Asthma in Children

Cause

The cause of asthma is unknown. Health experts believe that inherited, environmental, and immune system factors combine to cause inflammation of the bronchial tubes, which carry air to the lungs. This can lead to asthma symptoms and asthma attacks.

• Family history. Asthma may run in families (inherited). If this is the case in your family, your child may be more likely than other children to develop long-lasting (chronic) inflammation in the bronchial tubes.
• Immune system. In some children, immune system cells release chemicals that cause inflammation in response to certain substances (allergens) that cause allergic reactions. Studies show that exposure to allergens such as dust mites, cockroaches, and animal dander may influence asthma's development. Asthma is much more common in children with allergies (atopic children), though not all children with allergies develop asthma. And not all children with asthma have allergies.
• Environment. Environmental factors and today's germ-conscious lifestyle may play a role in the development of asthma. Some experts believe there are more cases of asthma because of pollution and less exposure to certain types of harmful bacteria and other germs.^{footnote 1} As a result, children's immune systems may develop in a way that makes it more likely they will also develop allergies and asthma.

Symptoms

Symptoms of asthma can be mild or severe. Your child may have no symptoms; severe, daily symptoms; or something in between. How often your child has symptoms can also change.

Symptoms of asthma may include:

• Wheezing, a whistling noise of varying loudness that occurs when the airways of the lungs (bronchial tubes) narrow.
• Coughing, which is the only symptom for some children.
• Chest tightness.
• Shortness of breath, which is rapid, shallow breathing or difficulty breathing.
• Sleep disturbance.
• Tiring quickly during exercise.

If your child has only one or two of these symptoms, it does not necessarily mean he or she has asthma. The more of these symptoms your child has, the more likely it is that he or she has asthma.

Many children have symptoms that become worse at night (nocturnal asthma). In all people, lung function changes throughout the day and night. In children with asthma, this often is very noticeable, especially at night. Nighttime cough and shortness of breath occur frequently. In general, waking at night because of shortness of breath or cough indicates poorly controlled asthma.

It can be hard to know how severe your child's asthma attack is. Knowing this is important, because severe attacks may require emergency treatment. But in most cases you can take care of your child's symptoms at home with an asthma action plan, which is a written plan that tells you which medicine your child needs to use and when you should call a doctor or seek emergency treatment.

What Happens

Asthma often begins during childhood or the teen years and may last throughout your child's life.

Asthma is classified as intermittent, mild persistent, moderate persistent, and severe persistent.

Asthma attacks and what makes them worse

An asthma attack occurs when your child's symptoms suddenly increase. While some asthma attacks occur very suddenly, many get worse over a period of several days.

Things that can lead to an asthma attack or make one worse include:

• A cold or another type of respiratory illness, especially one caused by a virus, such as influenza.
• Exercising (exercise-induced asthma), especially if the air is cold and dry.
• Triggers, such as cigarette smoke, air pollution, dust mites, or animal dander.
• Changes in hormones, such as during the start of a girl's menstrual blood flow at puberty.
• Medicines, such as nonsteroidal anti-inflammatory drugs.

Most asthma attacks result from a failure to control asthma with medicines. When your child strictly follows his or her asthma action plan and takes all medicines correctly, it is possible to prevent attacks.

Effect on your child's life

At times, the inflammation of the airways in asthma causes your child's airways to narrow and produce mucus, resulting in asthma symptoms such as shortness of breath.

Loss of lung function in asthma appears to start early in childhood. Asthma also may increase the risk of a partial collapse of lung tissue (atelectasis) or a collapsed lung (pneumothorax).

Sometimes asthma does not respond to treatment because children are not taking their medicines or are not taking them correctly, are not avoiding triggers, and are otherwise not following their asthma action plan. It is very important that you and other caregivers make sure your child is following his or her action plan to keep asthma from getting worse and to reduce the risk of death from asthma.

By following asthma plans, most children who have asthma can live a healthy, full life.

What Increases Your Risk

Many things can increase a child's risk for asthma. Some of these are not within your control; others you can control.

Personal and family history

• Gender. Among children, boys have asthma more often than girls.
• Race. Asthma is more common in black children than in white children.^{footnote 2}
• Bronchial tubes that overreact. Children who inherit a tendency of the bronchial tubes (which carry air to the lungs) to overreact often develop asthma.
• A history of allergies, including food allergies. Children who have an allergy are more likely than other children to develop asthma. Most children with asthma have allergic rhinitis, atopic dermatitis, or both. Studies show that 40 to 50 out of 100 children who have atopic dermatitis develop asthma. Having atopic dermatitis as a child may also increase the risk of a person having more severe and persistent asthma as an adult.^{footnote 3}
• A family history of allergies and asthma. Children who have an allergy and asthma usually have a family history of allergies or asthma.
• Respiratory syncytial virus (RSV) and wheezing at a young age. Early infection with respiratory syncytial virus (RSV) that causes a lower respiratory infection increases a child's risk for wheezing.^{footnote 4} Young children who wheeze have a greater risk for asthma than children who do not wheeze.

Other things that increase your child's risk

• Secondhand cigarette smoke. Children who are around secondhand cigarette smoke are at increased risk for developing asthma.^{footnote 5} If children already have the disease, secondhand smoke increases the severity of their symptoms.
• Cigarette smoking. Children who smoke are more likely to develop asthma when they become teenagers. A large study found that children who smoked at least 300 cigarettes in a year were almost 4 times more likely to get asthma.^{footnote 6}
• Cigarette smoking during pregnancy. Women who smoke during pregnancy increase the risk of wheezing in their babies. Babies whose mothers smoked during pregnancy also have worse lung function than babies whose mothers did not smoke.^{footnote 5}
• Obesity. Studies have found a link between obesity in children and a higher-than-average asthma prevalence. But the reason for the link is unclear.^{footnote 2} Also, symptoms caused by obesity are sometimes thought to be asthma symptoms.
• Dust mites. Being around dust mites may increase your child's risk for asthma.^{footnote 5}
• Cockroaches. In one study, children who had a high level of cockroach droppings in their home were 4 times more likely to have a new diagnosis of asthma than children whose homes have a low level.^{footnote 5}

Pets

Experts are also not sure about the effect that pets in the home have on getting asthma. An analysis of several studies found that having a pet cat appeared to protect against asthma. Having a pet dog slightly increased the risk for asthma. The effect of other furry pets on the risk of asthma was not clear.^{footnote 7}

If your child already has asthma and allergies to pets, having a pet in the home may make his or her asthma worse.

Risks for very bad asthma attacks

Your child may be at increased risk for severe asthma attacks if he or she:

• Is an infant with asthma symptoms.
• Has a history of severe symptoms, such as asthma attacks that get worse quickly and frequent nighttime symptoms.
• Has difficulty taking medicines or often has to use short-acting beta2-agonists such as albuterol.
• Has frequent changes in peak expiratory flow.
• Has symptoms that last for a long time.
• Does not use oral steroid medicines quickly enough during an attack.
• Does not have good support from families and friends.

Triggers also may make asthma worse and may lead to asthma attacks.

When To Call

Call 911 or other emergency services immediately if:

• Your child is having severe difficulty breathing. Signs of this include:
  • Breathing very fast. Children usually grunt with each breath. Shortness of breath can interfere with the ability to speak smoothly.
  • Appearing anxious and being unable to eat because it's too hard to breathe.
  • Using the neck, chest, and belly muscles to breathe so that the skin between, above, and under the ribs sinks inward with each breath. The nostrils may open wide when your child breathes in.
  • Taking longer than usual to breathe out and sometimes having a high-pitched, musical sound when breathing in.
  • Sitting up, leaning forward, or sitting with the nose tilted up as if sniffing the air.
  • Having skin color that stays pale, gray, bluish, or mottled, including the tongue, lips, earlobes, and nail beds.

Call your doctor now or seek immediate medical care if:

• Your child's symptoms do not get better after you follow your child's asthma action plan.
• Your child has new or worse trouble breathing.
• Your child's coughing and wheezing get worse.
• Your child coughs up dark brown or bloody mucus (sputum).
• Your child has a new or higher fever.

Call your doctor if:

• Your child needs to use quick-relief medicine on more than 2 days a week within a month (unless it is just for exercise).
• Your child coughs more deeply or more often, especially if there is more mucus or a change in the color of the mucus.
• Your child has asthma and their PEF has been getting worse for 2 to 3 days.

If you think your child has asthma

If your child has not been diagnosed with asthma but has asthma symptoms, call your doctor and make an appointment to have your child checked.

Watchful waiting

Watchful waiting is a wait-and-see approach. It may be okay as long as your child follows their asthma action plan and stays within the green zone. Monitor your child's symptoms, and continue to avoid asthma triggers.

Exams and Tests

Diagnosis of asthma is based on medical history, a physical exam, and simple lung function tests such as spirometry.

Diagnosing asthma in babies and toddlers is often very difficult. Symptoms may be the same as those of other diseases, such as infection with respiratory syncytial virus (RSV) or inflammation of the lungs (pneumonia), sinuses (sinusitis), and small airways (bronchiolitis). If you have a very young child, spirometry is not practical. So the diagnosis is made based on your report of symptoms.

Lung function tests

In an older child, lung function tests can diagnose asthma, determine its severity, and check for complications.

• Spirometry is the most common test to diagnose asthma in older children. It measures how quickly a child can move air in and out of the lungs and how much air is moved.
• Testing of daytime changes in peak expiratory flow (PEF) is done over 1 to 2 weeks. This test is needed when your child has symptoms off and on but has normal spirometry test results.
• An exercise or inhalation challenge may be used if the spirometry test results have been normal or near normal but asthma is still suspected. These tests measure how quickly your child can breathe in and out after exercise or after using a medicine. An inhalation challenge also may be done using a specific irritant or allergen.
• A bronchoscopy test involves using a flexible scope called a bronchoscope to examine the airways. Sometimes airway problems such as tumors or foreign bodies will create symptoms that mimic those of asthma.

A newer test to monitor asthma is the NIOX nitric oxide test system. This test measures nitric oxide in exhaled air. A decrease in nitric oxide suggests that treatment may be reducing inflammation caused by asthma. But some experts believe that this test is not useful for monitoring asthma.^{footnote 8}

Tests for other diseases

Asthma sometimes is hard to diagnose because symptoms vary widely from child to child and within each child over time. Symptoms may be the same as those of other conditions, such as influenza or other viral respiratory infections. Tests that may be done to determine whether diseases other than asthma are causing your child's symptoms include:

• A chest X-ray. A chest X-ray may be used to see whether something else, such as a foreign object, is causing symptoms.
• A sweat test, which measures the amount of salt in sweat. This test may be used to see whether cystic fibrosis is causing symptoms.

Other tests may be done to see whether your child has health problems such as sinusitis, nasal polyps, or gastroesophageal reflux disease.

Regular checkups

You need to monitor your child's condition and have regular checkups to keep asthma under control and to review and possibly update your child's asthma action plan. A checkup is recommended every 1 to 12 months depending on how well your child's symptoms are controlled.

During checkups, your doctor will ask you and your child whether symptoms or peak expiratory flow or both have held steady, improved, or become worse. He or she will also ask about asthma attacks during exercise, at night, or after laughing or crying hard. You and your child track this information in an asthma diary.

Tests to identify triggers

If your child has persistent asthma and takes medicine every day, your doctor may ask about his or her exposure to substances (allergens) that cause an allergic reaction. For more information about tests for allergies, see the topic Allergic Rhinitis.

Treatment Overview

Although your child's asthma cannot be cured, you can manage the symptoms with medicines and other measures.

It's very important to treat your child's asthma. Although he or she may feel good most of the time, even mild asthma may cause changes to the airways that speed up and make worse the natural decrease in lung function that occurs as we age.

Your child can expect to live a normal life by following his or her asthma action plan. Asthma symptoms that are not controlled can limit your child's activities and lower his or her quality of life.

Know the goals of treatment

By following your child's treatment plan, you can help your child meet these goals:

• Increase lung function by treating the inflammation in the lungs.
• Decrease the severity, frequency, and duration of asthma attacks by avoiding triggers.
• Treat acute attacks as they occur.
• Use quick-relief medicine less (ideally on not more than 2 days a week).
• Have a full life—the ability to participate in all daily activities, including school, exercise, and recreation—by preventing and managing symptoms.
• Sleep through the night undisturbed by asthma symptoms.

• Asthma: Taking Charge of Your Asthma

Babies and small children need early treatment for asthma symptoms to prevent severe breathing problems. They may have more serious problems than adults because their bronchial tubes are smaller.

Follow your child's action plan

An asthma action plan tells you which medicines your child takes every day and how to treat asthma attacks. It may include an asthma diary where your child records peak expiratory flow (PEF) or symptoms or both. You also can list the cause of the symptoms and the quick-relief medicine used for asthma symptoms. This helps you to identify triggers that can be changed or avoided and to be aware of your child's symptoms. A plan also helps you make quick decisions about medicine and treatment.

• Asthma: Using an Asthma Action Plan

Take medicines

Your child will take several types of medicines to control his or her asthma and to prevent attacks. These include:

• Inhaled steroid (corticosteroid) medicines. These are for long-term treatment of asthma and are usually taken every day. They reduce inflammation in your child's airways.
• Short-acting beta2-agonists and anticholinergics (quick-relief medicines). These medicines are used for asthma attacks. They relax the airways, allowing your child to breathe easier.
• Oral or injected steroid medicines. These may be used to get your child's asthma under control before he or she starts taking daily medicine. In the future, your child also may take these medicines to treat asthma attacks.

You and your child will learn how to use a metered-dose inhaler (MDI) or dry powder inhaler (DPI). An MDI delivers inhaled medicines directly to the lungs. Most doctors recommend using a spacer with an MDI. For more information, see Medications.

Go to checkups

Your child needs to monitor his or her asthma and have regular checkups to keep asthma under control and to ensure the right treatment. The frequency of checkups depends on how well your child's asthma is controlled.

Control triggers

Being around triggers increases symptoms. Try to avoid situations that expose your child to irritants (such as smoke or air pollution) or substances (such as animal dander) to which he or she may be allergic. Using an air filter machine in your house reduces smoke and other particles in the air, which can help prevent asthma symptoms in children.^{footnote 9}

• Asthma: Identifying Your Triggers

Monitor symptoms

You can monitor your child's symptoms by checking peak flow or by watching for changes in how much your child is coughing, wheezing, or short of breath.

It is easy to underestimate the severity of your child's symptoms. You may not notice them until his or her lungs are functioning at 50% of the personal best peak expiratory flow (PEF).

Measuring PEF is a way to keep track of asthma symptoms at home. It can help you and your child know when lung function is becoming worse before it drops to a dangerously low level. This is done with a peak flow meter.

• Asthma: Measuring Peak Flow

Get help for special concerns

Special things to think about in treating asthma include:

• Managing exercise-induced asthma. Exercise often causes asthma symptoms. Steps you and your child can take to reduce the risk of this include using medicine immediately before exercising.
• Managing asthma before surgery. Children with moderate to severe asthma are at higher risk of having problems during and after surgery than children who do not have asthma. Before any surgery is done, make sure your child's surgeon knows that your child has asthma.
• Taking care of other health problems. If your child also has other health problems, such as inflammation and infection of the sinuses (sinusitis) or gastroesophageal reflux disease (GERD), he or she will need treatment for those conditions.

Know what to do if asthma gets worse

If your child's asthma is not improving, talk with your doctor and:

• Review your child's asthma diary to see if he or she has a new or previously unidentified trigger, such as animal dander. Talk to your doctor about how best to avoid triggers.
• Review your child's medicines to be sure he or she is using the right ones and using them correctly.
• Review your child's asthma action plan to be sure it is still right for his or her condition.
• Find out whether your child has a condition with symptoms similar to asthma, such as sinusitis.

If your child's medicine is not working to control airway inflammation, your doctor will first check to see whether your child is using the inhaler correctly. If your child is using it correctly, your doctor may increase the dosage, switch to another medicine, or add a medicine to the existing treatment.

If your child's asthma does not improve with treatment, he or she may require more treatment, including larger doses of medicines. An asthma specialist typically prescribes these medicines.

Plan for emergencies

If your child has a severe asthma attack (the red zone of the asthma action plan), give him or her medicine based on the action plan. Talk with a doctor right away about what to do next. Your child may have to go to the emergency room for treatment.

At the hospital, your child will probably receive inhaled beta2-agonists and steroid medicines. He or she may be given oxygen therapy. Doctors will assess your child's lung function and condition. Depending on the response, further treatment in the emergency room or a stay in the hospital may be needed.

Prevention

While there is no certain way to prevent asthma, experts continue to look at things that may reduce a child's chance of getting asthma.

Irritants in the air

Common irritants in the air, such as tobacco smoke and air pollution, can cause asthma symptoms in some children.

Controlling tobacco smoke is important because it is a major cause of asthma symptoms in children and adults. If your child has asthma, try to avoid being around others who are smoking. And ask people not to smoke in your house.

• Pregnant women who smoke cigarettes during pregnancy increase the risk for wheezing in their newborn babies.
• Exposing young children to secondhand tobacco smoke makes it more likely that the children will develop asthma and makes symptoms more severe if the children already have the disease.

Consider keeping your child inside when air pollution levels are high. Other irritants in the air (such as fumes from gas, oil, or kerosene, or wood-burning stoves) can sometimes irritate the bronchial tubes. Avoiding these may reduce asthma symptoms.

You may also want to use an air filter machine in your house to reduce the amount of dust and other pollutants.

Living With Asthma

You can limit the impact asthma has on your child's life by learning about asthma and learning how you can help your child follow his or her treatment plan.

Learn about asthma and see your doctor

• Educate yourself and your child about asthma. This questionnaire can help you and your child see what you already know about asthma and what you may need to discuss with your doctor.
• See your child's doctor regularly to monitor asthma. The frequency of checkups depends on how well your child's asthma is controlled. Bring the asthma plan to each appointment.
• Set goals that relate to your child's quality of life. Decide together what you want to be able to do. Have symptom-free nights? Be able to play soccer? Feel secure in knowing you both can deal with an asthma attack? Work with your doctor to make sure your child's goals are realistic and your child knows how to reach them.

Follow your child's action plan

• The asthma action plan helps you minimize the long-term effects of asthma and describes which medicines to take every day. The action plan also contains the steps to handle asthma attacks at home. See an example of an asthma action plan .
• Your child also may have an asthma diary to help manage asthma. Use it to record peak expiratory flows or symptoms, or both. Also list the triggers of asthma attacks and the medicines that your child took for quick relief.
• Understand your child's barriers and solutions. What may prevent your child from following his or her plan? These may be physical barriers, such as living far from your doctor or pharmacy. Or your child may have emotional barriers, such as having undiscussed fears about the condition or unrealistic expectations. Talk with the doctor about your child's barriers, and work to find solutions.

Know your child's asthma triggers

A trigger is anything that can lead to an asthma attack. If your child can avoid triggers, he or she may reduce the chance of having an asthma attack.

• Asthma: Identifying Your Triggers

Check peak flow if your doctor recommends it

It is easy to underestimate the severity of asthma. Measuring peak expiratory flow (PEF) is a way to keep track of asthma symptoms at home and to know when your child's lung function is getting worse before it drops to a dangerously low level.

• Asthma: Measuring Peak Flow

Control allergens

Your child may be allergic to certain substances (allergens). You may reduce your child's asthma symptoms by limiting exposure to those substances. In some cases, your child's doctor may recommend immunotherapy, such as allergy shots.

• Control cockroaches, especially if you and your child live in an area where cockroaches are common.
• Control dust mites. House dust mites have been linked with asthma in children.
• Control animal dander and pet allergens. If your pet is a known trigger for your child, you may need to think about giving your pet away. If that is too hard, taking steps such as keeping your pet out of your child's bedroom and dusting and vacuuming often may help your child's asthma.
• Control indoor mold, especially if you live in an area with high humidity.

It also may be necessary to avoid exposure to other types of triggers that cause asthma symptoms.

• Have your child avoid foods that may cause asthma symptoms. Some children have symptoms after eating processed potatoes, shrimp, or dried fruit. These foods and liquids contain sulfites, which may cause asthma symptoms.
• If pain relief medicines such as ibuprofen seem to cause asthma symptoms or make them worse, use acetaminophen (such as Tylenol) for pain relief. (Do not give aspirin to anyone younger than 20 because of the risk of Reye syndrome.)

Control symptoms at night

Coughing and wheezing can wake your child. Special problems that might cause night symptoms include:

• Delayed allergic reactions. Sometimes allergens that get in the airway can cause problems up to 8 hours later. Talk to your doctor about treating allergies that affect your child at night. The doctor may be able to change your child's medicine or the time your child takes it.
• Medicine that wears off in early morning, causing your child to wake up. To make sure that the medicine lasts through the night, the doctor may be able to change your child's dosage or medicine or the time your child takes the medicine.

Treating a sinus infection, cold, or allergies can keep your child's symptoms from occurring at night.

Avoid upper respiratory infections

Upper respiratory infections, including the common cold, cause 85 out of 100 asthma attacks in young children.^{footnote 10} Basic preventive measures include the following:

• Avoid contact with other people who are ill. If there is an ill child in the home, separate him or her from other children, if possible.
• If you have a respiratory infection, such as a cold or the flu, or if you are caring for someone with a respiratory infection, wash your hands before and after caring for this person.
• Do not smoke. Secondhand smoke irritates the mucous membranes in your child's nose, sinuses, and lungs and increases his or her risk for respiratory infections.
• Children who have asthma and their family members should get an influenza vaccine (flu shot) every year.

Help your child take medicine

Taking medicines is an important part of asthma treatment. But it can be hard to remember to take them. To help you and your child remember, understand the reasons people don't take their asthma medicines. And then find ways to overcome those obstacles, such as taping notes on the bathroom mirror.

Most medicines for asthma are inhaled. With inhaled medicines, a specific dose of the medicine can be given directly to the bronchial tubes, avoiding or reducing the effects of the medicine on the rest of the body. Delivery systems for inhaled medicines include metered-dose and dry powder inhalers and nebulizers. A metered-dose inhaler (MDI) is usually used by older children, and nebulizers are used most often with infants. For more information, see Medications.

More tips for managing your child's asthma

To manage your child's asthma:

• Stay with a daily routine. Make treatment part of normal, daily activities to help your child adjust to the condition and take responsibility for managing treatment. Your child could, for example, get used to taking medicine before brushing his or her teeth.
• Check your child's symptoms. If your child is old enough to understand the process, teach him or her what symptoms to watch for. Help your child understand how to follow his or her asthma action plan.
• Inform others in your child's life about asthma. Inform the principal, school nurse, teachers, and coaches at your child's school that your child has asthma. Give the staff a copy of your child's asthma action plan so that they can help your child to take his or her medicine and will know what to do during an asthma attack. Encourage your child to participate in exercise and sports. Asthma, when well controlled, should not prevent your child from participating in sports and other physical activities.

It is important to treat your child's asthma attacks quickly. If your child does not improve soon after treating an attack, talk with a doctor.

• During attacks, stay calm and soothe your child. This may help your child relax and breathe more easily.
• Don't underestimate or overestimate how severe your child's asthma is. It is often hard to know how much breathing difficulty a baby or small child is having. Seek medical care early for babies and small children who have asthma symptoms.

Medicines

Medicine does not cure asthma. But it is an important part of managing the condition. Medicines for asthma treatment are used to:

• Prevent and control the airway inflammation to minimize long-term lung damage.
• Decrease the severity, frequency, and duration of asthma attacks.
• Treat the attacks as they occur.

Asthma medicines are divided into two groups: those for prevention and long-term control of inflammation and those that provide quick relief for asthma attacks. Most children with persistent asthma need to use long-term medicines daily. Quick-relief medicines are used as needed and provide rapid relief of symptoms during asthma attacks.

Medicine delivery

Most medicines for asthma are inhaled, because a specific dose of the medicine can be given directly to the bronchial tubes. Delivery systems include metered-dose and dry powder inhalers and nebulizers. A metered-dose inhaler is used most often.

Most doctors recommend that every child who uses a metered-dose inhaler (MDI) also use a spacer, which is attached to the MDI. A spacer may deliver the medicine to your child's lungs better than an inhaler alone. And for many people a spacer is easier to use than an MDI alone. Using a spacer with inhaled steroid (corticosteroid) medicines can help reduce their side effects and the need for the oral (pill) kind.

Medicine choices

The most important asthma medicines are:

• Inhaled steroid medicines. These are the preferred medicines for long-term treatment of asthma. They reduce inflammation of your child's airways and are taken every day to keep asthma under control and to prevent sudden and severe symptoms (asthma attacks). Examples include beclomethasone, budesonide, flunisolide, and fluticasone.
• Short-acting beta2-agonists (quick-relief medicines) for asthma attacks. They relax the airways, allowing your child to breathe easier. These medicines include albuterol and levalbuterol.
• Oral or injected steroid medicines (systemic corticosteroid medicines) to get your child's asthma under control before he or she starts taking daily medicine. Your child may also need these medicines to treat asthma attacks. Examples include dexamethasone, prednisolone, and prednisone.

Long-term medicines sometimes used alone or with other medicines for daily treatment include:

• Leukotriene pathway modifiers (such as montelukast, zafirlukast, and zileuton).
• Long-acting beta2-agonists (such as formoterol and salmeterol). They are always used with an inhaled corticosteroid medicine.
• Less commonly, your doctor may recommend a mast cell stabilizer (such as cromolyn) or theophylline.

Other medicines may be given in some cases.

• Anticholinergics (such as ipratropium) may be used for severe asthma attacks.
• Magnesium sulfate may be used if asthma does not improve with standard treatment.
• Your doctor may recommend other medicines if your child has severe allergic asthma and the symptoms aren't relieved by avoiding allergens or by taking standard medicines. Examples include mepolizumab and omalizumab.

Medicine treatment for asthma depends on your child's age, his or her type of asthma, and how well the treatment is controlling asthma symptoms.

• Children up to age 4 are usually treated a little differently than those 5 to 11 years old.
• The least amount of medicine that controls your child's symptoms is used.
• The amount of medicine and number of medicines are increased in steps. So if your child's asthma is not controlled at a low dose of one controller medicine, the dose may be increased. Or another medicine may be added.
• If your child's asthma has been under control for several months at a certain dose of medicine, the dose may be reduced. This can help find the least amount of medicine that will control your child's asthma.
• Quick-relief medicine is used to treat asthma attacks. But if your child needs to use quick-relief medicine on more than 2 days a week, the amount and number of controller medicines may be changed.

Your child's doctor will work with you and your child to help find the number and dose of medicines that work best.

Concern about medicines and growth

Some parents worry that children who use inhaled steroid (corticosteroid) medicines may not grow as tall as other children. A very small difference in height and growth was found in children using inhaled steroid medicines compared to children not using them.^{footnote 11} And one study showed a very small difference in height [about 0.5 in. (1 cm)] in adults who used inhaled steroid medicines as children compared to adults who did not use these medicines.^{footnote 12} But the use of inhaled steroid medicine has important health benefits for children who have asthma. If you are worried about the effects of asthma medicines on your child, talk with your doctor.

What to think about

• Controller medicines. One of the best tools for managing asthma is a daily controller medicine that has a corticosteroid (sometimes called a "steroid" medicine). But some people worry about using corticosteroid medicines because of myths they've heard about them. If you're making a decision about a corticosteroid inhaler medicine, it helps to know the facts.
• Quick-relief medicines. Because these medicines quickly reduce symptoms, children sometimes overuse them instead of adding the slower-acting, long-term medicines. But overuse of quick-relief medicines may have harmful effects, such as decreasing how well these medicines work in the future.^{footnote 13} Overuse of quick-relief medicine is also a sign that asthma symptoms are not being controlled. You should talk with your doctor right away if your child is using quick-relief medicine on more than 2 days a week.
• Oral corticosteroids. Research shows that the most important factor in reducing the severity and length of an asthma attack in children is giving corticosteroids by mouth early in a severe attack. These work best when given at the first sign of symptoms.^{footnote 14}
• Inhaled medicines. Try to avoid giving your child an inhaled medicine when he or she is crying, because not as much medicine is delivered to the lungs.

Other Treatment

Immunotherapy

If your child has asthma symptoms that are triggered by allergens, your child's doctor may recommend immunotherapy. For this treatment, your child get shots or uses pills that have a small amount of certain allergens in them. Your child's body "gets used to" the allergen, so your child reacts less to it over time. This kind of treatment may help prevent or reduce some allergy symptoms.

Allergy shots have been shown to reduce asthma symptoms and the need for medicines in some people.^{footnote 15} But allergy shots are not equally effective for all allergens. Allergy shots should not be given when asthma is poorly controlled.

• Allergies: Should I Take Allergy Shots?

Counseling

Research has shown that (in addition to taking medicine) family therapy, such as counseling, may be helpful to children who have asthma.^{footnote 16} In one small study, peak expiratory flow and daytime wheezing improved in children who had therapy compared with those who didn't. Another small study found that children showed overall improvement from therapy.

Complementary medicine

Complementary medicine is a term used for a wide variety of health care practices that may be used along with standard medical treatment.

While most mind and body practices such as acupuncture, breathing exercises, and yoga seem to be safe when used in the right way, be sure to check with your child's doctor first. Talk about any complementary health practice that you would like your child to try or that your child is already using. Your doctor can help you manage your child's health better if he or she has the whole picture about your child's health.