Children With Severe Asthma Need Prevention Medicine
Question: Our three-year-old son was recently admitted to the hospital again because of a severe attack of asthma. He had a lot of coughing and wheezing in his first year. Our doctor told us that he likely has asthma. We thought he was outgrowing the problem because he had no major attack, although he still needed mask treatment very often. After this bad attack, we have finally accepted the diagnosis. We are now looking to prevent these severe attacks. What kind of options do we have?
It is often not easy for parents to accept that their child has asthma. You may want to count this severe attack as a blessing in disguise. It allows you to see that he needs longer term prevention instead of short term treatment after treatment.
There are several different groups of preventative medicine for asthma. They all have advantages as well as disadvantages. It would be best for you to learn about them, and then make the decision together with your doctor.
The most common medications used to prevent asthma are inhaled steroids. If you are worried about inhaled steroids, you are not alone. However, research has shown that when used properly, inhaled steroids are very safe with little to no side effects. It is often used once or twice a day, and the dose should be monitored by an experienced physician. The dose and frequency, however, can be increased if asthma gets worse.
Inhaled steroids are available in solution that can be delivered through a maximist machine (also called nebuliser). It is very convenient especially for young children, although it is not too portable. It is also available in puffers; a spacer with a face mask should be used for young children. For those over 5, a spacer with a mouth-piece should be used. This will ensure the child inhales the medicine into the lungs (where it works), instead of squirting the medicine at the throat.
In older children, inhaled steroids are available in dry powder formulations which are easier to carry around, and can be used very effectively. Remember, the best choice of device depends on the child, and this decision should be made jointly with your physician.
A second group of preventative medicine is Intal and Tilade. Although they have been around for a while, we still don’t know exactly how they work. They are generally felt to be weaker in their ability to prevent asthma, the only advantage is that they are not steroids.
Intal is available in solution formulation through the maximist machine as well as puffers. However, the puffer doses are too small to be effective. If you want to use Intal, I would suggest that you use the solution through the maximist machine. To be effective, many children need to take Intal 3 or 4 times a day, which is not very convenient. Sometimes children don’t respond to Intal at all.
Tilade was derived from Intal, and is supposed to work a little better. However, it is only available in puffers. The powder in the puffers tends to cause coughing, and the bitter taste is not well accepted by many children.
In the past two years, a new class of preventative medicine has become available; it is called leukotriene-receptor antagonists (LRA). It works by blocking a key chemical leading to asthma. Two of these have been approved in Canada. I will explain about them even though your son is still too young, but the information can be helpful for many other parents.
Accolate was approved for children 12 years and over. It has to be used twice a day on an empty stomach. Singulair is more convenient, only once a day and can be taken with or without food. It is approved for children as young as six. Both of them are available as pills only.
Both of these medications are quite well tolerated. At the present time, many specialists are using them in conjunction with inhaled steroids for prevention of severe asthma. LRA provides better control than inhaled steroids alone, and sometimes physicians can even reduce the dose of inhaled steroids.
No doubt that LRA can be used alone for some patients to prevent asthma. However, because it is a new class of medicine with no long term track record, physicians are still cautious and tend to reserve it for more severe patients.
It is very important for you to discuss with your doctor about the best choice of prevention medicine for your son. You should also work out an “action plan” with your doctor, so that you know exactly what to do if he gets sick. Even with the best prevention, there will be flare ups when you need more medicine.
Before I finish, I want to emphasize this: No amount of medicine can work well if your son’s environment is unhealthy. If someone is smoking in the house, this has to stop right away. You should also look around to see whether you can reduce dust and mildew in the house. Some children may be allergic to the family pet. In spring time, hanging clothes and sheets outside can trap a lot of pollen. This can cause a severe attack by itself if you son is allergic to some of these pollens.
Your local Lung Association can also provide you with lots of useful information. Around the country, many hospitals have asthma education centres that can help patients to understand their conditions better, and monitor their progress with treatment. There may be one close to where you live.
[Note to Readers: There have been a lot of changes and improvements in the treatment of asthma since the publication of this column. Intal and Tilade were medications that we have used many years ago. I purposely kept them here for historical purpose. We don’t use Accolate in children; we still use Singulair for prevention of asthma. Please go to newer columns for more information.]