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In children with asthma, irritation of the airways can be caused by: infections such as colds; smoke from cigarettes, cigars, pipes or even a wood burning stove or fireplace; cold air; or allergies to dust, mold, pollen or animals. These irritants and allergens are called asthma triggers. You can learn more about triggers in topic number 2008. If your child has a chronic cough, especially at night, or always has wheezing with a cold, you want to tell this to your pediatrician. Remember: only a doctor can diagnose asthma.

• Does your child have wheezing, chest tightness / chest pain, especially at night, and shortness of breath?;
• What makes the symptoms worse and what makes your child feel better?;
• Has your child taken any medication that makes the symptoms better, or worse?
• Do you have a family history of asthma?
• Has your child ever been to the emergency room or hospitalized for respiratory symptoms?
• Does your child have allergies? Or history of eczema?
• Did Mom smoke during her pregnancy?

The doctor will want to do some tests that check the child's airway function. These are called pulmonary function tests. The doctor will measure the amount of air the child can blowout of his lungs over time. Sometimes medication is given during the testing to see if it changes the child's pulmonary function or how well the airways are working. It's important to remember that asthma can be a difficult condition to diagnose.

During an asthma attack, airflow through the child's air passages decreases and the child experiences difficulty breathing. Asthma attacks can be mild, moderate or severe. It will be important to recognize the severity of your child's attack. The American Academy of Pediatrics uses the following criteria.

Signs of a MILD asthma attack:

• Mild difficult breathing
• Breathing is slightly faster than usual
• The child is able to speak in complete sentences without difficulty
• The child complains of slight tightness in the chest, or shortness of breath
• The child has some wheezing and coughing
• Skin color is good
• The child's peak flow (if you have been trained to use a peak flow meter) is 70-90% of the child's personal best
• The child is not having "drawing in" of the muscles of the abdomen or between the ribs
• The child is aware of the surroundings and is alert

Signs of a MODERATE asthma attack:

• Breathing is moderately difficult
• Breathing is faster than usual
• The child cannot complete a sentance due to difficulty breathing
• The child complains of moderate chest tightness and shortness of breath
• There is wheezing and coughing
• The child's skin color is pale
• Peak flow is 50-70% of the child's personal best
• There is some "drawing in" of muscles of the abdomen and between the ribs
• The child is alert to his surroundings

Signs of a SEVERE asthma attack:

• Extreme difficulty breathing
• Breathing is VERY fast or VERY slow with a lot of distress
• The child can only speak one or two words
• The child complains of severe chest tightness and shortness of breath
• The child is having a lot of loud wheezing and coughing
• Skin color is pale or blue
• Peak flow is less than 50 percent of the child's personal best
• There is "drawing in" of the neck muscles, abdominal muscles and chest muscles
• The child is less aware of his surroundings or may be drowsy

IF YOUR CHILD IS HAVING A SEVERE ASTHMA ATTACK CALL 911 IMMEDIATELY AND ADMINSITER THE CHILD'S RESCUE MEDICATIONS AS ORDERED BY THE DOCTOR.

For a mild or moderate asthma attack, follow your child's asthma action plan and call your child's doctor to discuss the effectiveness of the treatment.

• A persistent cough, particularly at night
• Coughing, wheezing, chest tightness, or shortness of breath after play or vigorous activity
• Wheezing that comes and goes
• Feeling tired during play or physical activity
• Reluctance to participate in play or physical activity

Some general guidelines for peak flow readings are offered here. However, only your child's doctor can give guidelines for your child.

• The Green, safety, zone. This is when the child is at 80 percent or more of his personal best. This is a good reading and does not require treatment other than the normal daily medications if they have been ordered.
• The Yellow, caution, zone. This is when the child is between 50 percent and 80 percent of his personal best. The pulmonologist will give you instructions on what to do when your child’s peak flow has dropped to this level.
• The Red, danger, zone. This is less than 50 percent of the child's personal best. If your child's peak flow is in the red zone, and the symptoms do not improve after you've given rescue medications, you must contact your doctor or 911.

Reactive airways disease (RAD) merely indicates chronic small airway inflammation and hyper-responsiveness of the inner lining of the small airways which results in cough and wheeze with subsequent colds. Most of these children by the time they reach 3-4yrs of age have resolution of this disease. However, a large percentage of these children who have a strong family history of asthma will evolve in developing asthma.

The treatment for Reactive Airways Disease is similar to asthma using daily inhaled steroids to reduce airway inflammation and reactivity and a bronchodilator used as a rescue medication during colds. There are times where oral steroids may be indicated with severe wheezing. If you have any questions please discuss with your doctor or specialist.

Common triggers include:

• Infections in the airways for the common cold
• Viral infections of the ear, nose or throat
• Infections like pneumonia
• Cigarette, cigar or pipe smoke
• Smoke from a fireplace or wood burning stove
• Air pollution
• Very cold, dry air
• Sudden changes in weather
• Cockroach droppings
• Certain food allergies
• Pollen
• Dust / Dust Mites
• Animals / Pets
• Cleaning products
• Strong perfumes
• Mold
• Exercise
• Emotional stress
• Excessive laughing or crying
• Excessive heat and humidity

Hand washing is the best method of preventing the spread of colds. Teach your child to wash hands before meals and when coming in from outdoors. Adults need to wash their hands often as well since they too can spread the germ by touching infected toys or children with colds and then touching a well child.

The cold virus is very irritating to the airways of young children. In a child with asthma, a cold can trigger an acute asthma attack. Your child's doctor will give you instructions on which medications to give when your child has a cold. Follow the prescribed medication schedule and the asthma action plan.

Hand washing is the best method of preventing the spread of colds. Teach your child to wash hands before meals and when coming in from outdoors. Adults need to wash their hands often as well since they too can spread the germ by touching infected toys or children with colds and then touching a well child.

The Environmental protection Agency tells us that, "A few basic actions can protect children from secondhand smoke":

• Choose not to smoke in your home and car and do not allow family or visitors to do so.
• Do not allow childcare providers or others who work in your home to smoke.
• If your child is in the home of a Family Child Care Provider, make sure there is no smoking in that home. The RESPIRA staff can help you to find Asthma Friendly Family Day Care in your county area.
• Until you quit, smoke outside. Moving to another room or opening a window is not enough to protect your child.
• Finally, if you do smoke outside, make sure you are not near an open window or door that will allow the smoke to enter your home.

It is impossible to completely remove dust mites from your home. There are, however, some things you can do to reduce your child's chances of having an allergic reaction to them.

• Only choose washable stuffed toys for your child and keep them off the bed and out of the bedroom.
• If possible, remove carpeting from the bedroom.
• Place pillows and mattresses in dust mite-proof cases.
• Wash bedding often, at least once a week, in hot water(125 degrees).
• Vacuum the room at least once a week and pay attention to the area under the bed.
• Keep frilly curtains and throw pillows to a minimum.
• A HEPA vacuum cleaner can be very helpful in reducing dust mites but it can also be expensive.
• Use washable throw rugs, and shades or blinds instead of curtains.
• Dust often with a damp cloth.
• Keeping the humidity low in the home, below 60% can also reduce the number of dust mites.

If you are not sure if you have mold in your home, here are some clues:

• Black or brown growth on grout surfaces, especially in the shower, tub, around the toilet, under the sink or around faucets.
• Missing grout in showers or sink areas.
• Musty Smell.
• Brown or black dust clinging to exhaust fans.
• Green, gray or brown fuzzy growth on bread.
• Moldy smell from clothes hamper or dark spots on the inside surfaces of hamper.
• Moisture or dark areas on window glass, window frames or doorframes.
• White powdery coating on shoes in a closet.
• Dampness in the basement.
• Mold spots on walls, ceilings or doors.

• First, clean all the visible mold spores with an environmentally friendly cleaning solution. You can get suggestions for cleaning solutions from Topic #2015.
• Replace shower curtains with mildew resistant curtains.
• Dry the shower, bathtub and sink after use.
• Clean exhaust fans with the suggested cleaning solution.
• Discard any food that has visible signs of mold growth immediantely and discard all baked goods that are no longer fresh.
• Empty hampers daily and never leave wet items in a hamper.
• Keep hampers out of bedrooms.
• Keep plants out of bedrooms
• Keep indoor humidity at less than 60% if at all possible by purchasing an inexpensive humidity gauge and dehumidifier.

The United States Environmental Protection Agency offers the following steps you can take to reduce having cockroaches in your home.

• Place childproof, non-toxic cockroach bait in your kitchen. FOLLOW THE PACKAGE DIRECTIONS CAREFULLY!
• Do not leave food or garbage out.
• Clean all food crumbs or spilled liquids immediately.
• Wash dishes as soon as you are done using them.
• Keep counters, sinks, table and floors clean and clear of clutter.
• Fix plumbing leaks and other moisture problems.
• Seal crack or openings around or inside of cabinets.
• Remove piles of boxes, newspapers, brown paper bags and other hiding places for cockroaches from your home.
• Make sure trash is stored in containers with lids that close securely, and remove it daily.
• Clean pet food bowls every day and put them away when they are not being used.
• Never allow children or others to eat in bedrooms.

There are a few things you can try before you remove the pet from your home.

• Keep all pets out of bedrooms, off the furniture, carpets, and stuffed toys.
• Keep pets oudoors as much as possible.
• Remove carpet, heavy upholstery and drapes. These dander and should be removed from the bedroom of the allergic individual.
• Restrict pets to one area of the house.
• Vacuum often, at least once a week.
• Wash your pet at least once a month

In spite of many claims that there are hypo allergenic breeds of dogs and cats, Dr. Robert Wood reports: "There is no perfect furry pet for people with allergies to animals." If the time comes that the animal must be removed from your home, your child may continue to react for up to six months after the pet leaves. It takes that long for all of the animal dander to be eliminated from your home.

1. Clean mold and mildew by mixing:
• 1 tablespoon of baking soda
• 2 tablespoons of white vinegar
• 1 quart of water
2. Disinfect by mixing: (Choose one)
• 1/2 cup borax + 1 gallon of hot water
• 1/4 cup baking soda + 1/2 cup white vinegar + 1 gallon warm water
3. Clean shower grout by mixing:
• 2 cups baking soda
• 1 cup borax
• 1 cup hot water

Never expose a child with asthma to the spray from aerosol cleaning products, air fresheners, deodorants or pesticides.

Your child's doctor will tell you if your child is allergic to pollen. The doctor will also prescribe medications to reduce allergic reactions during seasons when the pollen count is at its highest, generally, from March to November. You will want to pay particular attention to the pollen count that is reported with the weather on television and radio news.

When the pollen count is high, keep the windows in your home closed and if it is warm, keep the air conditioning on. It is a good idea to limit outdoor play on days when the pollen count is at its highest.

During the hot, humid summer months, pay attention to ozone levels. The Air Quality Index or AQI will tell you if ozone pollution is high on any given day and is reported with your local weather forecast on the television or radio news. The AQI uses colors to identify the air quality in your area. Green and yellow mean air pollution levels are low. This means it is safe for a child with asthma to run and play outside. When the AQI measurement is in the red or purple range, the air pollution is at high levels and this can make asthma worse.

On days when the ozone levels are high:

• Keep children with asthma inside.
• If possible, keep your windows closed and the air conditioning on.
• Advise your child's provider that outdoor play is unsafe for your child when ozone pollution is high.
• Call the EPA or listen to the Weather channel for the pollution forecast for New Jersey.

The good news is that when asthma is well controlled, children can participate in these activities without a problem. Your child's pulmonologist will give you a plan that will include treatments that will prevent your child from having an asthma attack during exercise. It is important to follow these instructions carefully so that your child can fully participate in play and sports activities. Lots of very famous athletes have asthma. Follow the doctor's orders to keep your child fit and feeling great.

When you are learning about asthma, it is a good idea to write down each medication. Some medications are given every day when your child is sick and when he is well. These are called maintenance medications. You can learn more about maintenance medications in topic number 2022.

Rescue medications are given only when your child is sick or having an asthma attack. These are discussed in detail in topic number 2021. Again, when you are giving many different medications to your child, it is a good idea to write down what you give and when you give it so you can keep track of how you are treating your child's asthma.

Keeping a log will also help your child's doctor learn which treatments work best for your child.

Rescue medications are given by inhaler, nebulizer and sometimes by mouth. If symptoms do not respond quickly to rescue medication or get worse before the next dose is due, you should call the doctor for advice. If your child is having difficulty breathing after the medication has been given, call 911 immediately

There are different classifications of rescue medications. Bronchodilators relax the muscle around the air tubes making it easier to breathe. There are a number of medicines that are used for this purpose.

Some of the bronchodilators you may encounter include the following:

• Albuterol
• Xoponex
• Ventolin
• Proventil
• Accuneb
• DuoNeb
• Atrovent

These bronchodilators are given by inhaler with an aero-chamber or by nebulizer. Remember, if a bronchodilator is ordered by nebulizer, the treatment takes about 15 minutes to complete. Make sure all the medicine is gone before turning the machine off. Drugs that reduce inflammation may also be ordered. These medicines are called antiinflammatory medications or steroid medications. Again, some of these are given by inhaler or nebulizer, and some are given by mouth.

Steroids take a few hours to work and are usually ordered when bronchodilators alone are not making your child better. Your doctor may advise you to start inhaled steroids at the first sign of a cold, even before the child has worsening asthma symptoms.

If you are following the asthma action plan using bronchodilators every 3-4 hours and inhaled steroids, and your child is not getting better, call your doctor or 911.

Your child should take rescue medications along with maintenance medications for as long as prescribed by the doctor.

There are many different types of maintenance medications. Some are given in tablet form, by mouth. Others are inhaled or given by nebulizer. It is very important that you know the medication that has been prescribed for your child and how to give it. It is also very important for you to give the medicine every day as prescribed even when your child does not have asthma symptoms. If your child is wheezing, coughing during the day or night, or having a hard time keeping up with the other children even when medication is being taken, make sure you contact your child's doctor. Remember, parent's observations are very important to the overall treatment plan.

Aerosol inhalers can be difficult for very young children to use. For this reason, when an inhaler is prescribed for very young children, an aero-chamber or spacer will also be prescribed. The aero-chamber stores the medication in a chamber until the child is ready to take a breath. Topic number 2025 discusses aero-chambers.

Your child may have more than one medication given by this method. It's very important to keep track of each of the different medications. When many medications are being given during an acute asthma episode, or asthma attack, keep track by writing down what you give and when you give it.

Most medicine delivered by a nebulizer is pre-measured. It takes about 15 minutes to complete the treatment. Your doctor will tell you what to put in the nebulizer cup and how often to give it. Since children often receive many medicines during an acute asthma episode, or asthma attack, keep track by writing down what you are giving and when you give it.

Remember to clean the medicine cup and mask or mouthpiece by rinsing it in water after each use. You can put them in the dishwasher or simply place them in hot soapy water for 15 minutes once a day. Remember to rinse well and air dry. The face-mask or mouth piece, and medicine cup should be disinfected once a week. You can do this by immersing them in 1 cup of distilled white vinegar and two cups of water for 15 minutes. Rinse well and allow them to air dry. DO NOT ATTEMPT TO CLEAN TUBING. If the tubing looks unclean, replace it.

Always have extra tubing, face-mask or mouthpiece and medicine cups on hand. You will need to replace these pieces of equipment at least once every three months.

Aero-chambers need to be cleaned regularly since medication can stick to the inside of the tube. Remove the back piece only and do not tamper with valves. Clean the spacer once a week or more often if there is a film on the inside of the chamber. Soak in soapy water for 15 minutes and rinse it well. Let it air dry.

1. First, you need to ask your child's doctor for an asthma action plan. This will spell out the steps of how to manage his asthma.
2. You must tell the child care provider that your child has asthma and share a copy of the asthma action plan.
3. Discuss asthma triggers with the provider and record them on the asthma action plan.
4. Review the asthma action plan with the doctor and the child care provider at least on time during the year.

• Participation in play activities is comfortable.
• Sleep at night and during the day is free of coughing.
• There are minimal side effects from medicines.
• Rescue medication is used no more than two times per week.
• There have been no recent hospital admissions or emergency room visits

First, ask the school nurse for an asthma action plan and take that to your child's doctor, Also ask her for any other forms that will be needed so that your child can receive medication in school. There are a number of permission slips you and your child's doctor must sign.

When the asthma action plan has been completed make an appointment to sit down with the school nurse to review the plan and the medications that may need to be given in school. The nurse will need to know if your child self-administers medications or if she will be giving them.

Review your child's triggers with the nurse and try to identify ways of minimizing exposure to triggers at school.

You will also want to visit your doctor regularly to be certain the medication dosages are still appropriate for the height and weight of the child.

The Pediatric Asthma Coalition of New Jersey offers an Asthma Friendly School Award. Ask the principal if the school is interested in pursuing this award. Information about it can be found on the PACNJ web site at www.pacnj.org.

It will be important for you to follow the suggestions offered in topic number 2027, Managing Asthma in School, keeping in mind that children of this age seek independence from parents, and acceptance from peers.

Have the doctor complete the asthma action plan, remembering that the middle school child can self-administer medication with the appropriate parent and doctor approvals. Involve your child in this planning process. When you present the plan to the school nurse, be sure your child is there and can discuss his role in managing asthma.

You will also want to visit your doctor regularly to be certain the medication dosages are still appropriate for the height and weight of the child.

Refer to topic number 2029, Managing Asthma in School. It discusses the steps you need to take so your child will be appropriately managed. The school nurse does not go on high school field trips or to sporting events, so be sure your child always has rescue medications with him on these outings.

You will also want to visit your doctor regularly to be certain the medication dosages are still appropriate for the height and weight of the child.

Remember to tell the child's coach that he has asthma and share the asthma action plan with the coach. Most middle and high school coaches are accustomed to working with athletes who have asthma and will monitor your child's well-being. The school nurse can be a valuable resource in working with the coach and your child to coordinate his care. If your child becomes ill and is unable to participate for an extended length of time, keep the coach informed of his progress and be certain to get clearance from the doctor before your child returns to the sport.

• Wheezing or coughing continues after rescue medication.
• Your child's breathing is fast or he is having trouble breathing.
• The child has a fever of 101.5 orally or 100.5 under the arm.
• Your child is too weak or tired to take part in normal activities.

If you are using home remedies, be sure to tell the doctor exactly what they are.

FDA is working with Merck to further evaluate a possible link "between the use of Singulair and behavior/mood changes, suicidality and suicide in response to inquiries received by FDA. Due to the complexity of the analyses, FDA anticipates that it may take up to 9 months to complete the ongoing evaluations. As soon as this review is complete, FDA will communicate the conclusions and recommendations to the public.

Singulair is an effective medicine that is indicated for the treatment of asthma symptoms of allergic rhinitis. Patients should not stop taking Singulair before talking to their doctor if they have questions about this new information. Until further information is available, healthcare professionals and caregivers should monitor taking Singulair for suicidality (suicidal thinking and behavior) and changes in and mood.

The FDA urges both healthcare professionals and patients to report side effects from the use of Singulair, Accolate, zyflo, and Zyflo CR to the FDA's MedWatch Adverse Event Reporting program.

Information for Singulair.
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