The wheezing infant has confused health professionals for years. Many physician training programs taught that a child should not be diagnosed as having asthma before the age of two or, in some instances, age four. Other terms such as ” reactive airways disease,” “chronic bronchitis,” or “recurrent bronchiolitis” were used to describe infants and toddlers with recurring cough, wheezing, or labored breathing.
The current definition of asthma does not exclude any age group. In fact, guidelines from the National Institutes of Health make specific mention of the infant and toddler with asthma. The diagnosis of asthma is based not on age but on a child’s medical history and physical examination. If an infant or toddler meets the criteria and other possible diseases are excluded, the child is diagnosed with asthma. Yet there are some differences between infants and toddlers with asthma and older children and adults with asthma. Parents need to understand the special considerations for this youngest age group.
The Cold Connection
Many different types of triggers can cause an asthma flare in older children and adults. In infants and toddlers, however, the most common trigger is a cold caused by a respiratory virus, known as a “viral upper respiratory tract infection,” or URI. The usual pattern for an infant with asthma starts with a cold, then the cough gets worse, and finally labored breathing and wheezing begin. In young children whose asthma is not well controlled, other nonspecific irritants such as smoke or fumes can also trigger asthma symptoms. Allergies playa smaller role in these early years, although some children show allergic tendencies quite early in life.
Studies of the development of asthma have followed a large group of children from birth. These studies suggest that babies and toddlers with asthma fall into two categories:
Group One
The first group has asthma symptoms until age four or so and then no longer shows any symptoms. These infants and toddlers have asthma symptoms only with colds and have none when they are well. Parents of children in this group tend not to have asthma. Children in this group usually don’t have any signs of allergies, such as eczema. This is the only group that seems to “outgrow” asthma. Young children who have asthma symptoms only with colds might be treated with asthma medicines from the first sign of a cold until the last symptom is gone, and they may not need to take controller medicines in between. Consider this child’s situation:
Brenda got her first cold when she was two months old. The first day she had a runny nose, then she started coughing. The next day the runny nose disappeared, but the cough grew worse in severity and occurred during sleep. She also developed a “rattle” in her chest. Her cough continued for two weeks despite cough medicine and then gradually went away. She caught another cold a month later and almost immediately developed a hacking cough and chest congestion. Her pediatrician heard wheezing and prescribed albuterol by nebulizer. The albuterol helped temporarily, but her symptoms returned four hours later. These symptoms hung on for two weeks before disappearing. This pattern continued through a few more colds.
During a well baby visit, Brenda’s pediatrician prescribed an inhaled steroid to go along with the albuterol and advised her parents to start the medicines at the first sign of a cold. A month later, they began giving her medicines the first day her nose started running. This time her cough only lasted three days and seemed less severe. This plan was used for each cold, and the cough and wheezing were easily controlled.
In the spring following Brenda’s third birthday, her doctor recommended stopping this plan. Brenda had several minor colds over the next few years, but the harsh cough and wheezing never returned.
In youngsters like Brenda, asthma symptoms appear only with colds. Using a quick-relief medicine alone (albuterol) decreases the symptoms for the moment, but they return over two weeks. Adding an anti-inflammatory medicine (the inhaled steroid) to the albuterol at the first sign of a cold controls symptoms so they are not as severe and do not last long. This plan may work in some cases, but in other cases a child may need to take an anti-inflammatory medicine every day even when well to prevent asthma symptoms during colds.
Group Two
In the second category, infants and toddlers have symptoms not only during colds but also in between colds. Parents of children in this group usually have a history of asthma, and these children are more likely to show some form of allergic disease. They do not outgrow their asthma, although there may be periods of remission later in life. Some children in this group also experience a decline in lung function.
Young children who have symptoms in between colds benefit from daily controller therapy to guard against the inflammation that causes symptoms. Children in this group tend to have symptoms that are more severe and more difficult to control. Daily controller medicines may also guard against loss of lung function. Compare Brenda’s case with Michael’s below:
Four-month-old Michael developed a hacking cough, wheezing, and labored breathing after getting his first cold. His mother, who has had asthma all of her life, recognized the symptoms immediately and took her son to the doctor’s office. Michael was admitted to the hospital with “bronchiolitis” and treated with nebulized albuterol and oral prednisone. He was discharged with a nebulizer, and his parents were given instructions to give albuterol by nebulizer if the wheezing returned.
In the months following the hospitalization, Michael had several wheezing episodes. The albuterol made the wheezing disappear for a time. He also developed eczema. With the next cold, Michael had severe labored breathing despite several albuterol treatments and was hospitalized again. This time, he was diagnosed with asthma, and a daily inhaled steroid was prescribed as maintenance therapy. Two weeks later, the episodic wheezing stopped.
With each cold, he experienced three to five days of harsh coughing and wheezing, but these symptoms were easily relieved with albuterol. Throughout his school age and teen years, Michael continued to have brief, mild bouts of wheezing in response to a variety of triggers, and his symptoms got worse whenever the daily medicines were withdrawn.
His mother’s history of asthma, the appearance of eczema, and his wheezing in between colds suggested that Michael would have persistent asthma beyond infancy. Children like Michael need daily anti-inflammatory therapy to decrease symptoms, prevent asthma flares, and maintain good lung function.
When your infant or toddler is diagnosed as having asthma, keep in mind that he has about a fifty-fifty chance of “outgrowing” asthma. The chances of outgrowing it are better if all of the following are true:
- Your child only wheezes with colds.
- Neither parent has asthma (diagnosed by a physician).
- Your child does not have eczema (diagnosed by a physician).
- Your child does not have other signs of allergies.
No matter which group your child is in, he may need daily controller therapy with an anti-inflammatory medicine. You must also have an asthma management plan to use when your child has symptoms, even if daily medicine is not prescribed. You should be able to evaluate your young child for wheezing or labored breathing, because infants and toddlers cannot tell you how they feel or describe their symptoms.
Remember: a wheeze is a continuous musical noise when a child breathes out. Signs of labored breathing include breathing fast, flaring nostrils, and when the skin in between the ribs and underneath the rib cage seems to get sucked in, a sign called retractions. Review these signs with your child’s doctor or nurse practitioner so you can recognize them early and act promptly.
Using The Nebulizer With Infants And Toddlers
Infants are usually treated with inhaled medicines given by nebulizer at first. Parents generally learn how to use nebulizers easily, and young infants quickly accept them. It takes several minutes, however, to deliver medicine with nebulizers. Older infants and toddlers may not want to sit still for that period of time. Nebulizers can also be inefficient in terms of medicine delivery. In order to get the most benefit from the medicine, young children should wear a face mask while receiving the treatment, rather than using the “blow-by” method.
Metered dose inhalers (MDls) can be used to deliver inhaled medicines to infants and toddlers by using a valved holding chamber with a mask. Although this method requires more training for parents, it takes less time and delivers the medicine more efficiently than a nebulizer With either method, it may take some time for a child to become comfortable with the mask, especially a child between one and two years of age. When an infant or toddler fights the mask, it might be due to a fear of the mask, a poor mask fit, or applying the treatment at an inopportune time, such as when she’s fussy or wants to be more active.
You can help your infant or toddler get used to the mask by letting her play with it and by gentle, brief applications during nontreatment times. The mask should fit easily over her mouth and nose but should not extend above the bridge of her nose or below her chin. It might take several days of persistent mask application before a young child starts to accept the treatment with any consistency.
Choosing the treatment time is important. The treatment can be given more effectively while a child is sleeping or during “quiet times” when you are reading to her or watching television than at times when she’s cranky or unwilling to sit still.
Do Symptoms Always Mean Asthma?
The airways of infants are small, and other conditions besides asthma can cause wheezing. In young infants, an infection from a virus can cause coughs, wheezing, or labored breathing. The respiratory syncytial virus, or RSV; is the most common virus that can cause these symptoms in young infants, although other viruses can do the same thing. RSV usually appears in the late fall or winter. Some researchers believe that RSV infection can cause a child to develop asthma, while others think that RSV triggers asthma that was already present.
Since viral infections are the most common trigger of asthma flares in infants and toddlers, it is difficult to tell whether a first episode of wheezing is from the infection or from asthma. When wheezing or other symptoms keep coming back with every cold, however, it is more likely because the child has asthma.
Other disorders can cause asthma symptoms in young children. Gastroesophageal reflux, also called acid reflux, can lead to coughing and wheezing in some babies. This condition causes acid from the stomach to travel back up the esophagus, the tube that connects the mouth to the stomach. The esophagus is sensitive, and the acid sometimes irritates nerve endings in the esophagus and triggers coughing or wheezing. Sometimes stomach contents travel all the way up to the back of the throat and irritate the airway, again causing coughing or wheezing.
Acid reflux is easy to detect in young infants who spit up or have wet burps. But in older infants and toddlers, testing may be needed to detect it. The presence of acid reflux in infants or toddlers with asthma makes it more difficult to control their asthma.
Cystic fibrosis is another disorder that produces some of the same symptoms as asthma. Cystic fibrosis is a genetic disease that is most common in Caucasians. Your doctor may request testing to rule out this disease.
When asthma is not properly diagnosed or treated in a very young child, the quality of life for the whole family suffers. A prompt diagnosis and an appropriate treatment plan, however, will leave everyone in the family free to embrace the ordinary trials, tribulations, and joys of infancy and toddlerhood.