Severe Asthma

Dear Lisa,

My 8 year old son suffers from severe asthma. We have problems every week to two weeks. It seems that it is getting worse. We are currently taking Singulair, Advair diskus, and Maxair. We also do updraft treatments. Do you have any suggestions? I am worried that it might be something else. We have a family history of COPD, Asthma, alpha 1 antitrypsin def. and lung cancer.

Any thing would greatly be appreciated. Thanks.

“Mom4kids”

Dear “Mom4kids”,

Your son is lucky to have a mom that is so concerned about him and interested in finding ways to improve his condition. Unfortunately, Asthma is a chronic medical condition consisting of periods of exacerbations. It requires frequent medical evaluations, follow up care and in many cases daily medication and treatments.

When a child’s Asthma symptoms occur more than twice per week, the condition is considered to be out of control. The first step in gaining control of your son’s Asthma is to determine and eliminate the triggers that may be exacerbating his condition. Potential Asthma triggers include Allergies, infections, irritants, weather, medications, exercise, hormone fluctuations and emotional stress. (1) The most likely triggers for an eight year old child include Allergies, irritants and emotional stress.

It is important to rule out Allergies as a contributng factor in your son’s condition. If your son is constantly being exposed to products that he is allergic to, his Asthma will continue to remain out of control. Irritants in his environment should also be considered. Irritants known to trigger Asthma include cigarette smoke, wood burning stoves, diesel fuel, air pollution, household cleaning products, air fresheners, powder, perfume and scented candles.

Has there been a change in the environment which may be responsible for the exacerbation of your son’s symptoms? Does he have a new friend that he has been playing with who owns a pet? Does his condition worsen when he sleeps on the sofa or over a relative’s house? Are there cat or dog hairs on his coat or hat? Does he have a new coat or blanket made with down feathers? Is there construction going on in your home or at school? Have you changed the position of the bed in his bedroom? Is the bed now located under a heating vent with the air blowing dust and re-circulated irritants into his face all night while he is sleeping? Is he under stress at school due to a change in work load? These are some of the questions that you need to ask yourself in order to determine if there is something in his environment that is triggering his Asthma.

It may be helpful to keep a diary and write down the environmental conditions, exposures, his activities, the weather, his state of health and any over-the-counter medications that he may be taking. You should record information from the day before his symptoms begin. In some cases there may be a late phase response where symtpoms do not develop until up to 12 hours after an exposure. That is why it is important to record what he was doing the night before his symptoms begin. A consultation with a Nurse Practitioner at an Asthma Specialist’s office can guide you in determining your son’s triggers. There may be certain measures that you can take to control his environment, eliminate triggers and ultimately control his symptoms.

It is important that you have your son evaluated by an Asthma Specialist. Pulmonary Function Testing is a necessary part of the work up which will evaluate his lung function and determine the effectiveness of his medication regime. A complete evaluation should also include the evaluation for underlying conditions that that may be contributing to your son's Asthma. An infection with Sinusitis, Allergies, Gastroesophageal Reflux, Vocal Cord Dysfunction and side effects from medications can all contribute to the worsening of a child’s Asthma.(2)

An evaluation by an Allergist and allergy testing are recommended in order to determine if Allergies are playing a part in your son’s condition. Allergies and Asthma frequently come hand and hand. Allergen exposure happens to be a major trigger of symptoms in 80% to 90% of children with Asthma.(3) If a child is determined to have Allergies; measures taken to control the child’s allergies will also help control the child’s Asthma.

An association between the presence of Gastroesophageal Reflux Disease (GERD) and Asthma in the pediatric population has been noted. GERD is thought to contribute to ongoing Asthma symptoms and may be substantially involved in the underlying pathogenesis of Asthma.(4) Studies have shown that 50 to 63% of children with Asthma also have underlying GERD. Signs of Gastroesophageal Reflux in an older child include heartburn and difficulty swallowing. (5) Other symptoms may include abdominal pain, vomiting, coughing at night, belching and a sour taste in the mouth.(6)

In some cases Gastroesophageal Reflux can be silent, which means there may not be any vomiting or obvious symptoms. The symptoms could present as a cough or worsening of a child’s underlying Asthma. A significant amount of Asthmatic children with unstable disease have silent GERD.(6) A consultation with an Asthma Specialist or Gastroenterologist will be able to tell you if your son’s Asthma is affected by Gastroesophageal Reflux Disease and treat him accordingly.

Vocal Cord Dysfunction (VCD) is another condition that is associated with Asthma. VCD often occurs in patients with Asthma.(7) When a child suffers from VCD they experience a paradoxical movement of their vocal cords which leads to stridor, wheezing, voice changes and cough.(7) A child experiencing an episode of Vocal Cord Dysfunction appears to have difficulty breathing but continues to maintain normal oxygen levels in their body. VCD can be triggered by exercise and stress. An evaluation by an Asthma specialist during an acute episode can diagnose the problem. The treatment for VCD includes speech therapy performed by a speech therapist who has experience with the condition.

Medications that can trigger Asthma include Non-steroidal anti-inflammatory drugs(NSAIDs) and Beta-blockers. Examples of NSAIDs include Motrin, Advil and Aleve. These over-the-counter products are commonly given to children, many times without consulting a Physician. It is important for parents of children with Asthma to know that this drug class can trigger Asthma and should not be given unless under the direction and observation of your Physician. Asthmatic patients can have worsening of their condition when taking these medications and not realize the association.

There has been recent research linking the administration of Acetaminophen with prevalence of Asthma. The proposed mechanism includes the acetaminophen-induced glutathione depletion theory. Glutathione is found in its largest amount in the respiratory tract. It serves as an anti-oxidant and removes molecules that cause airway inflammation.(8) Results from clinical studies suggest that Acetaminophen can exacerbate Asthma.(9)

In regards to your comments about your family history of COPD, alpha 1-Antitrypsin deficiency and lung cancer; of the three, alpha-1-antitrypsin disorder is a potential cause for chronic respiratory symptoms in childhood. COPD is a chronic lung condition that occurs in the adult population and lung cancer is typically found in adults after years of exposure to carcinogens. Children may develop lung cancer if they have cancer in another part of their body that metastasizes to the lungs.

Alpha-1-Antitrypsin Deficiency is a condition that causes liver or lung disease. Jaundice within the first 3 months of life is usually the presenting sign.(10) The diagnosis is made through quantifying levels of Alpha-1-antitrypsin levels in the blood. Since there is a family history of Alpha-1-Antitrypsin Deficiency you may want to discuss having testing done to rule out this condition with your Doctor.

Other conditions that may cause chronic respiratory symptoms in childhood include Foreign Body Aspiration, Cystic Fibrosis, Pertussis, Tuberculosis and IgA deficiency.(6) Cystic Fibrosis is a chronic disorder that is typically found in Caucasians. It is usually associated with difficulties gaining weight, sinus disease and GI symptoms. When a child suffers from an IgA deficiency they experience an increased susceptibility to respiratory infections. IgA is responsible for fighting respiratory infections such as Sinusitis and Pneumonia. Children with a history of recurrent Sinusitis or Pneumonia should be tested for an IgA deficiency.

I hope this information helps and your son finds control of his Asthma symptoms soon.

If you are interested in reading other Pediatric Advice Stories covering the topics discussed:

Asthma Triggers

Asthma Treatment

Early Warning Signs of Asthma

Chronic Cough

Allergy Symptoms

Hayfever Treatments

Food Allergies

Pet Allergy

Pneumonia

Sinusitis

Gastroesophageal Reflux

GER in Infancy

References:
(1)Mahr T, Crisalida T, Holingsworth J, Ortiz G, Senske Heier B, Briscoe Waldrop J. Attaining the Inside Track on Asthma Control. The Clinical Advisor. 2006. Dec:S2-14.
(2)The Allergy Report. Allergic Disorders: Promoting Best Practice. Available at: http://www.theallergyreport.com/reportindex.html. Accessed March 2007.
(3)Phipatanakul W. Environmental Factors and Childhood Asthma. Pediatric Annals. 2006. 35(9):647-656.
(4)Gold BD. Review article: epidemiology and management of gastro-esophageal reflux in children. Ailment Pharmacol Ther. 2004. 19(supple 1):22-27.
(5)Hogan M, Wilson N. Asthma in the School-Aged Child. Pediatric Annals. 2003. 32(1):20-25.(6)Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006. 35(4):259-266.
(7)Kaplan A. All that wheezes is not pediatric asthma. The Clinical Advisor. 2007. Jan:31-39.
(8)Eneli I. Acetaminophen and Asthma: Any Connection? Consultant for Pediatricians. 2006. May:281-282.
(9)Eneli, Sadri K, Camargo C Jr, Barr RG. Acetaminophen and the risk of asthma: the epidemiologic and pathophysiologic evidence. Chest. 2005.127:604-612.
(10)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia,PA:W.B.Saunders Company. 1990:408-409.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Parents with Sick Children