Asthma and GERD in Children

RMacMahon, B.Sc. Chem. Min. Sc. and EMiller
January 2007

Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. This inflammation causes wheezing, breathlessness, chest tightness and coughing, particularly at night or in the early morning.

Facts:

In the US asthma affects approximately 5-10% of the population, equivalent to an estimated 14-15 million persons, including 5 million children. Internationally Asthma is common in countries such as Canada, England, Australia, Germany and New Zealand, where the rates in such countries range from 2-10%

Factors that can contribute to asthma:

• Environmental allergens including dust mite, animal allergies and fungi
• Viral respiratory infections
• Exercise
• Gastro esophageal reflux disease (GERD)
• Chronic sinusitis or rhinitis
• Aspirin or no steroidal anti-inflammatory drug hypersensitivity, sulfite sensitivity
• Obesity (Based on a prospective cohort study of 86,000 patients, those with an elevated body mass index are more likely to have asthma.)
• Environmental pollutants, tobacco smoke
• Irritants such as household sprays and paint fumes
• Prenatal factors including prematurity, increased maternal, breastfeeding has not been definitely shown to be protective. Both maternal smoking and prenatal exposure to tobacco smoke also increase the risk of developing asthma.

The GERD Link

Studies have shown a great connection with asthma and GERD. It is estimated that that approximately 1 in 4 asthma patients also suffer from GERD.

The relationship may be based on one or both of the following two factors:

• GERD has been shown to worsen asthma symptoms in some patients
• Asthma, and particularly some asthma medications, has been shown to worsen GERD symptoms.

GERD can affect asthma in a number of ways:

• Microaspiration of stomach acid or stomach contents, causing direct imflammation of the airways or predisposing them to increased reactivity to other triggers. This is attributed to the fact that with reflux there is generally a pressure difference between the abdomen and the chest. Asthma is a condition that results in an increased pressure in the chest, and for this leads to a tendency for the liquids in the gastrointestinal track to go up. Refluxed acid aspirated into the airways and lungs, making breathing difficult and causing the patient to cough.
• Triggered nerve reflex that causes the airways to narrow in order to prevent a foreign material from entering the lungs. This will then cause shortness of breath.
• Possible asthma medications have been noted to loosen the valve which may allow the acids to rise. d to be taken consistently to take effect.

Common Asthma medications

RELIEVERS/RESCUE MEDS – provide immediate relief from asthma symptoms by relaxing the muscles around the airways. Use of a reliever more than three or four times a week may mean that the asthma is not well controlled and you should speak to your doctor. This is the only medication to use in an asthma attack. These medications are taken as needed when you first begin to feel asthma signs and symptoms, such as coughing, wheezing, chest tightness or shortness of breath.

• Short-acting beta-2 agonists. These bronchodilators begin working within minutes and last four to six hours. But they can't keep symptoms from coming back. The most commonly used short-acting bronchodilator for asthma is albuterol (ventolin and proventil).
• Ipratropium (Atrovent). Your doctor may prescribe this medication for the immediate relief of your asthma symptoms.
• Oral and intravenous corticosteroids for asthma attacks. These corticosteroids — including prednisone, methylprednisolone, hydrocortisone and others — may be taken to treat acute asthma attacks or very severe asthma. They may take a few hours or a few days to be fully effective. Long-term use of these medications can cause serious side effects, see your Dr if you feel that your child is needing these medications frequently, it is a good indicator that their asthma is not very well managed.

Side Effects: The less common and more severe reaction to rescue meds is allergic reaction, which could be hives, swelling of mouth and tongue, lips or throat.

The more common side effects are headache, dizziness, sweating, dry mouth, hoarseness, nausea, upset stomach, hyperactivity.

PREVENTERS – make the airways less sensitive to triggers and reduce swelling and redness (inflammation) inside the airways. They are taken daily to keep you well. Do not stop taking the preventer, even when you are feeling better.

• Inhaled corticosteroids. Very effective in management of asthma, they decrease the frequency and severity of attacks. They work by delivering the medication directly to the airways, and thus have a lower risk of side effects. Inhaled corticosteroids include fluticasone (Flovent), budesonide (Pulmicort), triamcinolone (Azmacort), flunisolide (Aerobid) and beclomethasone (Qvar).
• Leukotriene modifiers. These drugs reduce the production or block the action of leukotrienes — substances released by cells in your lungs during an asthma attack. Leukotrienes cause the lining of your airways to become inflamed, which in turn leads to wheezing, shortness of breath and mucus production. Leukotriene modifiers include montelukast (Singulair) and zafirlukast (Accolate).  Used in conjunction with other medications — such as inhaled corticosteroids — leukotriene modifiers may help prevent more attacks. Although generally not as effective as inhaled corticosteroids, leukotriene modifiers are an option if you have mild asthma and want to avoid corticosteroids.

Side effects: Inhaled corticosteroids may affect growth and long-term use of may slightly increase the risk of skin thinning and bruising, these are both rare side effects, so consult your Dr if you are concerned. The most common side effect is mouth irritation and oral yeast infections, so make sure to get your child to use a spacer and gargle with water and spit it after straight after administering the drug to reduce this side effect. This then reduces the amount of drug that can be swallowed and absorbed into your body by way of your stomach.

SYMPTOM CONTROLLERS–are long-acting relievers that help to relax the muscles around the airways for up to 12 hours. They are taken daily and should be used together with a preventer. Symptom controllers should not be taken to manage an asthma attack.

A way to decrease the amount of asthma is to take preventative and also medication steps to control the GERD symptoms.

Asthma medication administration in children

Nebulizer:  Up to age 3, children generally use what's known as a nebulizer. This requires a machine that breaks liquid medication into very small particles so that they can be inhaled. The nebulizer can be used with a mouthpiece or with a mask (for small children a mask is preferable).

The nebulizer (or neb) gives continuous medication (more than one type of medication can be mixed together), and works best in children less than 3 years old and for older children who are having an acute asthmatic attack and cannot use a Metered Dose Inhaler, or MDI.
Start by adding the correct medication(s) to the nebulizer cup. Connect the tubing to the machine and then turn it on. Place the mask over your child's nose and mouth and make sure that it is comfortable (this may take some time to get used to). Your child need only breath normally until all of the medication is removed from the nebulizer cup.

Inhaler:  It is rare for children under the age of 4 to use a Metered Dose Inhaler. For MDI medications, the best method is to use a spacer with a mask Start by placing the canister bottom up in the plastic holder, then removing the cap from the inhaler. Shake the canister before each dose (this is important). Place the mask over his mouth and nose, making sure it's sealed tight. Release a puff of medicine by pressing down on the canister. Hold the mask in place until your child has taken at least six breaths. If you need more than one dose, make sure to shake in between puffs. If using an inhaled corticosteroid, make sure to rinse the child’s mouth after each session. If your child is scared or anxious, demonstrate or make a game of it on yourself first this usually settles their anxieties.