Little Sneezers to Chronic Wheezers – the Role of Allergy in Asthma

James L. Sublett MD FACAAI

 “But, Dr. Sublett, I understood that Johnny would probably outgrow his asthma.”

This all too frequent a parental lament, from the mother of an eight-year-old asthmatic, is one of the most understood myths about childhood asthma. In fact, the life-long severity of asthma is established between the ages of six to nine. Asthma, because it is an episodic disease, will wax and wane throughout an individual’s life.  Childhood appears to be the critical time to recognize, diagnose, and treat asthma. Of the 20 million people in the U.S with asthma, nearly all begin in early childhood. Current statistics indicate that nearly 80% begins before the age of three. As asthma progresses, without treatment, the disease tends to worsen and by mid-childhood, the dye is cast. We now recognize that the earlier treatment interventions begins, the better the life-long outcomes. Large ongoing studies of wheezing infants and young children have established certain risk factors for asthma. They include parental smoking, either parent (especially the mother) diagnosed with asthma, food allergies in infancy, atopic eczema, and chronic nasal allergies (a runny nose or cold that lasts for more than a couple of weeks, or reoccurs frequently). Some infants and children under the age of three may start to wheeze with viral bronchial infections (usually RSV) and then tend to wheeze even with common colds up to about age four or five. The majority of these children will stop wheezing with colds by school age, thus the myth that they have outgrown asthma, when they actually do not have asthma. Experts now agree that it is primarily young allergic children who develop asthma that continues throughout childhood into their teens and adulthood. The day-to-day lives of these children can be impacted dramatically. Asthma is the leading cause of hospitalization in children, one of the most common causes of school absenteeism, and can lead to dramatic restrictions in activities if not treated.

The goals for the management of asthma in children are simple: sleep, play, and learn without restrictions. The treatment of asthma can be divided into three components, which I often refer to as a “three-legged stool”:

  1. Avoidance of triggers ( allergic substances and irritants)
  2. Medications
  3. Allergen Immunotherapy (to be considered, but not recommended, for all).

The identification of those things causing the allergic reactions that trigger the asthma is best established through simple allergy skin testing by a board-certified allergist. A myth concerning allergies is that children have to be at least two before they can be tested. The allergy antibody is active at birth and there are examples of children sensitized shortly after being born. Per the American Academy of Pediatrics, age is not a barrier to skin testing.

Asthma is a chronic disease that begins in childhood. Treatment can allow the child to live a normal life and impact the lifelong progression of the disease. I divide the medications for treating asthma into three categories: Control, Prevent, and Rescue (CPR for asthma).

The most commonly used controller medicines are inhaled corticosteroids (ICS). They are the “gold standard” for treating persistent asthma symptoms. The newer ICS are available for either use in nebulizers for young children, and over the age of four in inhalers. Used regularly, they are effective in controlling symptoms and may prevent the progression of the disease.

Preventive medications are added if the ICS alone are not controlling the symptoms. Remember, our goal is nearly zero symptoms, no missed school, no exacerbations, and the ability to play at will. The two most common add-on prevent medications are either inhaled long acting bronchodilators or a leukotriene modifier. One popular inhaler combines the Control and Prevent medications in one discus. Very mild asthma may be treated with the leukotriene modifier tablet alone.

Finally, all asthmatics should have a “rescue” inhaler or nebulizer solution available in case of sudden exacerbations. Sometimes it is recommended to use the rescue inhaler regularly before exercise. A spacer should used with any pump type inhalers to assure good delivery of the medication.

Since asthma is often episodic and our goal is optimal control, step-up, step-down treatment is a common way of adjusting the treatment plan. All asthmatic children should have a written action plan for treatment. Some children may benefit from having a device called a peak-flow meter to measure their airflows at home.

Allergy shots may be recommended in children with significant allergies to things they cannot avoid. The immunotherapy is effective in asthma and is actually the closest way to “curing’ the underlying problem by down-grading the allergic immune response.

James L. Sublett, M.D., is a clinical professor and section chief of pediatric allergy at the University of Louisville School of Medicine. He is also Co-Founder and Managing Partner of Family Allergy & Asthma (, a multi-site allergy practice with offices throughout KY and  southern Indiana.

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