Cleveland_Clinic_Host: Asthma is a common condition of childhood that affects about 5 to 10 percent of children in the United States. Uncontrolled asthma in children 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 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.

Today, Dr. John Carl will be available to answer your questions concerning pediatric asthma and allergy diagnosis, treatment and management.

Your child's physician can effectively manage asthma and allergies by identifying and reducing exposure to known triggers (substances that produce asthma symptoms), offer an individualized disease management plan that includes measurement of disease severity, provision of medications, and means to seek medical attention and information.

Our speaker today, Dr. Carl, 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.

For more information regarding pediatric asthma and allergies, to make an appointment with Dr. John Carl, or any of our other specialists within the Cleveland Clinic Pediatric Institute and Children’s Hospital, visit our website.

newtonm: My son had an RSV type respiratory infection at about 6 months and needed to use a nebulizer every time he got sick for about 2 years. His doctor thought he might grow up with asthma. That does not seem to be the case. He is 8 now and seems to be fine, although he does seem to breathe slightly harder after running a lot. Can kids grow out of these conditions or is this something I need to keep my eye out for?

Speaker_-_Dr__John_Carl: Many children, in preschool years, seem to "grow out of" infant asthma symptoms. This is because the diameter of their airway grows as they grow. By early school years, most children will be able to sustain activity such as soccer or swimming for long enough to begin triggering exercised induced symptoms. Many then are "re-diagnosed" with asthma. The good thing is by this age, we can get objective measurement by pulmonary function testing.

ylb123: As an infant and child I had a lot of problems with breathing, bronchitis-chronic, asthma, etc. However, recently I was just diagnosed with Platypnea orthodeoxia and a PFO. Could my breathing problems been caused by that vs. asthma, bronchitis, etc.?

Speaker_-_Dr__John_Carl: Platypnea orthodeoxia will cause shortness of breath due to the connection between the left and right side of the heart and is associated with functional components, such as movement. The symptoms may be similar to, but obviously very different than asthma, which is tightening of the muscles surrounding the main airways. It is unlikely that all of your symptoms would have been caused by the Platypnea orthodeoxia over many years, but I would follow the lead of your cardiologist.

liane15: My friend was diagnosed with asthma when she was five years old. Her doctor told her that she has been treated when she turned 16. She has not had any asthma attacks for years now. However, yesterday she experienced difficulty breathing, chest pains, and dizziness. Would it be possible that she is again experiencing an asthma attack? Or is it something else?

Speaker_-_Dr__John_Carl: Even if her asthma has been silent for years, new allergens, new levels of exercise or other medications that she may be taking may precipitate the onset of an asthma attack.

Asthma Medications and Treatment

deena: Can you please list the medicines (or at least some) used in the treatment of childhood asthma and their side effects? Are there different medications used at different ages?

Speaker_-_Dr__John_Carl: The recommendations really don't vary too much between age groups. Inhaled steroids are the cornerstone of controller (preventative) therapy. Singulair® is also a controller medicine that is not a steroid and works by a different mechanism. Commonly used steroids include: Flovent®, Pulmicort®, Asmanex®, and QVAR®.

The primary rescue medication (used for short term relief) is Albuterol (ProAir®, Ventolin®, Proventil®) and LevAlbuterol (Xopenex®). At low to moderate doses, the inhaled steroids are very safe and generally without significant likelihood of side effect. Albuterol side effects include increase heart rate and jitteriness, but these are short-lived.

carriem: What would you consider as overuse of an inhaler in a child and what are the dangers?

Speaker_-_Dr__John_Carl: I presume you are talking about overuse of rescue inhalers, such as Albuterol. We aim to have children not need such rescue medicines more than a couple of times a week. Using dose after dose of Albuterol during an asthma attack without seeking medical care is very dangerous. This is very common, particularly in teenagers, who are often left to use their own medications. They use it because it relieves symptoms in the short term.

In an attack however, the problem is a huge inflammatory process for which Albuterol does nothing other than relieve symptoms. That is why getting an oral steroid and seeking medical care is absolutely essential.

Enystrom: What signs and symptoms tell a child it is time to use a PRN inhaler (puffer)?

Speaker_-_Dr__John_Carl: Cough, wheezing or shortness of breath. These should be the primary symptoms for which a child should be told to use a rescue inhaler such as Albuterol. The degree of improvement and ability to return to normal activities without symptoms should determine whether additional doses should be administered.

More is not always better. If after 2-3 doses of Albuterol the patient is still experiencing symptoms, then a doctor or Emergency Department should be consulted.

speerinl: Is there concern about over exposure to steroids (and thus the negative side effects of bone loss, muscle weakening, etc) when children regularly use nasal or oral steroids?

Speaker_-_Dr__John_Carl: These are very real concerns for many parents. A large US study, Childhood Asthma Management Program, followed children for over 4 years, who were consistently dosed with low-dose inhaled steroids and saw none of those effects. In particular, there was no significant change in achieved height or growth velocity. This has given us a lot of reassurance for using these medications.

Allergy Overview

funkytown: How can you tell the symptoms of a cold from the symptoms of allergies? How do you know how to treat?

Speaker_-_Dr__John_Carl: Prolonged nasal congestion or runny nose due to allergies may persist for much longer than the average cold, which should resolve in 5-7 days. Sneezing and itching or burning eyes may tip you off to allergies as the source, rather than a cold.

speerinl: I think I am more miserable watching my son with allergies, than he is. We have been trying a number of oral and nasal medications but as soon as the dose wears off he is symptomatic again. At what point are injections/shots warranted for seasonal allergies?

Speaker_-_Dr__John_Carl: Part of the difficulty is continuing the nasal medications for a long enough period of time. It is also important to identify which allergens he may be sensitive to enable you to do better environmental control and vary oral antihistamine dosing. Allergy shots should then be considered.

Enystrom: At what point is it necessary to consider allergy shots rather than OTC options such as Claritin® or Zyrtec®?

Speaker_-_Dr__John_Carl: Most seasonal allergic rhinitis should be addressed first by avoidance (environmental control), antihistamine therapy such as Zyrtec® or Claritin® and nasal steroids. Only after medications are tried should allergy shots usually be considered.

marilynmonroe: Is allergy testing on children reliable and at what age?

Speaker_-_Dr__John_Carl: Yes it is reliable. It can be done as early as 1 year old, but in my practice I usually wait until 2 years, unless there are overbearing reasons to get it done earlier.

Allergy Medication and Treatment

katw21: I have been on Claritin® for almost 3 weeks, but I am still sneezing constantly and have itchy eyes, is there something else I can try?

Speaker_-_Dr__John_Carl: You would have to speak with your clinician about obtaining a nasal steroid spray. Eye symptoms can be treated with Zaditor® eye drops, which are now available over the counter, but other medicines which require a prescription, like Patanol®, also are available and may help.

speerinl: What are the advantages to OTC allergy meds vs. prescription meds for allergies?

Speaker_-_Dr__John_Carl: Both Cetirizine (Zyrtec®) and Loratidine (Claritin®) are now both OTC. Fexofenadine (Allegra®) is still prescription. All these are considered to be non-sedating. These are preferable in children so as not to interfere in school performance. The OTC medications are usually Diphenyhydramine (Benadryl®) - containing compounds. Many have anti-cough medications such as Dextramethorphan as well. Most of these can cause some drowsiness.

chickadee: Will my son’s body to become used to a medication, so that it is no longer effective? For example, Claritin®?

Speaker_-_Dr__John_Carl: Yes, you can become tolerant after a long time on a single antihistamine. Usually I switch to a related agent and then often you can go back to the original medication after a couple of months with good results. It is not as though you are gaining a life-long tolerance to a medication.

Asthma and Allergy Triggers

alanb: Can stress and anxiety worsen asthma symptoms?

Speaker_-_Dr__John_Carl: Yes, they can worsen asthma, but not cause it. Particularly in adolescents, a syndrome called vocal cord dysfunction can simulate asthma and is particularly common in stressful circumstances. This is because the muscles controlling the vocal cords spasm and narrow the airway, causing wheezing. It is difficult for a parent or observer to separate the two in real time.

Asthma and Allergy Prevention

blanketp: Is there anything I can do at home or to my home to help my child with her asthma symptoms?

Speaker_-_Dr__John_Carl: If there are indoor allergens to which you know she is allergic, such as dust mites, there are many things you can do to help control the indoor environment. These include zippered pillow and mattress covers, covering vents from air ducts, and removing carpet from bedroom. HEPA filters can also be of significant help.

Pet Allergies

marykate: What are the recommendation regarding pets? My children really want a dog but my son has asthma and some allergies, although not to dogs.

Speaker_-_Dr__John_Carl: As a dog lover, it is possible to have a different allergic response between breeds. The problem is that if your child has not been exposed to that breed, it is unlikely that he would yet demonstrate an allergic response to it. There is much less variability in response to cat allergen. If you are allergic to cat allergen, it serves for all domestic breeds.

katw21: When it comes to pet allergies, how often should dogs be groomed to avoid severe symptoms, particularly in long haired breeds?

Speaker_-_Dr__John_Carl: I don't know that there is any perfect answer. The antigen for dogs and cats are found in dander, saliva and urine - so it is not just the hair.

Is Asthma Genetic?

newtonm: What are the genetic aspects of asthma? My husband has exercise induced asthma. Does this mean our children may also end up with asthma?

Speaker_-_Dr__John_Carl: The greatest genetic risk is having a mother, who as an adult is a diagnosed asthmatic. There is an increased risk if other first degree relatives have asthma. Asthma is multi-factorial however, which means that environmental exposures and one's own history of infections contribute substantially.

Talking to your child about Asthma

babybird213: My nephew is 6 and gets stressed over his asthma which brings on more attacks. He doesn't like being different from his classmates. He is only comfortable to talk within the family. Any recommendations to decrease his stress and improve his asthma?

Speaker_-_Dr__John_Carl: I would let him know that there are probably many other children in his school that have asthma. If his asthma is not well controlled, it is likely to be more of an issue. I would suggest that something other than stress may be triggering symptoms, like a seasonal allergen. If so, his controller therapy can be increased so that he does not experience symptoms through the school day. No kids want to feel "different."


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

Speaker_-_Dr__John_Carl: Thanks everybody for a lively discussion. I look forward to another opportunity to speak with you in the future!

More Information

For more information regarding pediatric asthma and allergies, to make an appointment with Dr. John Carl, or any of our other specialists within the Cleveland Clinic Pediatric Institute and Children’s Hospital, visit our website or call us locally 216.444.KIDS (4-5437) or toll free 800.223.2273 ext 4KIDS (4-5437).

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This chat occurred on May 27, 2009.
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