Chapter 18

Asthma during Childhood

In This Chapter

Figuring out how asthma affects your child

Diagnosing your child’s condition

Recognizing symptoms that suggest asthma

Looking at special concerns

Preventing asthma problems at school or daycare

P arents know that no one is more precious to them than their children. Therefore, parents want to treat any ailment that affects their youngsters as effectively as possible. If your child has asthma, the good news is that with a proper diagnosis, appropriate management, and a firm understanding of the disease, you can help your child effectively control his or her condition.

Unfortunately, some parents (and even some doctors) don’t understand asthma well enough to recognize or diagnose the disease properly. Too often, this misunderstanding results in the misdiagnosis of children with asthma as instead having chronic bronchitis or recurring colds. In these cases, children may not receive the appropriate treatment and their symptoms may worsen, leading to severe asthma episodes that may require emergency measures to treat.

In fact, asthma — the most common chronic childhood disease in the United States — affects at least 5 million children. Current estimates are that only half of these youngsters receive accurate diagnosis and effective treatment.

However, these alarming asthma statistics don’t need to continue. Treating your child’s asthma early and aggressively, as well as practicing long-term preventive maintenance, can make the difference between a sickly youngster and a healthy, well-adjusted kid who rarely experiences the problematic symptoms.

Understanding Your Child’s Asthma

Asthma is a chronic inflammatory disease of the airways that can make getting air in and especially out of the lungs difficult. Besides the serious health risks that asthma can pose for your child, properly managing the disease is vital for your youngster’s overall growth: Anything that restricts proper breathing can impair his or her physical and mental development.

Asthma often begins in childhood and affects boys more commonly than girls. Most children who develop asthma experience their first symptoms of the disease before they reach their third birthday.

Look for the following signs and symptoms as possible asthma indicators in your child. (Keep in mind, however, that not every child with the disease experiences all these signs and symptoms.)

Persistent coughing, wheezing, and recurring or lingering chest colds.

An expanded or overinflated chest and hunched shoulders.

Signs of coughing, wheezing, or extreme shortness of breath during or after exercise. These symptoms may signal the onset of exercise-induced asthma, or EIA (see “Participating in PE — exercise and asthma,” later in this chapter).

Snoring, especially in preschool children. According to recent studies, a strong association exists between snoring and asthma in children ages 2 to 5.

Coughing at night, in the absence of other symptoms such as a cold.

Because you may find recognizing the preceding symptoms more difficult when observing infants and young children, watch for the following signs of possible asthma trouble:

Cyanosis, due to severe airway obstruction blocking the normal flow of oxygen into the lungs, causes a very pale or blue skin color. This can occur in a very severe asthma attack and requires emergency treatment.

Deep and rapid rib muscle movements, also known as retractions, which can occur when an infant or young child is having trouble breathing properly.

Difficulty in nursing or eating.

Lethargic activity and reduced responses, including not recognizing or responding to parents.

Nasal flaring (rapidly moving nostrils), which can be a sign of severe asthma.

Soft, shallow crying.

In addition to these signs, you also need to consider the presence of atopy (the genetic susceptibility for the immune system to produce antibodies to common allergens, which leads to allergy symptoms) as a key predisposing factor for your child developing asthma (see Chapters 2 and 6).

Atopic conditions, including food allergies (see Chapter 8), allergic rhinitis (hay fever — see Chapter 7), and atopic dermatitis (eczema — see Chapter 1), can indicate a potential predisposition for asthma, especially in infants and young children. In fact, more than three-quarters of all children who develop asthma also have allergies. In many cases, allergic reactions associated with the response to inhalant and ingested allergens can also cause flare-ups in a child with asthma.

Inheriting asthma

If you think that your child may have asthma, consider your family’s medical history. Two-thirds of asthma patients have a close relative with the disease. Likewise, if you or your child’s other parent has asthma, your child’s chances of developing asthma are 25 percent; if both you and your child’s other parent have asthma, your child’s odds of developing asthma double to 50 percent.

However, asthma in your family doesn’t guarantee that your child will develop asthma. Your child inherits the tendency to the disease, not the disease itself. If neither you nor your child’s other parent has asthma, the odds of your child developing this disease are no greater than 15 percent.

Identifying children’s asthma triggers

Although hereditary factors may increase your child’s likelihood of developing asthma, environmental triggers and other precipitating factors usually bring on the symptoms. (See Chapter 5 for more detailed information on these triggers and precipitating factors.) Most physicians agree that viral respiratory infections are the most common triggers of asthma attacks in infants and young children.

The most serious air pollutant and irritant in terms of asthma is tobacco smoke. Parents absolutely should not smoke around a child, especially if the youngster has asthma. Even if your child is out (for example, at school), don’t smoke in the home. The lingering odor of tobacco smoke can still trigger your child’s asthma symptoms. According to numerous studies, exposure to maternal smoke is a major risk factor in the early onset of asthma in infancy. In fact, an infant whose mother smokes is almost twice as likely to develop asthma.

Controlling — not outgrowing — asthma

The idea that all children eventually “outgrow” asthma is a dangerous myth, and withholding treatment hoping that somehow your child’s asthma will just go away is a misguided approach. As children grow, their lungs and airways become larger. If the amount of airway obstruction stays the same, the blockage may proportionally constitute a smaller part of the total airway diameter, thus resulting in fewer symptoms as an adult. In addition, many children do have fewer symptoms and a decrease in airway hyperreactivity as they grow older, but early and aggressive treatment of asthma significantly contributes to a better outcome.

Your child’s sensitivities, however, may not entirely disappear, and the pos-sibility exists that a lack of treatment could result in irreversible airway changes. Clear and compelling evidence shows that early diagnosis and treatment results in fewer asthma symptoms.

Your child’s asthma symptoms may diminish or may no longer be apparent, but the increased airway sensitivity remains — just as your child’s fingerprints stay the same even though his or her body grows and develops. Asthma isn’t a disease that you can really cure; it’s a condition that you must control.

Treating early to avoid problems later

In my practice, many adult patients are referred to me with severe asthma. In many cases, their conditions may not have deteriorated to such an extent if only their asthma had been properly treated during childhood. The first two years after asthma has been diagnosed generally are considered to be the time when aggressive medical treatment can dramatically improve the potential for maintaining normal lung functions in your child.

Unfortunately, some parents only focus on immediately treating serious asthma attacks instead of managing the child’s condition on a consistent, everyday basis. This approach is misguided. Don’t watch and wait to see how asthma affects your child. If your child has a persistent cough, short-ness of breath, lingering colds, or other early signs of asthma (see the symptoms and signs I list in the first part of this section), make sure that a doctor checks your child’s lung functions. This testing can help to determine whether asthma is, in fact, the cause of your child’s symptoms.

Identifying Childhood-Onset Asthma

When dealing with a child, particularly one who is very young, what may seem an obvious and easily identifiable asthma diagnosis isn’t always the case. Asthma is a complex condition with many possible combinations of symptoms that can vary widely from patient to patient. In fact, your child’s symptoms can change over time.

The process of diagnosing your child’s condition should include the following steps:

A complete medical history

A physical examination

Lung-function tests

Any other tests that your doctor considers necessary to determine the nature of your child’s ailment

To diagnose your child’s asthma, your doctor should establish the following key points:

Your child experiences episodes of airway obstruction.

The airway obstruction is at least partially reversible.

Your child’s symptoms result from asthma, not other potential conditions that I explain in the “All That Wheezes Isn’t Asthma” section, later in this chapter.

Taking your child’s medical history

A thorough and complete medical history is vital to diagnosing your child’s condition. In addition to asking about the symptoms and signs of childhood asthma that I describe in “Understanding Your Child’s Asthma,” earlier in this chapter, your doctor may also inquire about the following:

Any family history of allergies and/or asthma. (As I explain in the “Inheriting asthma” section of this chapter, genetics play a major role in asthma development.)

Any exposures your child receives to common asthma triggers, such as inhalant allergens and irritants — especially tobacco smoke — or any other substances, as well as the precipitating factors that I describe in “Identifying children’s asthma triggers,” earlier in this chapter.

Any times your child has been hospitalized for respiratory problems. Your doctor should also ask about any medications that your child takes, whether for respiratory symptoms or for other conditions.

Examining your child for signs of asthma

The focus of a physical exam for children with suspected asthma usually involves the following:

Checking for signs of hunched shoulders, chest deformities, and pale skin.

Examining your child’s breathing passageways, from nose to chest. (See Chapter 2 for details of physical exams.)

Looking for evidence of other atopic diseases, such as allergic rhinitis or atopic dermatitis, which may indicate a predisposition to asthma.

Observing your child’s breathing rate and rhythm. Your doctor listens with a stethoscope to the chest and back over areas of your child’s lungs to check for the following signs and sounds of airway obstruction:

• Wheezing or other sounds not usually associated with normal breathing

• Unusually prolonged exhalations

• Rapid, shallow respirations (panting) in more severe cases

Testing your child’s lungs

After taking your child’s medical history and performing a physical examination, your doctor may conduct lung-function tests if your child is older than 4 or 5 years old. These tests are vital in diagnosing asthma because they can tell whether airway obstruction has limited or affected your child’s lung functions.

To diagnose asthma in children older than 4 or 5, doctors often use a procedure known as spirometry. Spirometry involves using a spirometer (pulmonary function machine) to measure your child’s airflow, before and 15 minutes after he or she inhales a short-acting bronchodilator, to determine improvement in lung function. See Chapter 2 for more details on spirometry.

Spirometry tests are difficult, if not impossible, to perform on children under 4 years old. However, by age 6, most children are quite capable of performing accurate and reliable spirometry (if they feel like it!). To properly diagnose an infant or young child with asthma, your doctor may need to rely on your child’s medical history and physical examination. In some cases, your doctor may prescribe a trial course of a nebulized beta ₂ -adrenergic bronchodilator and/or anti-inflammatory medications to evaluate your child’s response.

All That Wheezes Isn’t Asthma

Although the misdiagnosis of asthma (often as bronchitis) is a frequent problem in treating childhood respiratory conditions, in some cases, other ailments can cause symptoms that resemble asthma. These other ailments include

Abnormal development of blood vessels, known as vascular rings, around the trachea (windpipe) and esophagus

Congenital heart disease, often leading to congestive heart failure

Cystic fibrosis

Viral and/or bacterial bronchitis or pneumonia

Viral bronchiolitis (RSV), a serious respiratory infection that can occur in the first two years of life

RSV may resemble an acute asthma attack. This disease characteristically occurs during the winter months in children under 2 years of age. Studies have shown that more than half of children who experience infections of viral bronchiolitis and who have a family history of allergy go on to develop asthma.

Vocal cord dysfunction (VCD)

Numerous cases also exist in which children suddenly start wheezing because a coin, food particle, or other foreign body has become lodged in their windpipe, respiratory tube, or esophagus. If you suspect that a foreign object is lodged somewhere in your child’s respiratory system, seek medical help immediately.

Focusing on Special Issues Concerning Childhood Asthma

After your child’s doctor has diagnosed your child’s asthma, the doctor should develop an appropriate asthma management plan, in consultation with you and your child (if he or she is old enough to participate). Your child’s plan should consist of specific avoidance, medication, monitoring, and assessment measures, and it should also provide steps that you and/or your child can take in case his or her asthma symptoms suddenly worsen.

The basic components of an appropriate and effective asthma management plan include

Reducing your child’s level of exposure to asthma and allergy triggers. I describe these triggers in “Identifying children’s asthma triggers,” earlier in this chapter. (For detailed tips and information on avoidance measures, trigger control, and allergy-proofing, see Chapter 5.)

Monitoring your child’s peak-flow rates. Your doctor should show you and your child (if your youngster is older than 4 years old) how to use a peak-flow meter. (See “Peak-flow meters and school-age children [ages 5 to 12],” later in this chapter.) Using this simple device at home and school to measure peak expiratory flow rates (PEFR) can help detect early deterioration of asthma, prompting you or your child to make the appropriate change in medications or, if needed, to seek medical attention.

Children and their parents very often don’t perceive the early symptoms of worsening asthma without a peak-flow meter. As a result, you may not understand or notice when your child’s asthma symptoms worsen, thus critically delaying the proper medical treatment. (For detailed instructions on using peak-flow meters, see Chapter 4.)

Assessing and monitoring your child’s lung functions during regular office visits. These tests and assessments, as well as the PEFR numbers that you (or your child) record in an asthma symptom diary (see Chap-ter 4), are vital to tracking how your child’s condition develops and responds to prescribed treatment.

Using long-term preventive medications that control your child’s underlying airway inflammation, congestion, constriction, and hyperresponsiveness. (See Chapter 2 for details of how asthma affects the body.)

Implementing an asthma management plan for your child’s school or daycare. Prepare an emergency asthma management plan, which specifies short-term, fast-acting rescue medications for use only in the event that your child’s condition suddenly deteriorates. This type of action plan should also clearly explain how to adjust your child’s medications in response to particular signs, symptoms, and PEFR levels. Likewise, this action plan should tell you (or your child) when to call for medical help. (See “Handling Asthma at School and Daycare,” later in this chapter, for more information.)

Educating yourself, your child, your child’s teacher, and your family. This education can involve information and resources that your doctor, clinic staff, and patient support groups provide or recommend, as well as relevant books, newsletters, videos, and other helpful materials. (See the appendix for information on these resources.)

Teaming up for the best treatment

Integrate any treatment your youngster may receive from an asthma specialist (an allergist or pulmonologist) and your child’s asthma management plan with the general care that your pediatrician, family doctor, and/or primary care physician provides. A team approach by your child’s physicians can eliminate the risk of different doctors prescribing treatments for various childhood ailments that may, in combination, produce adverse side effects.

Managing asthma in infants (newborns to 2 years old)

The most difficult part of treating an infant with asthma is that the child isn’t old enough to tell you what’s wrong. Unfortunately, no devices are currently available for practicing physicians to use in order to measure infants’ lung functions. Special techniques do exist at a few major medical centers at this time, but scientists only use them for research purposes and not in clinical practice. Therefore, determining the extent and type of your baby’s respiratory problems can present some unique challenges. In these cases, your doctor mainly relies on medical history (including family history), physical examination, and response to medical therapy.

Depending on your child’s condition, your doctor may prescribe some of the following medications to control your baby’s asthma:

If your infant’s asthma symptoms are mild or intermittent, his or her doctor may prescribe an inhaled, short-acting beta ₂ -adrenergic in a nebulizer or oral beta ₂ -adrenergic syrup to reduce airway obstruction. Your doctor also can prescribe a recently approved pediatric, oral gran-ule formulation of montelukast (Singulair) for ages 12 to 23 months. Administer the medication directly into the baby’s mouth or by mixing it with the baby’s soft food. According to the product insert, the recommended foods are applesauce, carrots, rice, or ice cream.

If your child suffers from more severe symptoms, your doctor may prescribe a daily, long-term preventive medication, such as cromolyn (Intal) via nebulizer or inhaler; nedocromil (Tilade) via inhaler; an inhaled corticosteroid (Flovent) via inhaler; or a nebulizer form of budesonide (Pulmicort Respules). Because of your child’s young age, administering any of these medications with an inhaler requires using a holding chamber (spacer) and a mask. Occasionally, your child’s doctor may also recommend theophylline in a syrup, tablet (crushed), or capsule (sprinkled) form. (See Chapters 14 and 15 for information on asthma medications and delivery devices.)

Physicians prescribe theophylline syrup or suggest emptying beaded contents of a theophylline capsule on food such as applesauce so that your baby can easily ingest the medication.

In the event that your child suffers a severe asthma episode, your child’s doctor may prescribe a short course of oral corticosteroids, available in syrup form (Orapred, Prelone, Pediapred) or as a tablet (prednisone).

Listening to your children

Because children under 2 years old aren’t able to use a peak-flow meter, you may consider using a stethoscope to listen to your child’s lungs. Some parents find that using a stethoscope can help them detect an asthma attack in their infant or young child at an earlier stage and may enable them to more accurately report their youngster’s asthma symptoms to their child’s physician.

Consult your child’s physician to see whether using a stethoscope can help you. Likewise, ask your doctor for instructions on using the device properly. Keep in mind that a stethoscope detects breathing problems only if your child’s lung function drops by about 25 percent.

Using a nebulizer with your infant or toddler

If your doctor prescribes nebulizer therapy for your infant or toddler, make sure that you, as well as any other person who may be taking care of your child (such as a nanny, babysitter, and/or daycare provider), understand how to use a nebulizer appropriately and effectively. Using this device may challenge an older child, but for an infant or toddler who may be struggling to breathe, using a nebulizer can prove especially difficult. Chapter 14 provides more detailed instructions and tips on using nebulizers properly and effectively.

When using a nebulizer with a very young child (your doctor should give you specific advice based on your child’s condition), make stress reduction — for both you and your child — your first consideration. Try making the use of the nebulizer a more pleasant experience and maybe even a special daily occasion. Hold and cuddle your child first, and then slowly but firmly move the mask closer to your youngster’s face.

If your child isn’t experiencing sudden-onset severe respiratory symptoms, you can introduce the mask initially, before running the air compressor component of the machine. The air compressor can be noisy, and it may frighten your child at first. If your child suffers more severe symptoms, hold the mask fairly close to his or her face and then slowly move it closer until the mask is properly in place.

Delivering nebulizer doses properly

Keep in mind that a “blow by” (holding the nebulizer several inches from your child’s face and merely misting the medication) doesn’t help your child because the medication doesn’t effectively enter his or her airways, which is where your child needs the medicine. In order to properly deliver your child’s medications, the nebulizer must work as a closed system, with the mask fitting snugly on your child’s face, covering both the nose and mouth.

As with many other situations that involve very young children, you can use music, appropriate toys, a special cartoon video, or other types of entertainment as a helpful distraction for your little one. If all else fails, remain firm and steady, and make sure that your child receives the necessary medicine. Even the smallest infants ultimately discover that nebulizer treatments make them feel better. Eventually, that realization makes the time you spend administering nebulizer therapy more effective, comfortable, and rewarding for both you and your child.

Treating toddlers (ages 2 to 5 years): Medication challenges

Few medications are available in the United States for children ages 2 to 5 years. The Food and Drug Administration (FDA) has recently approved the use of montelukast (Singulair), a leukotriene modifier (see Chapter 15), in a 4-milligram chewable tablet, for use in this age group. However, inhaled topical corticosteroids and long-acting inhaled beta ₂ -adrenergic (beta ₂ -agonist) bronchodilators (or nonsedating antihistamines for allergic rhinitis) aren’t specifically formulated for children under 4 years. Therefore, nebulizer use can be extremely important during the toddler and early school-age years (see Figure 18-1).

The lack of specific medications for children under age 4 is a serious concern for doctors and parents. This age group has experienced the highest increases in asthma rates in recent years, yet is the last group to receive attention in the development of new asthma medications.

Fortunately, the U.S. Congress has established a program of incentives to encourage pharmaceutical manufacturers to conduct clinical trials of med-ications, including those for asthma, in the pediatric age group. In fact, FDA regulations require pharmaceutical companies to submit detailed plans for studying formulations specifically for children (for example, syrups and chewable tablets) when seeking approval for development of new drugs. With hope, this program can lead to improved medical treatments for young children with asthma and other allergic diseases.

Figure 18-1: Young child using a nebulizer.

Because very few effective asthma medications have gone through the drug development process for FDA approval for use with children under 4 years of age, many doctors prescribe drugs that haven’t been studied extensively for use in that age group. Therefore, determining the appropriate dosages of asthma medications for toddlers can prove challenging. Children react differently to medications than do adults, and determining the correct dosage for children isn’t as simple as assuming that the toddler receives half of an adult dose.

Peak-flow meters and school-age children (ages 5 to 12)

By the time children reach age 5, they can generally use a peak-flow meter at home. This device allows you and your doctor to assess the state of your child’s lungs. Using a peak-flow meter each morning and night can help you and your child manage his or her asthma in the following ways:

Educate both you and your child about what works in terms of treatment and what triggers may cause problems

Enable you to discuss your child’s condition in terms of specific criteria, thus enhancing communication between you and your child’s doctor

Provide an objective way of tracking your child’s response to his or her asthma medications

Warn you and your child that an asthma episode is looming

Establishing your child’s personal best peak-flow rate enables you and your child to tell when problems occur, because you can note when the rate goes down according to the green, yellow, and red zones of the peak-flow zone system. For more information on using peak-flow meters, turn to Chapter 4.

Getting kids into clinical trials

Conducting clinical trials with young children — especially those under 4 years — is very costly and time-consuming compared to clinical trials involving children older than 12 years and adults. Because of the great need for pediatric patient participation, make a commitment to enroll your asthmatic infant and toddler for clinical trials. Doing so can help develop new and better medications that benefit all children. In addition, you and your child can probably discover a great deal about asthma and its management, and you may love all the extra attention while participating in these studies. In addition, the medicines being tested are free, and patients are reimbursed for their time and travel while participating in a clinical trial.

Pharmaceutical companies also need to make a commitment to conduct trials for younger children. These trials may cost more and prove difficult, but the lives and health of young children depend on such studies.

Using inhalers: Teens and asthma

Many teens with asthma feel different and insecure because of their disease. Unfortunately, adolescent anxieties about fitting in and being cool can result in teen asthmatics ignoring or not properly managing their disease. In some cases, adolescents may even allow their symptoms to worsen rather than simply taking a whiff or two from their inhalers.

To avoid these types of potentially dangerous asthmatic situations, allow your teenager a voice in the management of his or her asthma. Depending on the severity of your adolescent’s asthma, your doctor and teenager can work together to develop a plan for adjusting medication therapy in order to control symptoms, thus avoiding serious episodes that may seem especially embarrassing for a teen. Some asthma medications last 12 hours (see Chapter 15), and therefore your adolescent can use them at home in the morning and the evening, minimizing the need for your teen to be seen using medication while at school.

Your child may also benefit from participating in a support group with other teenage asthmatics. Encourage open and honest discussions with your children about their conditions to ensure that they feel better informed and more respected. Participation in setting goals for therapy, developing a treatment plan, and reviewing its effectiveness can also help teenagers build a positive self-image, increase personal responsibility, and gain problem-solving skills, thus making them more likely to make better decisions about managing their condition.

Handling Asthma at School and Daycare

If your child has asthma, inform the teachers, administrators, and school nurse about your child’s condition. Some schools and daycare centers institute asthma management programs that provide the following:

Policies and procedures for administering students’ medications.

Specific actions for staff members to perform within the program.

These actions may include establishing clear policies on taking medications during school hours, designating one person on the school staff to maintain each student’s asthma plan, and generally working with parents, teachers, and the school nurse (if one is available) to provide the most support possible for students with asthma, especially so they can have access to medications they may need while at school.

An action plan for treating students’ asthma episodes.

Whether or not the school or daycare center administers such a program, take the following steps to ensure that your child’s school days are as healthy, safe, and fulfilling as possible:

• Meet with school staff to inform them about any medications your child may need to take while on campus, as well as any physical activity restrictions that your doctor may advise. (Properly managing their condition allows most children with asthma to participate in sports and PE classes.)

• File treatment authorization forms with the school office and discuss what school personnel must do if your child suffers an asthma emergency. Also, provide instructions on how to reach you and your child’s physician during an emergency.

• Inform school personnel of allergens and irritants that can trigger your child’s asthma symptoms, such as pets in the classroom, and request that the school remove the sources of those triggers, if possible.

Make sure your child understands that everyone’s asthma is different and that asthma medications shouldn’t be shared. Exchanging asthma medications among kids can cause dangerous problems because individual prescriptions vary according to the severity of each child’s asthma and other factors. Don’t let children use each other’s inhalers, because doing so can also spread potential infections, such as colds and flu. Chapters 15 and 16 contain specific information about controller (long-term) and rescue (short-term) asthma medications.

Indoor air quality (IAQ) at school and daycare

From about the age of 2, most children spend the majority of their waking hours at school or daycare. Therefore, ensuring that these environments are as free of potential asthma triggers as possible is essential to your child’s health.

According to the Environmental Protection Agency (EPA), recent studies indicate that indoor pollutant levels can often be two to five times higher than outdoor levels, occasionally as much as 100 times higher. Irritants and allergens that can affect your child at school often include the following:

Outdoor smoke, soot, chemicals, pollens, and mold spores

Animal dander from a furry classroom pet

Indoor mold from ventilation ducts as well as indoor irritants such as tobacco smoke, scents from printers and copiers, and fumes from heating, ventilation, and air conditioning (HVAC) systems

Asthmatic symptoms related to poor indoor air quality (IAQ) may resemble those that you typically associate with colds, allergic rhinitis, fatigue, or flu. For this reason, you may not as easily realize that your child’s asthma suffers as a consequence of poor IAQ at school and daycare. However, the following tips may provide clues that can help you decide whether IAQ is a factor:

Many students, teachers, administrators, and other personnel experience similar symptoms.

Your child’s symptoms (and those of other affected people) improve or disappear after school or daycare.

Symptoms begin to appear rapidly following physical changes, such as construction work, painting, or pesticide use at the school or daycare.

Your child and other people with allergies or asthma only experience symptoms inside the building.

If you think that your child may experience symptoms related to poor IAQ at school or daycare, contact an appropriate staff member. Your child’s school (or school system) may staff an IAQ coordinator or health and safety coordinator to respond to your concerns.

Participating in PE — exercise and asthma

Living with asthma doesn’t mean that your child needs to sit on the side-lines. Participating in PE and other opportunities for exercise are vital for a child’s development, regardless of whether or not the youngster has asthma. Nonetheless, make sure that the school’s PE instructors are aware of your child’s condition and that they know what to do in case an asthma episode develops.

PE instructors and coaches should encourage your asthmatic child to par- ticipate actively in sports, but they must also realize and respect your child’s limitations. In addition, extended running and any exercise that takes place in cold, dry air appears to trigger asthma flare-ups, known as exercise-induced bronchospasms (EIB) or exercise-induced asthma (EIA). Exercise is one of the most common precipitants of asthma symptoms that most doctors see in clinical practice. More than 90 percent of patients identify physical exertion as a major cause of their asthma symptoms. Although EIA can develop at any age and occurs equally among adults and children, it is a much greater problem in kids because of their characteristically greater degree of physical activity. (See Chapter 9 for more information on EIA.)

Your child’s doctor may prescribe medications to control and prevent EIA, as well as advise appropriate warm-up and cool-down activities that can also reduce the risk of EIA. Having an action plan in place prior to an emergency can ensure that your child receives the proper treatment when he or she needs it most. Part of that plan should include providing immediate access to your child’s rescue drug in case it’s needed to treat the onset of any acute respiratory symptoms.

As long as your child sticks to his or her asthma management plan, the disease shouldn’t preclude your child from enjoying or even excelling at a wide range of physical activities. Consider the example of Olympic Gold medalist Jackie Joyner-Kersee and many other top athletes with asthma.