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Sneezing, Wheezing and Coughing, Oh My!

Diagnosis and Treatment of Pediatric Asthma and Allergies

Online Health Chat with Dr. John Carl

May 4, 2011


Introduction

Cleveland_Clinic_Host: Asthma and allergies are the most common chronic childhood diseases. Asthma affects nearly five million children in the United States and is the cause of almost 3 million physician visits and 200,000 hospitalizations each year. Uncontrolled asthma can lead to missed school days, interrupted sleep patterns, and, ultimately, poor school performance. It is important to realize, however, that asthma symptoms can begin at any age -- from infancy through adulthood. Allergies affect about 50 million American children. Allergies are the body's incorrect response to a foreign substance.

Exposure to what is normally a harmless substance (such as plant pollen, mold, or animal hair) causes the immune system to react as if the substance is harmful.

A Cleveland Clinic Children’s Hospital pediatrician or specialist can effectively manage asthma and allergies by identifying and reducing exposure to known triggers (substances that produce asthma symptoms), and offering an individualized disease management plan that includes measurement of disease severity, provision of medications, and means to seek medical attention and information. In addition to treating hospitalized children and adolescents at Cleveland Clinic's main campus, our specialists have outpatient practices at Cleveland Clinic's main campus, and at Fairview and Hillcrest hospitals.

John Carl, MD, is a pediatric pulmonologist at Cleveland Clinic Children's Hospital who diagnoses and treats pneumonia, asthma, bronchitis, emphysema, and other respiratory problems in infants, children, and adolescents. He specializes in growth and development of the lung, airways, and respiratory function in children, and uses a variety of invasive and noninvasive diagnostic techniques on young patients.

Cleveland Clinic Children’s Hospital pediatric pulmonologists, critical care specialists, and allergists have unparalleled expertise, attracting national and international patients seeking diagnosis or advanced treatment, often for rare or complex disorders. In providing effective treatment for children with respiratory illnesses, our pediatric pulmonologists collaborate with top Cleveland Clinic pediatric specialists and surgeons in areas such as cardiothoracic surgery, cardiology, hematology/oncology, infectious disease, and rheumatology.

In addition to comprehensive clinical evaluation, we emphasize patient/parent education to enable self-management. We provide access to both complete pulmonary function and allergy diagnostic testing, and can provide specialty care from board-certified pulmonologists and allergists with a single visit.

Cleveland_Clinic_Host:Welcome to our Online Health Chat with Dr. John Carl, pediatric pulmonologist at Cleveland Clinic Children's Hospital. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


trish: My 14-year-old son developed seasonal allergies a few years ago. Each season they become worse and worse. He was put on an inhaler in the fall because he had some rattling in his lungs. Can allergies become progressively worse? Can they develop into asthma?

Dr__John_Carl: Yes. Allergies (particularly to environmental allergens such as pollens, grasses, and molds) can get worse over several years. It sounds as though your son has been provided with an albuterol inhaler to help with short-term symptoms. While this medication may help in the short term, it will not help with addressing any of his allergic symptoms. The allergies themselves can be separate from -- or triggers of -- asthma. I recommend you seek further evaluation of these triggers if he doesn't completely resolve the "rattling" symptoms.

kelley: I've been told that my son has "mild" asthma. What does this mean?

Dr__John_Carl: Hi Kelley. Mild asthma usually means the physician doesn't consider the level of asthma to be life-threatening. Your son may not have needed to consult an emergency department or have inpatient hospitalization for asthma care. That's great, but it doesn't mean that he doesn't need ongoing therapy for asthma. At the milder end of the asthma spectrum, we talk about symptoms as being "intermittent," when patients have one or fewer episodes of cough, wheezing, or shortness of breath per week, in which case albuterol alone may be sufficient treatment. If these symptoms occur more than twice per week, we usually term it "mild persistent" asthma. The recommendations for this level of asthma are that patients receive daily controller therapy -- usually low-dose inhaled steroids.

quincy: I want to ask the age-old question: can you 'grow' out of having asthma?

Dr__John_Carl: You are right. This is an "age-old" question. Our best understanding is that those children under 3 years of age who have wheezing only with viral respiratory infections may not necessarily later develop the older child or adult form of asthma. Children between 3 and 6 years of age who have wheezing apart from viral infections usually will continue to wheeze or have asthma in later life. Once a child is older than 6 years of age, wheezing even during a respiratory infection likely represents asthma. These age break-points are actually more tied to the cross-sectional diameter of the airways at those ages -- smaller airways of younger children may reach a critical narrowing to cause wheezing -- so not all infant wheezing will become asthma.


Symptoms

greatdad: My daughter just started playing fourth grade volleyball. When she runs she complains of breathing difficulty and pain in her neck. Is it asthma? What signs should I be looking for? Why would she complain of pain in her neck?

Dr__John_Carl: Exercise is often a trigger for asthma symptoms, and complaints of neck "pain" are used by some children as a main descriptive term. I would review her symptom pattern with your pediatrician and discuss a possible trial use of an albuterol inhaler prior to exercise to determine if she has fewer symptoms. If not, then other possibilities should be considered.

jaka: Over the last two years, my (now) 14-year-old son has had three or four bad asthma attacks, twice going to the emergency room. He has also had a few more minor attacks. All of these attacks were brought on by respiratory illnesses (bad colds). One doctor has said he has asthma because of these attacks. He was tested for asthma, and we were told the reports were not typical of an asthma patient and, based on the results of the test, he did not have asthma. He takes Flovent® now as a preventive during cold season and uses albuterol for asthma episodes. What criteria do you use to diagnose a child with asthma? What causes him to have these attacks when sick, and will this be a problem that he has to deal with for the rest of his life? Can it get worse? He has had no breathing problems, except when sick

Dr__John_Carl: Your description of his episodes certainly sound like asthma. I think it sounds likely that he is receiving Flovent® (fluticasone) therapy only during "cold" season. He may not be receiving a sufficient dose of inhaled steroid to control his symptoms or keep him out of the emergency department. He also may not be using the Flovent® consistently enough (or long enough). I would recommend that he have a pulmonary function test (PFT) performed in addition to reassessment by his pediatrician. The PFT may well give information that he has lower lung function even when not experiencing cough or wheezing symptoms, and would show that he really needs controller (or more controller) medication all the time.

gonefishing: Can allergies cause a young child to cough for weeks, even while on medication? My 4-year-old seems to be fine otherwise (besides the cough).

Dr__John_Carl: Allergies may cause long-term coughing in children from "post nasal" discharge falling backward onto the vocal cords and triggering cough. If the allergy medications are insufficient to control symptoms, this can last for a long time. You should still discuss this with your pediatrician, however, since even cough as a single symptom can reflect other problems.


Medications

polly7: What medications are best for the treatment of asthma? What are their side effects?

Dr__John_Carl: Hi, Polly. Albuterol is usually the primary "rescue" or short-term medicine that is used to help acute asthma symptoms, such as coughing or wheezing. When a patient needs to use albuterol to relieve daytime symptoms more than twice per week, however, it usually reflects the need to use daily "controller" or anti-inflammatory medications. Many people are concerned about possible side effects of inhaled steroids, which are the largest group of "controller" medications available. When used in low- to medium-doses, however, inhaled steroids are very safe, even used on a daily basis for years. They are much safer than either multiple courses of oral steroids OR uncontrolled/undertreated asthma symptoms.

mara: My son was prescribed albuterol to use when he is wheezing. It is not very effective. What else can we try?

Dr__John_Carl: Albuterol is most often very effective if used properly. I hope he/you have been instructed to use the inhaler with a valved holding chamber (spacer) device. Using one can greatly increase the amount of the "puff" administered that reaches the lower respiratory tract, making the medicine much more effective overall. If your concern about it not working is just that his symptoms come back after several hours, then he may need a "controller" medication as well.

berta: With severe allergies that require an EpiPen®, how old should a child be before he or she is allowed to carry it with him or her? Also, is there an age when you say it is okay for a child to carry their own rescue inhaler?

Dr__John_Carl: The laws vary by state about allowing a child in a school setting to carry either an EpiPen® (epinephrine injection) or a rescue inhaler. I think it also varies by individual patient, too. I have some adolescent patients for whom I recommend supervised administration of albuterol, though many early school age children can appropriately self-administer inhalers. Use of either medication in a school setting should include open communication with school personnel and parents.

jenk2: My 5-year-old daughter has asthma. What is the effect of using an asthma preventer long term? I heard that using it for years might cause bone shrinkage. Is it true?

Dr__John_Carl: There is a lot of discussion by parents and physicians about the use of daily inhaled steroids (the "preventers" that you mentioned). When used at low dose, I feel there is robust data to support that they are very safe, even if used for years. There are good long-term studies that show there is not any significant effect on achieved height or growth velocity, and no effect on things that are associated with use of oral steroids, such as diabetes, hypertension, and immune suppression. At low dose, they won't cause bone shrinkage. Most pediatric asthma specialists choose to decrease doses of any inhaled steroids used about every three to six months if they achieve good symptom control.

Lex400: How old should a baby be before you use a decongestant? My 10-month-old gets so clogged up, and using saline and a bulb syringe just does not seem to help.

Dr__John_Carl: Lex, the American Academy of Pediatrics has discouraged use of decongestants in most children under 5 to 6 years of age. I certainly wouldn't use them for a 10-month-old child. You should discuss other measures with your pediatrician. Hang in there, the bulb suctioning can be frustrating for older infants.


Over the Counter (OTC) Medications

soccermom: Do you recommend an OTC allergy medication over prescription medications for allergies? If so, which is the best?

Dr__John_Carl: There are several OTC (over the counter) allergy medications now available. The best non-sedating ones are: loratadine (brand name: Claritin®) cetirizine (brand name: Zyrtec®); and fexofenadine (brand name: Allegra®). All can be effective for many people with allergies. Allegra® just became an OTC agent, and I don't think it is yet available as a generic. You can also get these medications in combination with decongestant (pseudoephedrine), but alone they can be very helpful. They come in many forms (pill, liquid, dissolvable tablets), so you have many choices.

Tamara68: Is the new Allegra® OTC medication the same strength and potency as the prescribed Allegra®?

Dr__John_Carl: Yes. It should be the same dosage and potency. If choosing an OTC product in place of a prescriptive product that was previously used, however, I would check the dosage that was prescribed and compare it to the now available OTC preparations.


Genetic Influence

daredevil: Does it really help to delay milk and solid foods for babies in the hopes of preventing allergies and asthma?

Dr__John_Carl: No, only if they have a genetic push (or tendency) for allergies.

sandcastles: Does it help to have pets or to expose children to animals at a young age?

Dr__John_Carl: Great question! This also depends on genetics. Most people don't have a genetic tendency to an allergy to dogs or cats. If you do, however, they can accelerate the onset of symptoms. The data on cats and dogs are variable, however.

gordie: My 16-year-old daughter has been having a lot of trouble recently with eczema. She had this as a child; was nickel sensitive, etc. Until recently, she had a patch here or there. Is eczema allergy related? What can she use to get rid of it? Hydrocortisone ointment does not seem to help.

Dr__John_Carl: Asthma, allergic rhinitis, and eczema are all considered "atopic" conditions with some common genetic basis. It is possible to have one or all of them, however, which obviously means there are individual environmental and infectious differences between individuals. Your 16-year-old daughter likely still has allergies, reflected in part by her current eczema. OTC hydrocortisone preparations are often not strong enough to have a good result in children with as much eczema as your daughter seems to have. Longer-term use of lower potency topical steroids can also result in long-term changes in skin pigment, so I would recommend discussing this with your allergist or dermatologist.

2hard: Does day care/preschool, etc. have an effect on children developing allergies or asthma?

Dr__John_Carl: Yes, it does. Most children in day care or preschool settings experience more viral respiratory infections in the first two to three years of life than children who are at home with no siblings. If you control for genetic background and environmental triggers, however, the children who attended day care/preschool had a lower incidence of asthma later in life.


Colds vs. Virus

violette: My 17-month-old daughter has been coughing a lot the past month or so. Her pediatrician says it's just a cold, but it seems to be getting worse. What should I look for to be sure it isn't anything more serious?

Dr__John_Carl: Violette, a great question! I agree with your concern that a month-long cough needs to be evaluated further and not simply dismissed as a "cold." Unfortunately, her symptoms may just represent "back-to-back" viral infections. In Ohio, we have seen a lot of Parainfluenza viral infections this spring. (This is one of the viruses in the "croup" virus family.) These infections have been causing prolonged symptoms. In any case, however, a month of symptoms probably deserves a chest X-Ray, careful re-exam, and further discussion with your pediatrician.

violette: Referring back to my earlier question, how long should viral symptoms last?

Dr__John_Carl: I usually feel that viral "cold" symptoms should last fewer than seven days.

Celia: How does one differentiate between allergies and just a good old-fashioned cold?

Dr__John_Carl: Allergies usually include sneezing, runny nose, eye itching and redness. These won't resolve until the offending allergen (grass, dog, cat, etc.) are removed (or the season changes). Cold symptoms usually resolve with the decrease in runny nose within a week. Colds (viral respiratory infections) may also be accompanied by fever, which is very unusual with allergic rhinitis.


General Questions

2011: I have read that excessive use of antibacterial products (such as Purell®) is contributing to children being sick more often, as they do not naturally develop antibodies. Is this true with allergies as well? Is there any connection?

Dr__John_Carl: What you are referring to is what physicians and asthma researchers term the "hygiene hypothesis," which reflects that exposure to certain bacteria at an early age may actually decrease the likelihood of a child later developing asthma. This is population data, and shouldn't be interpreted in your child. I certainly wouldn't discourage routine use of hand washing or hand sanitizers for any child (I don't for my children, either).

midtown: Is there anything you should or should not eat while pregnant that can help prevent allergies in children?

Dr__John_Carl: I think the prudent answer would be to include a well-balanced diet throughout pregnancy, directed by your obstetrician/midwife. If you have specific food allergies, it would be advisable to avoid them.

CampMom: What is the big deal with peanut (or any nut) allergies? I know that some people can have severe allergic reactions, but why do so many kids seem to have this allergy now compared to when I was growing up in the late 70's?

Dr__John_Carl: Exposure to peanuts or other nuts is life-threatening to some people. This can be from exposures as "innocuous" as sitting next to someone eating them, or touching a cookie that contains peanuts to your lip. Avoidance is the best strategy. The issue of increasing incidence requires a longer answer (sorry).


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Carl is now over. Thank you again Dr. Carl for taking the time to answer our questions today about pediatric asthma and allergies.

Dr__John_Carl: Thanks, everyone, for your excellent questions. I enjoyed talking with you.


More Information

To make an appointment with John Carl, MD or any of our pediatricians or pediatric specialists at Cleveland Clinic Children's Hospital, please call 216.444.KIDS (5437) or call toll-free 800.223.2273, ext. 5437. You can also visit us online at www.clevelandclinicchildrens.org.

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