Illustration: Caitlin Doherty Photo: Erik Putz
When Meghan Rosen’s* daughter, Isla*, was an infant, she would start to wheeze whenever she had a cold. At night, her mom could hear the fluid in her lungs and airways. “She sounded almost like a smoker when she coughed. She would cough a lot, and you could see her belly and chest really going up and down as she was struggling to breathe.” As a preschooler, Isla’s breathing problems persisted—many nights when she had a cold, she slept propped up on pillows to make breathing easier. When she woke up coughing, her mom would give her a few puffs of an inhaler, which the doctor had prescribed to keep on hand for when she got sick.
At age five, Isla had a particularly severe episode of coughing and wheezing, which landed her in Toronto’s SickKids Hospital overnight. At that point, she got an official diagnosis for her breathing trouble: asthma.
Asthma is a chronic airway condition estimated to affect 600,000 children under age 12 in Canada, making it the most common chronic condition in Canadian kids. Those with untreated asthma have inflammation in their lungs, which can lead to their airways narrowing or tightening, causing breathing difficulty. This tends to happen when the child is exposed to a trigger, like a cold virus, cigarette smoke, exercise or an allergen (such as pollen, animal fur or perfume). With proper medical management, kids with asthma should be able to run, play and lead regular lives, symptom-free. But according to a 2016 survey by the Lung Association, nine out of 10 Canadians don’t have their asthma under control, and when a kid’s asthma is not well-managed, they might miss school, sit out of activities or even wind up in the emergency room with an asthma attack.
A telltale sign of asthma in kids is frequent coughing, says Padmaja Subbarao, a respirologist, and allergy and asthma researcher at SickKids. If you notice your child coughing while running, coughing when asleep or coughing from a cold that doesn’t seem to be going away, these are signs they could have asthma. Experiencing two or more episodes of wheezing in a year is also an indication of the condition, says Subbarao.
A kid is more likely to develop asthma if it runs in the family or if they have allergies or eczema. Having a mother who smoked during pregnancy, being exposed to second-hand smoke or air pollution, or being obese can also raise the risk.
Kids often show signs of asthma, like wheezing or persistent coughing, from an early age, but because it’s difficult for a doctor to know for sure, they often aren’t given an official diagnosis until age four or five. Some will develop asthma later in childhood or even as adults. To diagnose asthma, doctors sometimes use a lung function test, which requires the child to rapidly breathe into a tube. The test, called spirometry, measures the amount of air a person can breathe in and out of their lungs, and how fast they can breathe out. But this test isn’t typically used for kids under five, because they will have trouble doing it properly.
In younger kids, the diagnosis tends to be based more on symptoms and the way the kid reacts to medications, explains Connie Yang, a paediatric respirologist at BC Children’s Hospital. For example, a child might have severe wheezing and wind up in the hospital. There, the emergency room doctors will treat them with asthma medication, and if the symptoms improve and these episodes occur repeatedly, the doctor will diagnose them with asthma. Other times, a child ends up going to their primary-care doctor with shortness of breath or a cough that doesn’t seem to clear up, and is put on a trial of medication for two to three months. “If symptoms improve, then it’s asthma,” explains Yang.
There are two types of medications commonly used to treat asthma: controller medications, meant to decrease the underlying inflammation; and reliever, or “rescue,” medications, which calm the symptoms of an asthma exacerbation or attack, like coughing, wheezing or shortness of breath. There are a few kinds of controller medications, but the most commonly prescribed is a corticosteroid that’s taken every day using an inhaler (sometimes called a puffer). Less commonly, daily pills are used to control asthma.
Asthma relievers, or rescue medications, are used to open up the airways when asthma symptoms, such as coughing or wheezing, are present. Ideally, your child’s asthma will be well-controlled with an inhaled corticosteroid and these medications will not be used very often. Relievers are always taken by inhaler to get the medication to the lungs quickly.
Parents work closely with their child’s doctor to make sure the medications are working as they should and to check whether the dose or type of medication needs adjusting.
Many parents, and even some physicians, are hesitant to give young children medication every day, so they stop giving the controller medication when the kid seems well. But a lack of symptoms can be deceptive. “If you have asthma, you still have inflammation, even when you’re not sick,” explains Subbarao. So if the child gets a cold virus or plays with a dog they’re allergic to, the inflammation can turn into more acute symptoms, like wheezing, coughing and shortness of breath. If these symptoms don’t get better with the rescue inhaler, the child can end up in the emergency room, where they will be treated with oral steroids. “The types of steroids you get in an inhaler have very few side effects in comparison to the oral steroids you’re going to get when you have a serious flare and present to the emergency room,” says Subbarao.
Your doctor might give you something called an Asthma Action Plan, which outlines what medication your child should be taking on a regular basis and when to give the rescue inhaler or seek medical attention. It can be helpful to work with an asthma or respiratory educator who can help you fine-tune your understanding of the medications and symptoms, says Andrea White Markham, a registered respiratory therapist and certified respiratory educator.
Generally speaking, if your child is starting to breathe rapidly, “it’s time to start giving treatment,” says White Markham, referring to the rescue inhalers. Wheezing is another sign that symptoms are getting bad. “You cough a lot before you wheeze. It’s a sign your airways are really tight,” she says.
If, after a few hours, the symptoms aren’t subsiding, White Markham says it’s time to go see your doctor. Head straight to the emergency room if your kid’s nose is flaring, if the areas around the ribs and in the neck pull in when she’s trying to inhale or if she’s starting to turn blue or grey.
In some cases, signs of an asthma emergency are very subtle—the child might just seem really tired or lethargic. This past spring, for example, Rosen was called to pick up Isla from school because she wasn’t feeling well. When she got there, Isla appeared to be sleeping, but Rosen quickly realized she was having a severe asthma attack. She took Isla to the hospital, where she spent three days recovering. “Figuring out when your child is not well takes practice,” says White Markham. “It may take some trial and error to figure out what symptom you should jump on and which symptom you can watch.”
You may recall the kid who sat out of gym class because of asthma when you were younger, but doctors say that’s an outdated approach to managing the disease. “Our goal is that people with asthma should lead normal lives,” says Yang. And that includes exercise. If physical activity is causing your kid’s asthma to flare up, that’s a sign it’s not well-controlled and you should talk to their doctor about adjusting their medication. “In an ideal world, these kids would be well-treated with appropriate therapy and would not be distinguishable from other kids who don’t have asthma,” says Subbarao.
Aside from daily medication, there are some things you can do to reduce the chances of your child experiencing symptoms or having an asthma attack. Cold and flu viruses are a major trigger, and having your child get the flu shot, encouraging handwashing and teaching everyone in the family to cough into their sleeves can help reduce the child’s chance of catching a virus. Another common trigger is cigarette smoke, so keeping your child away from smoke will decrease their symptoms.
Many kids with asthma have what’s called “allergic asthma,” meaning that the things that trigger allergy symptoms, like pollen, cats, dust and mould, can also bring on asthma symptoms. Allergies are your body’s reaction to a substance it thinks is harmful. In response, it produces a substance called immunoglobulin E (IgE), which can cause inflammation in many parts of your body, including your lungs. “If the child is having difficulty controlling the asthma, it could be helpful to find out what they are allergic to,” says White Markham. A detailed symptom diary can also help pinpoint triggers, says Subbarao. Once allergy triggers are known, you can reduce your child’s exposure—for example, remove the dog or cat from the home (or, at the very least, keep the pet out of the kid’s bedroom, and wash sheets and blankets regularly). If dust mites are the problem, replacing carpets with hard floors, and buying mattress and pillow covers will help.
Today, Isla is six and has her asthma well-managed. “She’s a very active kid and loves sports,” says her mom, explaining that she swims, plays soccer, downhill skis, skates and dances. Isla carries her inhaler with her at school in a fanny pack and knows how to take it if she starts to cough or has trouble breathing. There’s also a backup puffer in her backpack. “It’s like practising for fire alarms,” says Rosen. “Usually, everything’s OK. But when it’s not, you better know what to do.”
*Name has been changed.
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