Ireland has the fourth-highest rate of asthma in the world, with an estimated one in 10 children affected. If the condition is well-managed, the vast majority of children can get on with daily life as normal but, for a few, an asthma attack may prove fatal.
"It is important this is recognised because there is still a degree of underappreciation and underdiagnosis of asthma," says Dr Dermot Nolan, an asthma specialist and general practitioner in Tramore, Co Waterford. Failing to recognise and manage it could have repercussions for a child's socialisation and education, through missing activities and days at school, as well as for their overall health, he says. "Often parents will spend a lot of time going in and out of pharmacies buying cough bottles but failing to realise it could be asthma."
What is asthma?
It is a chronic disease that causes inflammation of the alveoli, the tiny airways at the end of the lungs. They can get clogged with mucus and the chest has to work harder to breathe, which results in tightening of muscles around the airways. The condition causes the airways to be oversensitive and to react to things that wouldn't normally cause a problem, according to the Asthma Society of Ireland.
What are the triggers?
Different people have different triggers and identifying what causes your child’s symptoms to flare up can help in trying to avoid them. Common triggers include house dust mites, pollen, dog hairs, cold air, exercise, cigarette smoke, air pollution and viruses that cause coughs and colds.
Some of the preventative measures adopted widely during the Covid-19 pandemic, such as regular handwashing, cough etiquette, mask-wearing and social distancing, have greatly reduced the incidence of all respiratory illness, including asthma attacks.
A 30-40 per cent fall in the hospitalisation of asthma cases is “probably due to kids not being exposed to normal viral triggers”, says Nolan.
Are you born with it?
No one really knows. It’s undoubtedly partly genetic, says Nolan, because it has been shown that when Irish people emigrate to countries with low incidence of asthma, a high incidence of asthma persists in the Irish community. It is a condition that seems to be carried more strongly down the maternal rather than paternal line.
If they just wheeze when they have a bit of a head cold or virus, that tends not to be asthma
But it is also partly environmental. Theories that increased cleanliness and modern housing, for instance, may have contributed to the rise in asthma over recent decades are backed by research that Nolan cites, which found that the rate of asthma in the historically more deprived eastern side of Germany had risen since unification with western Germany.
There is also increasing interest in a possible connection between asthma and obesity. “It’s a bit chicken and egg,” says Nolan. Have obese children been avoiding exercise because they are out of breath or does the link between obesity and inflammation lead to asthma?
What are the first signs that a child might have asthma?
Typically a “wheeze” is the predominant symptom, but a lot of children will wheeze and it’s not asthma, says Nolan. Look out for any symptoms that occur when the child doesn’t have a cold. “If they just wheeze when they have a bit of a head cold or virus, that tends not to be asthma.”
A wheeze is a “musical noise heard on expiration”, ie as the child breathes out, not in. A dry cough, particularly in the early mornings and at night time, is also a sign, as is waking at night.
Less running around in comparison with their peers may also be an indication. “They get a chest tightness and some of the young children can’t quite describe that symptom so they just stop; they won’t participate in sport. That can have a real impact on their socialisation.”
How is it diagnosed?
While everyone likes “fancy-schmancy tests”, says Nolan, generally a diagnosis can be made by sitting down and listening to parents. They are usually pretty good at giving an accurate history of what is going on with their child.
The new thinking is that a blue inhaler should be used only once or twice a month – at least, in response to symptoms
Other allergy-related conditions, such as eczema or hay fever, may also suggest a higher likelihood of symptoms being due to asthma. Lung function is measured but tends not to be so accurate in children under five. Older children are asked to blow into devices such as a peak flow meter, which indicates lung function and assists GPs with the diagnosis.
What age are children typically diagnosed?
It can be difficult to diagnose under the age of two and usually it is between ages two to five that it is identified, or at least when it comes on to the radar.
How is it treated?
Asthma can usually be managed through the use of both controller and reliever inhalers. While controller inhalers should be used daily, there is a problem with the overuse of reliever inhalers, says Nolan.
The salbutamol (generally blue) inhaler is good for alleviating symptoms but “it doesn’t get rid of the fire”, he warns.
The new thinking is that a blue inhaler should be used only once or twice a month – at least, in response to symptoms. The exception would be preventative puffs in advance of sport but these can become a bit of a habit. Patients can be advised to try just one puff, or none at all, to see if they’re necessary.
Parents who worry about their child taking steroid medication in the controller (brown) inhaler can be inclined to stop using it when the child has been well for months. However, oral steroids that may have to be prescribed if the asthma suddenly worsens is a “much, much higher dose”, says Nolan. His advice is “if you really don’t want to give your child steroids, you give them inhaled steroids” because, with the help of a spacer device, these should go straight into the lungs, whereas the stronger oral steroids go all over the body.
About 90 per cent of asthma cases are managed under a GP, while five to 10 per cent will require specialist referral. GPs should have a treatment plan for your child and give you clear advice on how to manage the condition.
There are new treatments coming on track, such as “house dust mite desensitisation”, says Nolan. “We put a tiny bit of house dust mite under your tongue to try to desensitise you. That is beginning to gain a bit of popularity on the continent as well as here.”
I’m not sure my child could use an inhaler properly
You’re right to be concerned because if inhalers are used incorrectly very little of the medicine will reach the lungs where it’s needed. Also, if too much of the controller medication ends up on the throat it can cause thrush.
There are spacer devices to use with inhalers to help parents, and older children doing it themselves, to make sure the medication is reaching its target. If in doubt, see videos demonstrating inhaler techniques on asthma.ie.
The thought of an asthma attack terrifies me, are there warning signs?
Increased frequency of cough or starting to not sleep as well may be signals, says Nolan. Children should be encouraged to use a peak flow meter every day to monitor themselves. “That is very useful as that will actually drop three or four days before they get symptoms.”
But it can be fatal?
Unfortunately, yes. Fatalities are rare but that is no comfort to families who lose a child. The circumstances of every asthma death are examined and it's always sad and poignant, says Nolan, if the severity of the asthma has been underestimated by the parents, a teenager or even the healthcare professionals involved. There may have been a massive overuse of blue inhalers yet that hadn't raised red flags.
Central Statistic Office figures suggest a fall in death rates from asthma among all ages over the two years since 2015, with 61 deaths in 2016 and 57 in 2017. However, the Asthma Society says “these figures remain unacceptably high, in light of asthma being a largely manageable disease”.
Will my child grow out of asthma?
A lot of the experts would say that if you grow out of it, you probably never had it, says Nolan. The “asthma” in those cases is more likely to have been a virus-induced wheeze. Most people don’t grow out of it, he adds. “You might get a lull in your early teens but it often tends to come back in early adulthood.”
Presumably then it is included in the Long-Term Illness scheme to cover the cost of medications?
Actually it’s not. An omission that the Asthma Society of Ireland says “is a major contributory factor to Ireland’s considerable asthma public health challenge". Its CEO Sarah O’Connor reports that asthma is more prevalent in disadvantaged communities and asthma-related health outcomes are worse there.
“We hear from parents, teachers and those caring for children that the cost of asthma medication is a huge limiting factor in keeping children well. Because patients are not taking their preventative inhalers daily, they can become over-reliant on their reliever inhalers or steroid tablets. Some will be hospitalised. All utterly avoidable.”
