Six year old Meagan’s mother remarks to her friend, “It’s the same thing every fall—Meagan gets a terrible cough and chest cold that seem to last through the winter. I don’t even take her to the doctor anymore,” she says with exasperation, “I give her cough medicine, and on the bad days, I keep her home from school,” It may be that Meagan’s recurrent cough isn’t a respiratory infection at all. She may be one of the 17 million Americans who have asthma. According to the American Academy of Allergy, Asthma and Immunology (AAAAI), asthma is increasing at an alarming rate.
A recent report from an AAAAI conference in San Diego indicated that school asthma screening programs have identified as many as 15 percent of the student population as asthmatic. “Nobody knows for sure why asthma is increasing,” says Dr. David Rosensteich, Director of the Division of Allergy and Immunology at Albert Einstein College of Medicine and Montefiore Medical Center in the Bronx. “But one leading theory is that it’s because we spend a lot more time indoors now, where we are exposed to a lot more potent allergens.”
Asthma is the number one cause for school absenteeism and pediatric hospitalization, and according to information from the Centers for Disease Control, the number of asthma sufferers in the Metro Atlanta area approaches half a million people. How is it, then, that Meagan’s asthma could so easily go undiagnosed? Part of the answer lies in the variable nature of asthma, as well as its resemblance to other common respiratory diseases. It is often not an easy diagnosis to make, due to several important factors.
The variable nature of asthma symptoms
Asthma is a chronic inflammatory lung disease in which the airways become obstructed, making breathing difficult. For asthmatics, exposure to certain environmental stimuli, known as asthma triggers, causes the airways to react in an overly sensitive way. During an asthma attack, the lining of the airways becomes swollen and secretes thick mucus. The muscles around the airways then tighten, causing them to narrow. The end result of these changes is an inability to move air adequately in and out of the lungs.
“A good number of asthmatics just don’t have classic attacks,” says Dr. Gerald Teague, Pediatric Pulmonologist and Director of the Division of Pediatric Pulmonary and Critical Care Medicine at Children’s Health Care of Atlanta, at Egleston. “What they tend to have is an indolent, persistent cough that gets called bronchitis. It doesn’t get identified as asthma.” Cathy Dugger, BSN and Registered Respiratory Therapist with St.Vincents Hospital in Jacksonville, Florida agrees. “Sometimes asthma is not detected by medical professionals as well as lay people,” Dugger says, “And this is due to the fact that asthma is a variable disease, with good times and bad times.”
Dugger explains to patients that the bad times—the days when asthma symptoms are severe—are brought on by the presence of triggers in their environment. Dugger’s patients also learn that the presence of triggers in the environment is variable. When Johnnie visits grandma, the cigarette smoke in her house makes him cough. Every time Susie holds her neighbor’s cat, she gets an itchy throat. Remove him from the smoke filled environment, and his symptoms improve. Take the cat away, and she feels better. This variable occurrence of symptoms and triggers can be confusing to a parent trying to understand what’s happening.
The good times for an asthmatic, those days when symptoms are absent or very mild, can also be a source of confusion for a parent of an asthmatic. “She can’t have a chronic disease like asthma,” a mother may erroneously conclude, “her breathing problems go away after the spring.” Until one fully understands the disease, symptom- free periods appear to be proof that the child’s symptoms were a part of some other type of respiratory illness. Understanding the relationship between environmental triggers and the symptoms of asthma helps to demystify the problem of recurrent respiratory illness.
A further complication involved in detecting asthma in children, is the fact that not every asthmatic reacts to the same triggers. Nor do they manifest the same symptoms. The response to a given environmental trigger will vary from one asthmatic to another. “Wheezing is overrated as an asthma symptom,” says Dugger, “People wait to hear the wheeze, and when they don’t hear it, they don’t recognize the problem as asthma. We try to bring to their attention that other symptoms also indicate asthma”.
The allergy/asthma connection
Of the children under 16 years of age who have asthma, 90 per cent are allergic. While asthma and allergy are two different diseases, they often coexist, and have the same triggers. A child with the sniffles and a cough, due to asthma alone, or asthma plus allergies, often looks like a child with a common cold or virus. And given that allergy season coincides with the cold and flu season, making the distinction between a seasonal cold and an asthma/allergy condition is tricky. This is especially true of younger children, who, until their airways mature, manifest asthma-like symptoms when they have a cold. “One third to one fourth of toddlers will wheeze at some point,” says Dr. Teague. He points out that this doesn’t mean, however, that they will later be diagnosed as asthmatic.
Add to the dilemma of differentiating asthma/allergy from other respiratory illnesses the problem of accepting that one’s child has a chronic condition, for which medications and consistent medical follow-up will be necessary. It’s a frightening idea for many parents, as well as for their children. In the initial stages of any chronic illness, no one wants to acknowledge that there may be a major health problem. There is a natural tendency to minimize the symptoms as a way of dealing with the anxiety involved in acknowledging the disease. The good news is that there is help available to parents and their asthmatic children in learning how to cope. Working closely with the physician and other healthcare providers, parents can learn to recognize the symptoms of asthma and to successfully manage the disease through the use of medications and lifestyle modifications.
Making the diagnosis—Where to start
Meagan’s mother, unable to understand all of her symptoms, stopped taking her to the pediatrician every fall when her coughing began. A better approach would have been to continue seeing the doctor, and to voice her concerns about the recurrent cough. Then there would have been an opportunity to discuss the option of seeing a specialist. The specialist to see is a pediatric pulmonologist, a pediatrician who has undergone extensive training in pediatric lung disease.
Pediatric pulmonologists are board certified in their specialty. Some parents hesitate to ask for a referral to a specialist for fear that they will offend their primary care physician. “I think the pediatrician usually doesn’t feel that this is a problem,” says Dr. Gary Montgomery, of Georgia Pediatric Pulmonology Associates, Children’s Health Care of Atlanta, at Scottish Rite. “Close to half of the kids we see are referred to us because the parent says they’d like to see a specialist,” he says.
Simply communicating concern to the primary care physician is the first step in getting to a specialist. “I recommend that parents talk with their child’s physician first and say, for instance, things aren’t working out they way I’d like them to, and I’d like to get a second opinion. What do you think?”, says Macon pediatric pulmonologist Dr. James Logan. Dr. Logan reports that the majority of patients he sees are referred by their primary care physician. “Sometimes the parent just needs to give the pediatrician the message that there’s a problem … that the cough is so bad that the child does it every time he tries to run and play, and not just when he has a cold. Those are the types of symptoms that indicate it’s asthma and not just bronchitis,” he says.
Self-management is a key element in the successful treatment of asthma. In order to manage the symptoms of asthma properly, children and their parents need to be educated about the disease, the medications used to treat it, and the issues involved in self-treatment.
An asthma education program, where group and individual instruction is given, is an important forum for this learning. The following are examples of such programs in the Atlanta Metro area.
• The Asthma Center for Education (ACE). Children’s Health Care of Atlanta, Scottish Rite Hospital. This program accepts self and physician referrals. Call for information: 800.325.5671.
• The American Lung Association (ALA) provides referral to patients about education programs in the metro area. Contact: Michelle Woods, 770.434.5864.