A Guide to Managing Child Asthma

Childhood asthma causes mild to severe symptoms that can get in the way of everyday activities and could be life-threatening in certain circumstances. Thankfully, asthma can usually be successfully managed with an inhaler, a handheld device that delivers medications right into the lungs.
Inhalers for kids may contain rescue medication to respond to an emergency asthma attack or maintenance medication that helps prevent attacks from happening.

Why a Child Might Need an Inhaler
Inhalers are a mainstay of asthma treatment because they either help stop an attack or prevent one from happening. To manage childhood asthma, healthcare providers may prescribe one of three types of inhalers for kids:
• Rescue inhaler: Used only when it’s needed to stop an asthma attack
• Controller inhaler: Usually used daily to prevent an asthma attack
• Combination inhaler: Used daily to prevent an attack and relieve asthma symptoms
Long-Term Control of Asthma
Children usually begin to show signs of asthma before age 5. These symptoms may include frequent incidences of:
• A cough that lingers for days or weeks and is more pronounced at night
• Wheezing or whistling when exhaling
• Trouble breathing
• Recurring chest colds
If you notice these signs, a healthcare provider should examine the child. If asthma is diagnosed, long-term control medication may be prescribed. This can include using a controller or combination inhaler daily to prevent symptoms.
Asthma Attack Treatment
When the child is diagnosed with asthma, your healthcare provider will help you create an asthma action plan, which may include using a rescue inhaler in the event the child has an asthma attack.
Symptoms of an attack in the caution zone include:
• Shortness of breath
• Cough
• Chest tightness or pain
• Wheezing
• Waking at night due to asthma symptoms
• Having any signs or symptoms after exposure to a known trigger
• Having breathing difficulty when sick with a cold or respiratory illness
In children, symptoms of an attack in the danger zone include:
• Tightness or pain in the chest
• Severe shortness of breath
• Breathing may be shallow and faster or slower than normal
• Skin around and between ribs or above the sternum is sucked in
• Nasal flaring
• Exaggerated belly breathing
• Lethargy
• Tongue, lips, fingertips, and around the eyes appear grayish on darker skin tones and bluish on lighter skin tones
A child who is having an attack with red or yellow zone symptoms should be given a rescue inhaler. At the danger zone stage, you should also call 999 or head to the emergency room.
Asthma Attack Prevention
Some children are diagnosed with exercise-induced asthma (EIA). This is when physical activity may trigger asthma.
In order to prevent an attack, children with EIA may need to use a rescue inhaler 10 to 15 minutes before playing sports or participating in physical activities.

Types of Inhalers
There are three types of inhalers:
• Controller inhalers are used regularly to keep asthma under control
• Rescue inhalers are used when an asthma attack is in progress or is about to occur
• Combination inhalers, which do both
Controller Inhalers
Controller inhalers contain corticosteroids, medications that prevent inflammation. This reduces swelling and the production of excess mucus, which contribute to wheezing, difficulty breathing, and other common symptoms of asthma.
Inhaled corticosteroids (ICSs) delivered via controller inhalers are important for asthma management. To effectively prevent symptom flares and asthma attacks, they must be used regularly. For most children, this means several times a day according to a prescribed schedule.
Some children 12 and over who have mild persistent asthma may not need to use an ICS every day. These children may be able to use an ICS and a rescue inhaler as needed.
When prescribing a controller inhaler for kids, healthcare providers likely will start with the lowest possible dose needed to control the child’s symptoms.
Rescue Inhalers
Rescue inhalers are used as needed—when a child feels they’re having an asthma attack or is about to based on the onset of symptoms (wheezing, chest tightness, shortness of breath, and so on). These inhalers are not meant to be used on a regular basis.
Rescue inhalers contain bronchodilator medication, known as short-acting beta-agonists (SABAs), which work by widening the bronchi (airways) that lead to the lungs. Narrowing of the airways, or bronchoconstriction, is a key aspect of asthma that needs to be treated along with inflammation, swelling, and excess mucus.
The rescue medication prescribed most often for children (and adults) is salbutamol, a short-acting beta-agonist that relaxes the airways so they can more easily widen. It’s available under a number of brand names as well as a generic medication.
Combination Inhalers
For children 4 and over (as well as adults) who have moderate to severe persistent asthma (the two most severe categories of asthma), your healthcare provider may advise an inhaler containing two medications—an ICS and a drug called formoterol, a long-acting beta agonist (LABA).
This combination inhaler works as both a controller medication to be used daily and as a rescue therapy to relieve acute symptoms.
Inhaler Devices and How to Use Them
Inhalers are devices that allow you to breathe medication right into the lungs. How they work depends on the type of device. The two types of inhaler devices are:
• Metered-dose inhalers (MDIs)
• Dry powdered inhalers (DPIs)
While it’s ideal to use the medication that controls asthma best, any medication is only as good as how well it is used. MDIs and DPIs each deliver medication a little differently, and the child might feel that one device is easier to use than the other.
DPIs
DPIs are breath-actuated, which means that medicine comes out as the child breathes in deeply and forcefully.
DPIs typically aren’t prescribed until children are at least 5 or 6 because younger kids can’t inhale strongly enough to get a full dose of medication. The exceptions are Advair Diskus and Asmanex Twisthaler, which both may be prescribed for children as young as 4. Some older children prefer the level of control offered by DPIs.
There are multidose inhalers and single-dose inhalers. For single-dose devices, you must load a capsule with the medication into the device’s chamber before use. A multidose device has the medication pre-loaded.
To use DPIs:
1. Sit or stand straight and exhale completely.
2. Close your lips tightly around the mouthpiece.
3. Take one full, quick breath in.
4. Take your mouth off the inhaler and hold your breath for five to 10 seconds.
5. Slowly exhale.
6. Repeat the process if your asthma action plan requires it.
MDIs
MDIs release medication automatically and require coordinating a deep breath while operating the inhaler. They contain hydrofluoroalkanes (HFAs), a substance that propels the medication with pressure.
(Another type of MDI, which uses chlorofluorocarbons (CFCs) to pressurize the medication, has been phased out by the Food and Drug Administration because of environmental concerns.)
To use MDIs:
1. Shake the inhaler to mix medication and, if necessary, prime the inhaler by releasing a few puffs of medication into the air (see device instructions on when this is needed).
2. Sit or stand up straight and exhale completely.
3. Position the inhaler upright with the mouthpiece at the bottom.
4. Follow instructions from your doctor about whether to place the inhaler mouthpiece directly into your mouth between your teeth (move the tongue out of the way), position it one or two inches away from your mouth, or use a spacer.
5. Start to inhale slowly as you press down on the canister. Continue breathing in for three to five seconds.
6. Hold your breath for 10 seconds.
7. Exhale slowly.
8. Repeat the process if your asthma action plan requires it.
Helping a Child Use an Inhaler
Children may have some trouble learning to use an inhaler. For example, kids who use MDIs often breathe too fast instead of taking a slow, deep inhalation when using the medication. Practicing breathing with the child without the inhaler can help them be prepared to use the device when needed.
Other common issues to work on with children:
• Helping them not blow out into the inhaler when they need to breathe in
• Positioning the inhaler incorrectly
• Remembering to exhale fully before using the inhaler
• Remembering to hold their breath for about 10 seconds after inhaling the medicine
• Being able to breathe out slowly afterward
If the child is prescribed an MDI, you can also ask your healthcare provider about a spacer. This small device has a holding chamber that keeps the medicine inside until a child takes a breath so they don’t have to coordinate inhaling with activating the inhaler.
Spacers come in different forms, including a mask for infants, toddlers, and children up to 4. A child can use a spacer for as long as they need one, typically up to age 8 to 10.

When a Nebulizer Is Used Instead

Babies and very young children with asthma who aren’t yet able to manage an inhaler typically receive inhaled medications via a nebulizer—a machine that turns the medicine into a mist.
With a nebulizer, liquid medication for asthma is placed into a cup. On one side, the cup is connected to a mask that will fit over a young child’s mouth and nose. On the other side, it’s attached to tubing. The tubing runs into a motorized device. When you turn on the motor, the liquid medication is vaporized and comes out into the mask.
Babies, toddlers, and young children don’t have to do anything to receive the correct dosage of medication. They just need to breathe in the midst. It can take some time to get the child comfortable using the mask. Arranging a simple activity that encourages them to sit still, like looking at a picture book, will help ensure they get the required dosage.