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Allergy prevention. Some forms of asthma, as described above, may be caused by allergies to substances in the environment such as: dust, mold, cigarette smoke, pets, dairy products, food, seasonal pollens and plants, or aerosol sprays.
The types of asthma that may benefit from allergy prevention include:
If you feel that there is an allergic component to your child's asthma, click on Allergies or Food Allergies for a detailed discussion on how to minimize your child's exposure to these substances. This prevention is vital to long- term management of your child's asthma.
Asthma medicines. There are a variety of inhaled and oral medications used today in the treatment of asthma. They are available only by prescription. These can be confusing at times, especially when your child is using more than one type of inhaler. Here is a guide to the different medications used for asthma.
Remember at the beginning of this discussion you learned about the two different processes in the airways of the lungs that cause wheezing – bronchoconstriction and inflammation. Medications for asthma treat either one or the other of these processes. There is no medication that can treat both.
The way medications for asthma are used falls into two categories: Rescue medications – mostly bronchodilators, and maintenance and preventative medications – mostly anti-inflammatories.
The term rescue refers to the fact that these medicines are designed to treat wheezing or chest tightness during an attack. These medicines are used on an "as needed" basis to "rescue" your child from active symptoms. Here is a brief discussion of the various types of rescue medications:
Xopenex. This is an exciting new form of albuterol, available in nebulizer form, and hopefully soon as an inhaler. It is much more potent than regular albuterol, which means that much lower doses can be used to achieve bronchodilation, with less side effects. It also does not become less effective with prolonged use (years) as is sometimes the case with plain albuterol. As of 2000, it is only approved down to age 12, but safety studies are being conducted as young as age two.
MAINTENANCE OR PREVENTATIVE MEDICATIONS
These medicines are used to prevent wheezing or chest tightness from even starting. They "maintain" a symptom-free state. They are taken on a daily basis whether the child is sick or well in order to prevent an asthma attack from starting. These medications mainly treat inflammation, not bronchoconstriction. Therefore they don't work to immediately open up a child's airways during an attack (only rescue bronchodilators do this).
There are three main goals of maintenance therapy:
1. Keep the child in a symptom-free state on a daily basis. Proper maintenance therapy can help a child go through life without suffering from daily wheezing, chest pain, chest tightness, and shortness of breath.
2. Decrease the frequency and severity of attacks. Adequate maintenance therapy should prevent attacks from even occurring in the first place. When they do occur, they should be milder.
3. Decrease reliance on albuterol. If albuterol is used continuously for many months or years, your child may become resistant to it. It is important not to let this happen since albuterol is one of the only bronchdilators available to us. Important note – don't be afraid to use albuterol. It takes several months to years of daily use to become resistant to it, and resistance is rare anyway. Most people use it frequently for years and have no problems with resistance. It is preferable to be on one of the maintenance medications daily than to use albuterol daily.
Here are two different types of medications used for prevention:
Note: anti-inflammatory inhalers do not work right away. It usually takes one or two weeks for their effects to build up enough to prevent asthma symptoms. Parents should take this into account when deciding whether or not this type of medication is working.
SIDE EFFECTS OF ASTHMA MEDICATIONS
Albuterol has side effects including:
All of these effects are uncommon, and most children tolerate the medication very well. The effects are only temporary. If your child experiences any of these effects, but they seem tolerable, then it is safe to continue the medication. These effects are well known and usually don't mean you need to stop the medicine.
Oral bronchodilators cause side effects both more often and more pronounced, therefore inhalers are preferred when feasible.
Theophylline side effects include the above, plus heart arrhythmias, nausea, vomiting, and very rarely convulsions.
STERIOD ORAL LIQUID OR TABLETS
There are two different situations when these are used:
1. Short course steroid "burst". A short five-day course is often used to help a child get over a severe asthma attack. The side effects from this short- term use are minimal. You virtually never see any of the severe side effects that occur with months or years of use. These mild effects include:
2. Long-term use. When steroid pill (not inhaled steriods) are used for months to years to control severe asthma, many severe side effects can slowly begin to occur, such as:
We would like to emphasize again that these serious side effects are almost unheard of with the commonly used and very effective five-day short course of steroids, and they are not a concern with inhaled steroids.
Side effects include:
Side effects are minimal but may include:
Side effects include:
There are a variety of different ways to give a child inhaled asthma medications, depending on the child's age. Here are the different ways to give inhaled meds:
Dr. Sears advice: Before using an inhaler ask your physician or pharmacist to demonstrate the proper use. Also, carefully read the package insert. One of the main reasons inhalers are ineffective is because they are used improperly.
Inhalers work well for older children who can coordinate the spray and inhalation. Inhaler technology is now going through some changes. For many years inhalers have used Freon as a propellant, and most inhalers were the same. Because Freon destroys the ozone layer, it has now been banned from use. New dry powder inhalers are available which don't use Freon. Studies have shown these new inhalers work better than the Freon ones.
HOW TO USE AN INHALER
Follow these five steps:
For standard Freon inhalers:
New dry powder inhalers. Instructions for these can vary. Basically, you place your lips over the mouthpiece and inhale deeply and slowly. The powder is picked up by your inhale and carried down into the lungs.
Inhaler with aerochamber or spacer device with mouthpiece. this is a small, palm-sized tube that attaches to the inhaler. It has an empty air space inside. This is ideal for younger children who can't coordinate spraying or aiming the inhaler while breathing in. Follow these steps:
Inhaler with aerochamber or spacer device with mask. This is designed for younger infants but instead of the mouthpiece, a mask is used that fits snuggly over baby's mouth and nose. The instructions are the same except that after spraying the inhaler, you hold the mask snuggly to baby's face while he breathes for 10 seconds. He may cry, but will still inhale the medication.
Nebulizer machine. This is a lunchbox-sized portable air compressor. You may be familiar with this machine from your pediatrician's office. You squirt in the prescribed amount of liquid medication, often with some saline to dilute it, into a reservoir. The machine turns the liquid into a mist that comes out the end of a tube. You can direct the spray at your baby's face (best for protesting babies), hold a facemask over baby's face, or have a child inhale through a mouthpiece. The treatment takes several minutes. You can rent or buy this machine and it is generally covered by health insurance. Nebulizers are the best way to deliver the most medication to infants and young children.
WHICH METHOD IS BEST FOR YOUR CHILD
Infants and young children. The nebulizer is the most reliable way to deliver the medication to this uncooperative age group. However, if it seems your child may only need the medication for a short time, you can probably get by with an inhaler. You should definitely use a spacer device with a mask for infants and a mouthpiece for children.
Older children. You can decide when your child no longer needs a spacer device for his inhaler. In general, a spacer is needed for children younger than ten years old. Nebulizers are usually only needed in this age group for children with moderate to severe asthma who require frequent treatments. The nebulizer can help keep you out of the emergency room.
GUIDELINES FOR CHOOSING MEDICATIONS FOR SPECIFIC ASTHMA SCENARIOS
The world of asthma medications can be a very confusing one. Choosing the right combination of medications is important. It is important to avoid treating too aggressively, but you also want to keep your child symptom free. Here are some standard guidelines to help you understand what medications may be right for your child's case.
Reactive airway disease. If you feel your child falls into this category, she should only need treatment during colds. The best medication for this condition is inhaled albuterol or the new Xopenex. Inhalers are generally the most appropriate. However, if your child has frequent colds that require albuterol treatments, and you find the inhaler difficult to use, then a nebulizer is a must. Some infants also do well with the oral liquid. This is a good choice if the side effects are tolerable in your infant. Here's how to treat these attacks:
Exercise induced bronchospasm. The main treatment for this condition is also an albuterol inhaler.
Nighttime cough. If your child is generally healthy during the day, but has had a tight cough or wheezing at night that sometimes wakes her up for as long as you can remember, there is probably something in the bedroom she is allergic to. We suggest before you use medication, do everything you can in the bedroom to prevent the allergy. If you need to resort to medication, albuterol or Xopenex may be the best choice. Try either the long-acting or just plain albuterol. If it seems your child needs this almost every night, then nightly cromolyn or an inhaled steroid may be a better choice. Discuss this with your pediatrician.
Infant asthma. If your infant develops persistent asthma (not just reactive airway disease due to colds), there is probably a strong allergic component to it. The first step to take is to have the breastfeeding mom eliminate foods in her diet that the child may be allergic to. Click on elimination diet for this. If formula feeding, switch to another type. If using a cow's milk formula, switch to soy. If using soy, switch to a cow based formula. It may take two weeks for symptoms to improve. If these don't work, try a more specialized hypoallergenic formula such as Nutramigen or Alimentum. If medication is needed, then follow the guidelines below under allergic asthma.
Allergic asthma. This is by far the most complicated type of asthma to treat. After you have done this, here are some guidelines for medication use. These guidelines go in order from least aggressive treatment for mild asthma to most aggressive treatment for severe asthma.
Mild, occasional symptoms. This is a child who is well most of the time, but has mild flare-ups maybe three to six times a year that only last a few days. The wheezing and slight labored breathing don't slow him down too much. These don't seem to be caused by colds. This type of mild asthma may not even warrant extensive allergy prevention, depending on how much it affects the child. You can decide this.
Moderate to severe, but occasional symptoms. This is similar to the mild situation above, but the flare-ups are more severe, causing rapid, labored breathing and retractions. The flare-ups last for several days, but only occur three to six times a year. Your child is very healthy in between episodes, and may go for two or three months at a time without trouble. This degree of asthma does warrant allergy prevention measures at home. Here are some guidelines for medication use:
Mild but persistent symptoms. In this situation your child doesn't really seem to have many moderate to severe attacks. He may have a few flare- ups each year, but they are generally mild and easily controlled. However, your child seems to have mild, underlying shortness of breath, exercise intolerance, mild wheezing, and nighttime cough that seem to be affecting him more often than not. He seems to have these symptoms two weeks out of each month, or sometimes one or two month's straight.
Most of these medications can be used in any combination, even three at a time. The main idea is to get symptoms under control for a while, then wean off the medications as able. When symptoms flare up again, increase the maintenance medications again.
Moderate to severe persistent symptoms. This is the most troublesome degree of asthma. Not only does your child have flare-ups throughout the year, but always seems to have underlying symptoms that significantly limit his daily activities more days than not.
Seasonal asthma. In this type of asthma, your child is generally well all year round; except for a particular season that has the pollens and plants your child is allergic too.