Being a parent is a job with lots of ups and downs, as any mum or dad will tell you. As parents, we have enormous responsibility and often have to weigh the short-term and long-term implications of the decisions that we make.
A parent on the team recently has been put to that test with her experience with her child. This week’s blog post features some of her questions to a doctor, about the care of her son’s asthma. Her first concern was about treatments that would resolve his immediate issues with asthma, but she was also worried about whether those treatments will affect his growth.
Dear Dr. Friendly,
I’m wondering if you could provide some insight into my son’s condition. So far this week we have seen three doctors.
I first took him to see our family doctor, as his wheezing was getting worse – we thought he had a cold. I had stayed up with him most of the night, sleeping in his room and monitoring his breathing.He wasn’t looking much better in the morning and by the time we got to the family doctor’s office, his oxygen saturation was at 90%. I gave him two more puffs of Ventolin (at this point he had already had 3/4 of his daily Ventolin) during the visit, and he improved to 94%.
Up till now, we were advised to give Alvesco once a day (and Ventolin as needed up to 6 times/day) when he’s sick and for a couple of weeks after. The family doctor prescribed Flovent twice daily (with Ventolin as needed) instead of Alvesco.
I took him home, gave him his meds and he fell asleep but was still having lots of in-drawing in his chest. I called the family doctor back and she told me to take him to the emergency department.
Based on family history, and the fact that we’ve had to take him to the emergency department on several occasions since he was an infant, the emergency doctor told us he has asthma. Up till now, his condition had been referred to as wheezing.
The doctor directed us to go back to using Alvesco once a day (not Flovent). He emphasized the importance of giving him inhaled steroids every day, and not just when he’s sick. We were also told to follow up with the pediatrician. My son was given oral steroids both in the emergency department and at home the next day.
My questions are:
- What is the difference between wheezing and asthma?
- Why is there a clinical preference/opinion re: Flovent or any other inhaled corticosteroid??
- I’ve heard that the daily long-term use of steroids may have an impact on children’s growth – is this true, and if so should I worry about it?
Dear Concerned Mother,
Not having seen your son, I don’t really feel comfortable providing specific direction. I can answer some of your questions:
In response to your questions above:
1) Your story is familiar to many clinicians and families! Before asthma is diagnosed in children they often receive many different diagnoses, such as “wheezing”, “wheezy bronchitis”, “croup”, “recurrent croup”, “bronchiolitis”, “etc. In its early stages, and with first presentations, wheezing may result from many causes; however, if wheezing is recurrent, then asthma must be near the top of the list of diagnoses.
Diagnosis is made based on the child’s medical history, his family history, his response to bronchodilators and lung testing called spirometry. It’s a difficult issue because wheezing can result from many things in kids and spirometry testing is difficult to do in young children under about 6-8 years of age.
In addition, other more sophisticated tests are available to rule in (e.g., methacholine challenge test, induced sputum, blood and radiographic tests) or rule-out (e.g., sweat chloride test to rule-out cystic fibrosis) asthma in unusual cases (it can be hard work at times). The differences in terms of diagnostic testing, however, are more relevant to clinicians and researchers than they are to patients and parents.
For your purposes, if your son has recurrent episodes of wheezing, and these episodes respond to bronchodilators (such as salbutamol or Ventolin), and he is otherwise maturing appropriately, then it is appropriate that he be treated with the medications we use for asthma, regardless of whether or not he has had formal testing or been labeled as an “asthmatic”.
2) Flovent (Fluticasone), Alvesco (Ciclesonide), QVar (Beclomethasone), and Pulmicort (Budesonide) are all inhaled corticosteroids. Symptoms should be assessed and include: night-time wakening, missed school or other activities, number of short-acting beta-agonist activations/puffs each week (such as salbutamol or Ventolin), health care visits/flare-ups and so forth.
If avoidance of triggers and use of short-acting beta-agonists (such as salbutamol or Ventolin) isn’t controlling his symptoms, then the first step is to add a low-dose inhaled corticosteroid. There are strengths and weaknesses of each inhaled corticosteroid , and in general, it’s more important to be on an inhaled corticosteroid than the type of inhaled corticosteroid.
If asthma symptoms are severe and require emergency department visit or hospital admission, some patients require a short course of systemic (usually given by mouth) corticosteroids (such as prednisone). While we try to avoid giving these agents, when needed, they are safe and extremely effective.3) This is an important question for parents and children. There has been a fair amount of research on the impact of long term inhaled corticosteroids on growth. The results show that there may be a small difference in linear growth over a one year period (<1cm) for children using inhaled corticosteroids at low or medium dose.
Fortunately, this difference is very small, and there is pretty good evidence that if you have a chronic disease that’s poorly treated (aka asthma), you’ll have growth retardation. Worry more about his asthma control rather than his height. With good control, he will be able to: 1) sleep through the night (improves growth and everyone’s quality of life); 2) play sports (improves fitness and avoids obesity); 3) play, participate and interact in all activities (builds self-esteem); miss less school time (allows him to find a job and move out of your basement). It’s all relative!