Asthma: What Parents of Young Children Want and Need to Know - Q and A with Dr. Clark Kaufman

Nearly five million children in the United States have asthma. How do new parents deal with an asthmatic baby, or preschooler? What can they do when their child goes off to school without them? What do parents want to know…and what do they need to know?

Dr. Clark Kaufman of Allergy & Asthma Center is an allergist who has seen many hundreds of asthmatic children in his years of practice. He is also an avid reader and traveler, as well as one who favors plant- based foods such as soy products and whole grain rice as part of his daily diet. In addition, before training in allergy, he worked as a pediatrician in a large group practice for several years.

Q - Dr. Kaufman, before we begin to talk specifically about children and asthma, let's get rid of some common myths. I will give you the myths, you give me the facts.

Myth: Asthma is all in the mind.

Dr. Kaufman -This was a long held belief because when people had trouble breathing there was very little that could be seen objectively and these attacks were attributed to psychological problems. We now know there are internal reactions that occur in the lungs when somebody has asthma and although the mind can aggravate asthma it is very seldom an actual cause for the asthma itself.

Q - Myth: Asthma is not a serious condition.

Dr. Kaufman - Asthma has always been a serious condition and in the last 10 to 15 years even more so. It is the #1 cause of missed school days other than acute colds. It is also a significant cause for missed time in the work place.

Q - Myth: No one dies from asthma anymore.

Dr. Kaufman - Up until five years ago there was an increasing rate of deaths from asthma that seems to have reached a plateau. We think part of that is attributable to a more comprehensive asthma treatment campaign and more use of controller medications which help control the underlying symptoms that result from causes of asthma.

Q - Myth: People with asthma shouldn't exercise.

Dr. Kaufman - The exercise activity you get by stretching the lungs and the bronchial tubes is actually something that can help asthma in the long run. People who exercise regularly, or who even need medication to help them exercise, generally need fewer) controller medications over time to manage their asthma. We like to do whatever we can do to get a patient to the point where they can exercise as often as they would like, preferably at least three times per week.

Q - Myth: Children will grow out of asthma.

Dr. Kaufman - What I correlate with that is that children outgrow their pediatricians but may not outgrow their asthma. The majority of children will have milder asthma at the end of adolescence than they had earlier in childhood but very few, perhaps only 15% of school age children and adolescents with asthma will outgrow it by the time they finish high school. There is a higher propensity of growing out of asthma in children by school age who develop asthma solely with respiratory infections as toddlers and preschoolers.

Q - You see hundreds of children every year with asthma and today we are talking about children with asthma from birth through elementary school. How do you define asthma?

Dr. Kaufman - Asthma is a sensitivity or a touchiness in the airways, in the bronchial tree in the lungs. That sensitivity or irritability in the airway makes that person more prone to cough, get tight or wheeze.

Q - Why does it sometimes go undiagnosed?

Dr. Kaufman - It is not unusual for asthma to only cause a cough. This has been referred to as cough-variant asthma. Although a case can be made that more asthma involves a cough than a wheeze, generally coughs and wheezes have been treated as a tip of the iceberg. They are treated because that is what is seen and they are often treated with cough suppressants or antibiotics for bronchitis rather than searching for an underlying cause. If that cough or wheeze is a repetitive problem, it's a strong case for asthma.

Q - Considering that often a cough is the only symptom, what kind of cough indicates the possibility of asthma?

Dr. Kaufman - I would be suspicious if somebody had a barky, croupy cough, particularly on a repeated basis, rather than a deep, loose cough, which is less likely to be asthma.

Q - Can mucus also indicate the possibility of asthma?

Dr. Kaufman -Yes, although airway sensitivity is of primary importance in asthma, there are three other components that create the obstruction in the airways that cause the asthma with its coughing and wheezing. There can be swelling in the airway, mucus in the airway, or smooth muscle tightness around the airway. Some people make more mucus than others with their asthma and when mucus fills the airway tubing there is more chance there will be some wheezing as the air passes through the mucus. Some people with their asthma have more muscle tightness without mucus and those people would be more prone to cough.

Q - When should a parent of an asthmatic child take that child to see a specialist, like an allergist?

Dr. Kaufman - It is our opinion that children should see an asthma specialist for their asthma if a diagnosis of asthma is made and first line medication is not effective in completely controlling symptoms and exacerbations.

Q - What do you mean by first line medication?

Dr. Kaufman - The treatment for asthma is to use measures that will reduce the sensitivity of the airways. The most important way to do that is to reduce exposure to allergens that create that sensitivity in the first place. There are a group of medications that are considered anti-inflammatory controller medications, which work to make the airways less sensitive, less swollen and less clogged with mucus. When someone requires that type of medication on a daily basis it is important to know exactly what the underlying causes for asthma are. My personal feeling is everybody who has a diagnosis of asthma made should see an asthma specialist to determine what the causes of the asthma are. Then intervention might be done immediately rather than waiting for that asthma to worsen and require more medication before that referral is made. More can be done with asthma when it is a mild problem than when it becomes severe requiring more than one medication to help control it.

Q - When you are talking about taking medications every day are you including inhalers?

Dr. Kaufman -Yes, I am particularly talking about school age children and adolescents who need either a daily inhaler to control their asthma and/or people who need a daily oral form of anti-inflammatory medications such as Singulair. Daily medication is required to control asthma and an allergy evaluation should be considered to evaluate their air flow and their lung function. It's also important to evaluate allergy since allergy is the cause of asthma in 90% of children over the age of five. In children under five, where allergy is not as common, if their asthma is associated only with respiratory infections without symptoms in between those infections, those children have a better chance of outgrowing their asthma and need not be referred. But I think if a child needs daily medication for more than six months it would be an indication to see an allergist for an environmental evaluation of those allergic and non- allergic factors that may be contributing to that chronic asthma and daily need for medication.

Q - Can you diagnose asthma as early as infancy or preschool?

Dr. Kaufman - The most practical way to diagnose asthma is to look at the response to asthma medication. If young children have a good response to a nebulized bronchodilator, a medication that can relax the muscle around the bronchial tubes on repeated occasions, then they should be considered as having asthma. If there is some coughing or wheezing that does respond to asthma medication that only happens with one infection and doesn't recur, we generally call that reactive airway disease to that particular infection. But when that becomes repeated that should be diagnosed as asthma. So, asthma can occur and can be diagnosed even in the first year of life.

Q - Can it occur even in the first few months of life?

Dr. Kaufman - Yes, asthma can occur even in the first few months of life, particularly if there are respiratory infections from cigarette smoke exposure, in certain cases where there is food allergy, and when a baby has difficulty with acid reflux. I also want to stress the influence of infection on asthma in toddlers and preschoolers. If asthma comes on only during the infection and seems to resolve completely between the infections, then that is the type of asthma that children might outgrow by the time they start school. Also dust mite allergy is the #1 cause for asthma so it's important to know whether your child has this allergy. If so, parents should use dust mite control measures for that child within the bedroom to reduce his exposure to dust mites. That would make the child less prone to becoming allergic to it and therefore lessen the chance of having day to day asthma once the child starts school.

Q - What measures should be taken within the bedroom?

Dr. Kaufman - It means maintaining the type of environment children have when they are babies and toddlers. That is keeping the mattress, pillow and box spring encased with plastic covers, washing the blankets on the beds every two weeks in hot water, vacuuming the carpet every week or keeping the floor bare, and limiting the number of stuffed animals in the room to no more than a couple that can be washed in hot water every two weeks. Those are the measures I have seen make the biggest difference in reducing the risk of developing allergy to dust mites. I tell parents that, if they do everything else to control dust mites and not do the bed, it is not going to be enough to help… but if they only do the bed that might be enough to get them on the right road.

Q - And, if there are pets, keep the pets out of the bedroom?

Dr. Kaufman - Yes. The other thing I found is if someone has asthma and animal allergy and needs daily asthma medication there is almost no chance that child will be able to stop that daily medication to control that asthma as long as the pets are in the house. Mammals and birds are problems. The price to have pets in the home is often daily use of controller asthma medications and that is obviously a decision a family must make.

Q - In other words, pick a pet with scales like a fish, or a reptile or amphibian?

Dr. Kaufman - Those are good options, yes.

Q - What questions do parents of a newly diagnosed asthmatic child have? What do they want to know?

Dr. Kaufman - Parents want to know two things…Is it asthma and can my child outgrow it.

Q - What else do they need to know?

Dr. Kaufman - They need to know there are underlying causes for asthma. Asthma doesn't happen in a vacuum. Until they are in the first two to three years of life when infection is the primary cause for asthma, we may not be able to find any other underlying factors that are responsible. But, as children get closer to school age and certainly through childhood and adolescence, 90% of the time there is some allergy responsible and control of exposure to that allergy is likely to result in fewer asthma symptoms and less asthma medications. It may even result in the stopping of all medication if that allergen can be completely removed from the environment particularly if it is a pet.

Q - What are some risk factors?

Dr. Kaufman - Most significant is genetic family history. If one parent has allergy and/or asthma, the child has at least a 35 to 50% chance of developing allergy and asthma themselves and if both parents have allergy or asthma the risk goes up to 80%. The more allergic diseases a parent has such as allergic rhinitis or hay fever, eczema, or atopic dermatitis and asthma, or a food allergy, the more risk that child is in developing allergic diseases themselves, and at an earlier age.

Q - How about triggers? You mentioned smoking in the home. What else?

Dr. Kaufman - Well, children exposed to cigarette smoke are more prone to wheeze as well. Molds may be an issue in a house if there is obvious dampness, mildew growth in the house, not necessarily in the basement but in the house itself. If the house is damp or in the woods, that may be a factor for mold spore exposure. Animal dander in the house is a common cause for asthma, particularly asthma that can start even as young as a year of age. There has been some recent press on children who grow up in homes with two or more pets that says they may have less of a chance of developing allergy and asthma and that appears to be true. The problem is, if the child does have asthma and the pets are in the home, then it is likely to be due to the pets until proven otherwise by testing. Other outdoor environmental triggers for asthma would be extreme heat/cold outside, or elevated levels of ozone we see on the ozone action days when air is polluted and stagnant.

Q - What else do parents need to know about triggers?

Dr. Kaufman - There is a lot written about triggers and I think it is important to divide triggers into two categories. There are those triggers that actually cause asthma and those triggers that aggravate the asthma that is already there. There would no longer be triggers if you can deal with the ones that cause asthma. So, what some allergists have proposed is that if you take the triggers that cause asthma in the first place, such as infections and allergy and control those well enough then the other triggers that aggravate asthma, like cold air and exercise and cigarette smoke, may not be as much of a bother.

Q - Are you saying often untreated allergies can develop into asthma?

Dr. Kaufman - Yes.

Q - So…don't wait.

Dr. Kaufman - That's right. About 20% of children with allergy will develop day to day, chronic asthma. We also know that treating nasal allergy early enough particularly with allergy injections can significantly decrease the risks of that child developing asthma in the future.

Q - At what age can a child begin to get allergy injections?

Dr. Kaufman - Generally, allergy injections can start at 4 to 5 years of age. There are rare cases before four but it takes until preschool age to develop an allergy to outdoor allergens which respond most to allergy injections.

Q - Are there warning signs we haven't covered?

Dr. Kaufman - Any coughing, especially when children are out-of-breath during exercise. The most common symptom children complain about when they have asthma is being out-of-breath with exercise. Adults tend to cough. It is important to question allergic children to see when or whether they may be out of breath with exercise… or ask their teacher whether that is an issue in gym class. That is one of the early signs that there may be some asthma along with the allergies.

Q - They also need to know about getting and using the proper medications in the proper way, right?

Dr. Kaufman - Yes, that is really critical. In the last 20 years there has been an explosion in the numbers of treatments for asthma. All asthma medications, indeed all allergy medications, work better if they are used on a daily preventive basis to control asthma. If children have asthma with nasal allergies in the spring and late summer, they may only require their asthma medication during that time. If a child's asthma is year-round then year-round medication would be required.

Q - When you see an asthmatic child, you tell the parents what medications need to be used. How do you impress on them the child MUST do this?

Dr. Kaufman - Well, one of the ways is to write down what I am saying. I think a physician needs to take time to either repeat or write down instructions or show them other written material or direct them to some web site that is helpful.

Q - Like ours?

Dr. Kaufman - Yes, like ours at www.allergydoctors.com. But I also think that when the physician takes time to write down and review some of the environmental measures that need to be taken within the home and the use of medications it impresses on the parents the importance that the physician places on the overall treatment of asthma.

Q - You have also stressed the importance of being calm as much as you can around the child.

Dr. Kaufman - You try to get the parent and then eventually the child to feel they are completely in control of the asthma and the asthma is not controlling them. The best way to do that is to impress upon the child and the parents that asthma can be controlled very well with the current treatments we use. There is hope in reducing medication if environmental issues are maintained and to reinforce their improvement they have with their asthma with frequent follow-up visits to help maintain their good control. They have to be reinforced for the good work they are doing in maintaining environmental measures and in using the medications as directed.

Q - Do you encourage normal activities?

Dr. Kaufman - Yes, it's important to do this and then to reinforce or to praise them for maintaining that activity.

Q - When children start school, are there additional concerns?

Dr. Kaufman - It is very important for a parent to speak with a teacher about that child's asthma. Since about 10% of school age children have asthma, there are going to be at least three or four children in each class with asthma. It is important to tell the teacher a little bit about that child's asthma and what is necessary when that child has a problem. If the child is coughing or having any difficulty breathing, then that child should be sent to the nurse who should have specific information available about the child provided by the parents, and can them make an evaluation.

Q - Does anyone else at school need to know?

Dr. Kaufman - I think it would be helpful to mention it to the gym teacher as well. Children with asthma needs to exercise at their own pace and shouldn't be pushed to do anything that would be more than the those children can handle. I think gym teachers need some guidance also because they will generally treat asthmatic children like everybody else in terms of pushing, pushing to do more activities than the children may be capable of doing. Ideally with enough treatment the asthmatic children will be capable of doing any type of activity the other children are doing.

Q - What else should teachers and nurses know?

Dr. Kaufman - They should know the triggers, the things that make a child's asthma worse. It may be playing outside right after the grass is being cut, or being out on a rainy day or a very cold day. It may be certain foods the child eats which may aggravate that child's asthma.

Q - And, whether or not medications are needed, for example, before exercise?

Dr. Kaufman - Yes, as far as what medications should be or may be used during the school day either to treat an exacerbation of the asthma or to use prior to exposure to things, particularly exercise that may trigger their asthma.

Q - What is the child's role in his or her asthma management to foster the sense of control and responsibility?

Dr. Kaufman - The main thing to get across to children is that they are going to be able to do what their friends are doing and not be limited because of their asthma. Although we would love to wish asthma away, it is a fact, and the way to deal with it is to take medication to treat it. So they have to be encouraged to take their medication regularly and to know when they need help. That's when they need to ask the teacher or responsible adult to get their medication when they are in trouble.

Q - Since the child who develops asthma may very likely have it for life, is the primary goal of the allergist to see that it is under control?

Dr. Kaufman - I see the primary goal of the allergist to see what is causing the asthma and to deal with those underlying causes in terms of controlling allergies and then controlling infections. The allergist needs to give children some understanding of their asthma and what they can do to make them feel as well as they can. Although the potential for asthma may be there throughout life, with environmental control measures and certain situations with allergy shots there is some chance asthma symptoms can resolve and their need for medications end as well. Especially with children, I like to be more hopeful that asthma may not necessarily become something they have to live with throughout their lives. We generally find by using environmental controls, and sometimes allergy injections, that we can get our patients to the point where they don't need medication anymore and they don't have any asthma symptoms. Not that it can't come back… it can. I think anybody, whether it is a child or adult, who has daily need for medication should plug into an allergist right away because the milder the asthma is when we start to deal with the environment and triggers and causes the more effective the response to those measures would be.

Q - Is it sometimes hard to get this control, particularly since the young child has to take controller medications exactly as the allergist says?

Dr. Kaufman - Ideally, there should be a good working relationship between the allergist, the child, and the parent to use as much medication as is necessary to control symptoms but to also be willing to make adjustments in that treatment as symptoms improve. After all, the only way to know whether continued asthma medication is needed in somebody who is well controlled is to reduce the amount of frequency of the medication.

Q - Would you agree that what is equally as important as using proper medication to keep the child's asthma under good control is the knowledge that by doing so, he or she usually can do what the other kids who don't have asthma can do… and that is to live a normal, happy life?

Dr. Kaufman - Yes, I often impress upon children with asthma, particularly children who are particularly athletic and involved in sports that there generally should not be enough about the sport that should keep them from participating if they follow directions. I remind them that at least 20% of the athletes on our Olympic teams have asthma and use medications for their asthma. A lot of them are excellent spokespeople for asthma. But asthmatic children don't have to be athletes to prove something. With the proper medications, they can live normal, happy lives doing whatever it is that gives them a sense of satisfaction, or achievement, or hope. As an allergist, I get tremendous satisfaction helping them to do this.

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