but because a child's likelihood of becoming asthmatic increases 20 percent if Mom smokes during pregnancy).

To confirm a suspicion of asthma, the pediatrician should take a thorough history, perform an exam, and then, if this information rules out other illnesses (like pneumonia), proceed with a "therapeutic trial" of asthma medication: That is, the child will be treated as if she is asthmatic; if she gets better, the diagnosis is basically a forgone conclusion. Therapeutic trials are especially useful when a child coughs at night but seems normal by day at the doctor's.

Once asthma is diagnosed, make sure your doctor is up-front with you about your child's health and willing to enter into a partnership with you regarding care and treatment. Be aware that "wheezy bronchitis," "reactive-airways disease" and "wheezing-associated respiratory illness" are euphemisms for asthma. "Some doctors see 'asthmatic' as a stigmatizing label, like 'four-eyes,' and think they're protecting parents by not using it. That often reflects an ignorance of proper treatment '" says Lynn Devine, director of school health programs for the American Lung Association of San Diego and Imperial Counties. If your doctor seems to be hedging about your child's condition, get a second opinion. Look for a medically ally who (at the very least):

• evaluates lung function of patients age five and older with a peak-flow meter or a spirometry, devices a child blows into to measure how much his airways have constricted, and advises you on home use of a peak flow meter as well;
• gives written instructions on dosage, timing and technique for administering all medicines, as well as an asthma diary - a chart on which to record how your child responds to medication and when symptoms flare up;
• provides hands-on training - perhaps through an office staff member - to help you and your child learn to use devices needed to administer medicine;
• focuses on prevention as well as treatment; and
• expects you and your child to achieve excellent control of the asthma.

Disarming Major Triggers

Cigarette Smoke Establish a strictly smoke-free home and car. If anyone smokes anywhere in the house, it will reach other rooms.

Viral Infections They're a significant trigger in children under six, so be sure your child gets a flu shot every year.

Dust Mites These tiny bugs thrive not just in dust but in fabric, upholstery and carpets. Besides dusting often with a damp cloth:

• To kill in bed linens, wash in water that's hotter than 130 degrees. If you set your Water heater at 120 degrees to prevent scald injuries, turn it up when you do a load and remember to turn it back down when you're finished.
• For your child's room, choose rugs and curtains that are washable as directed above. Replace hard-to-clean venetian blinds with shades.
• Encase your child's mattress, box spring and pillows in dust mite-impermeable Covers; vinyl or plastic are more effective than tightly woven fabric. Choose polyester fiberfill pillows; foam rubber is just as allergenic as feathers.
• Avoid having your child sleep on upholstered furniture (even for a nap).
• Try a vacuum cleaner with HEPA (high efficiency particulate arresting) filtration, which traps not only tiny dust mites but pet dander, pollen, and mold spores; or see if your current machine can be fitted with HEPA-type filters, HEPA air cleaners may also help; these are available at allergy-supply stores.
• Change furnace, ventilation and air-conditioning filters at least every six months.
• Buy your child only machine-washable stuffed toys, and keep them out of his bed.

Cockroaches Place roach traps in kitchen and bathrooms (out of kids' reach). As much as possible, keep food out of bedrooms, living room, etc., to avoid attracting insects as well.

Mold An underestimated asthma trigger, mold flourishes in moist areas, particularly basements and ventilation systems. To control:

• Fix leaky pipes and clean up water damage promptly. Water standing longer than 24 hours breeds mold spores, which can become airborne.
• Use an air conditioner or dehumidifier to keep humidity below 40 percent.

Pet Dander For asthma, cats are a leading culprit, and the animal should move out if it proves a trigger. At the least, ban pets from your child's room, and bathe them every two weeks in distilled water or a shampoo formulated to reduce dander.

Ozone A full 25 percent of American children reside where ozone levels exceed federal safety standards. Listen for ozone and smog alerts in hot weather and restrict outdoor play, especially strenuous activity and sports, accordingly.