Asthma

What Is Asthma?

Bronchial Asthma is a common problem in childhood. It affects about 20% of the children in Singapore. Parents are usually anxious and worried when told that their child has bronchial asthma. However, if one understands the nature of the condition, one can be reassured that the asthmatic child can remain healthy and physically active despite the problem.

Asthma is a condition whereby there is chronic inflammation of the airways. The inflamed airways are more sensitive than normal. No one knows for sure why some people get asthma. However, we do know that when the sensitive airways are exposed to a trigger factor, it over-reacts by releasing chemicals that result in the airways becoming narrowed.

This narrowing is due to 2 factors:

• The muscles around the airways contract or tighten, making the air passage narrow
• The lining of the airways swells or becomes inflamed and produces excessive mucus secretions which may plug up the airways. Airway inflammation is present all the time, especially in children with chronic symptoms.

Symptoms & Triggers

The common symptoms are wheezing, cough, shortness of breath and chest tightness.

• Wheezing is a high pitched whistling sound that occurs when a child breathes out. This is caused by the air flowing through the narrowed airways. Although this is the most important symptom of asthma, it may not be present in all children.
• Cough is generally most troublesome at night or early in the morning. This cough can be dry and irritating. Yet others have a wet cough, and may produce whitish or yellowish phlegm. Cough may be the only complaint in a small group of asthmatic children.
• Shortness of breath may be severe enough to interfere with normal activity, sleep or exercise. It is usually preceded by a respiratory infection. In older children, it may occur after exercise.
• Chest tightness may be a complaint particularly of the older children after vigorous exercise. This may be mistaken for a heart problem.
• Presentation of asthma varies from one child to another. While some children are predominantly troubled by wheezing, others may be bothered by a chronic cough.

What Are The Common Triggers Of Asthma?

Various triggers can affect the sensitive airways of children with asthma, and bring on symptoms of wheezing, cough, shortness of breath and chest tightness. However, it is often difficult to pinpoint the exact trigger. It is important to know that your child's breathing difficulties can occur hours after exposure to the trigger.

In practice, it is almost impossible to create an allergen-free zone, but try to keep as many allergens and irritants out of the house and bedroom as possible.

• Viral Infections: Asthma is often brought on by viral respiratory infections in young children. The child starts with what seems to be a mild cold. Then 1-2 days later, he develops a cough and wheeze. The asthma symptoms can persist for 1-2 weeks. Such viral infections are unavoidable and are very common in the young child. As the child grows older and resistance to viral infection improves, asthma attacks also decrease.
• Exercises: Most children with uncontrolled asthma develop wheeze, cough, shortness of breath or chest tightness with exercise. This is particularly so in older children who take part in more strenuous physical activities. Symptoms may occur a few minutes after exercise starts, or it may cause trouble many hours later e.g. in the night. The more intense the exercise, the more severe the attack. This is known as exercise induced asthma. Exercise induced asthma is believed to be related to the breathing in of cold, dry air which irritates the airways and hence triggers off an acute asthmatic attack. Therefore, it is commonest while exercising in cold weather or in air conditioned environment, and least likely to occur during swimming which takes place in a warm, humid environment.
• Allergies: Asthmatic children are sensitive to certain substances called allergens, which when inhaled cause asthma. Common allergens are house dust and house dust mites (sensitivity to a protein found in the droppings of house dust mites), animals/pets (sensitivity to fur, dried saliva, proteins from urine, droppings), pollen and mould. Food allergy is uncommon but occasionally peanuts, peanut butter, citrus fruits, strawberries, egg or milk products or bird's nest may provoke asthma symptoms.
• Irritants: Air pollution can cause breathing problems. Children with asthma have more symptoms during periods of haze. Paint can also induce asthma. Cigarette smoke is particularly bad for children with sensitive airways and should be avoided at all cost.
• Weather Changes: Sudden changes in temperatures and humidity may worsen asthma. Cold, dry air is a trigger to the sensitive bronchial airway. Exercising in cold air may also increase the symptoms of exercise induced asthma.
• Drug and Chemicals: Aspirin and other anti-arthritic medicines e.g. ibuprofen (Brufen), diclofenac (Voltaren) may cause asthma in some children. Certain cough mixtures, particularly those containing codeine, may sometimes worsen asthma symptoms. Children with asthma also react adversely to artificial coloring (tartrazine dye), food preservatives (metabisulfite) and monosodium glutamate (MSG).
• Emotional Factors: Emotional problems on their own do not cause asthma but anxiety, excitement and stress can aggravate the condition. Over-protective parents may create unnecessary anxieties for their children which may in turn lead to emotional and behavioural problems. Parents must discuss such problems with the doctor.

Asthma Related Allergies

Some children with asthma have other related allergic conditions.

• Eczema: This is particularly common in infancy. It is an itchy skin disorder affecting the cheeks, neck, creases in the elbow and behind the knees. The lesions may be red, scaly or weepy. Chronic skin lesions become thickened and darkly pigmented.
• Allergic Rhinitis: This is the recurrent episodes of runny nose and sneezing which is particularly bad in the morning. It can be aggravated by changes in the weather, a hazy or dusty environment or when in contact with pollen or paint. It is an allergic response to an inhaled allergen, the commonest being house dust mite. In severe cases the nasal obstruction is so bad that it leads to mouth breathing and the child may snore during sleep.
• Allergic Conjunctivitis: The affected child has recurrent episodes of red, itchy and watery eyes. They tend to rub their eyes frequently.

Does Asthma Run In The Family?

Careful enquiry will reveal that most asthmatic children have close relatives who have asthma or asthma related allergic conditions. However not all children with asthma have a family history.

How Do Doctors Make A Diagnosis of Bronchial Asthma?

Doctors usually make a diagnosis based on a detailed history and a careful examination. Special tests are usually not required, unless there are certain doubts in the diagnosis.

However, lung function tests are useful objective measures of the severity of the problem and for monitoring the progress after treatment. The following are the tests that may be ordered:

• Chest X-Ray: This may be necessary to exclude other medical conditions such as chronic chest infection or foreign body in the lung. Narrowing of the airways from other causes may be excluded.
• Lung function tests: These tests measure airflow obstruction and therefore give an objective indication of the severity of the disease and the response to treatment. They are safe, simple and most school-going children can cope with them.
• Peak flow rate: This is a measure of the maximum speed with which air can be forced out of the lungs. A simple instrument called a peak flow meter is used. The peak flow meter is portable and can be used easily at the clinic, even at home, in school or at work. With proper instruction, children as young as 5 years old can use peak flow meters adequately. The child is asked to breathe in deeply, then blow out as hard and as fast as possible through the meter. If the airways are blocked, the child will not be able to breathe out as fast and as hard, resulting in a lower peak flow rate. After treatment with asthma medicine, the peak flow rate improves.
• Spirometry: It involves the child performing some breathing manoeuvres into a machine called a spirometer. It measures the volume of air that can be expelled from the lungs after full inspiration and the speed at which the air is expelled. With this test the doctor gets a detailed assessment of airflow in the smaller airways.
• Challenge tests: In children whose history is not definitive and breathing tests are normal, "stress" tests may be used to induce airflow obstruction. A child is exposed to a short period of exercise or made to breathe in a chemical, following which serial measurements of peak flow rates are made. Most children with asthma will demonstrate a fall in the peak flow rates.
• Allergy tests: Allergy tests may be useful to confirm certain suspected allergens. This information may be helpful in the control of the home environment and allergen avoidance.

Are There Medicine To Cure Asthma?

At the present moment, there is no cure for asthma. However, there are effective treatments to keep asthma under control. Spontaneous improvement may occur as the child grows older. Asthma medicine can modify the underlying disease, improve symptoms and allow the child to lead a normal life, participate in sports and have normal lung function.

What Drugs Might The Doctor Prescribe?

his depends on many factors such as the type of asthma experienced (e.g. nocturnal, exercise induced), the severity of the asthma (mild, moderate or severe), the triggers and the presence of other medical conditions.

Asthma Medicines

There are 2 main groups of medicines which can improve the symptoms due to asthma. The first group is called relievers. These medicines act to relax the muscles around the airway, hence they relieve the obstruction to airflow rapidly.

The second group is called preventers. These act to reduce the inflammation or swelling of the airway lining and reduce mucus production. They do not provide immediate relief of symptoms but treat the underlying disease.

Reliever Medications

Relievers or Bronchodilators

These medicine make breathing easier, provide rapid relief of symptoms but do not modify the underlying disease. Hence they are useful in an acute attack or in prevention of exercise induced asthma. They are often used on an as-needed basis.

Reliever medications should be carried at all times and be used promptly to treat any asthma symptom. School children should carry reliever medicines in their school bags too.

Beta-Adrenergics

Most widely used in the treatment of acute asthma. They include Salbutamol (Ventolin, Respolin) and Terbutaline (Bricanyl). These can be given orally as tablets or syrups, by inhalation as a dry powder (turbuhaler, diskhaler, easyhaler), wet aerosol (metered dose inhaler, autohaler) or nebuliser with a small air compressor, or some can be given as an injection.

These medicines have side effects like increasing heart rate or causing tremors of the fingers. They are especially safe if they are given by inhalation as the dosages are very small. As the medicine is delivered directly to the lungs and the effect is very fast, the child gets relief within 5 minutes. With the help of spacer devices and holding chambers, even young infants can use an inhaler.

Bambuterol (Bambec), Formoterol (Oxis) and Salmeterol (Serevent) are bronchodilators. Unlike Salbutamol, their effects can last longer. However, except for inhaled Formoterol, the other long acting relievers have a slow onset of action and are not suitable as quick relievers. These medications are used in addition to preventive medications to achieve improved control of the asthma. It is important to remember that they never replace preventive medicines.

Theophylline

Commercially available as Aminophylline, Austyn, Nuelin, Nuelin SR, Quibron, and Theodur, they are usually given orally, but may be given by injection through the vein for acute asthma. Special formulations enable the medicine to be released slowly, therefore they can be used in the treatment of night asthma in children where more than 8 hours of action is necessary.

However, theophyllines are less widely used today because of side effects such as nausea, vomiting, headache, hyperactivity, irregular heartbeat, behavioural and learning disorders.

Ipratropium Bromide (Atrovent)

Ipratropium bromide is slower-acting than beta-adrenergics, taking about an hour to reach peak effectiveness but is more long-lasting than the latter. It can be administered via a puffer (inhaler) / nebuliser, in combination with a beta-adrenergic inhalation for treating acute asthma. The common side effects include dry mouth and palpitations.

Preventive Medicine

Unlike bronchodilators, they do not provide immediate relief. However, they modify the sensitive airways by reducing inflammation and thus preventing further attacks of asthma. Anti-inflammatories are now the first line of treatment in many programmes for managing problematic asthma.

They have to be given over a long period of time in order to modify the disease. Preventive medications should always be used, whether or not there are symptoms of asthma. Never stop your preventive medications without medical advice.

Sodium Cromoglycate (Intal)

This is a safe medicine with virtually no side effects. About 60% of children with mild asthma will show improvement with sodium cromoglycate. However, it takes at least 4-6 weeks of regular treatment of 3-4 times a day before benefits can be seen.

Sodium cromoglycate is usually given by inhalation from a metered dose inhaler. Throat irritation and dry mouth have occasionally been reported. It is not used frequently because of difficulty in administering medicine 3 - 4 times a day in the long term.

Nedocromil Sodium (Tilade)

Nedocromil sodium (Tilade) has preventive action similar to that of sodium cromoglycate. It replaces sodium cromoglycate in older children.

Cortisone/Steroid Medicine

These are extremely valuable medicines for asthma but unfortunately long term usage of oral cortisones can lead to serious consequences. Besides cataracts, hypertension, obesity, the most worrisome in children is permanent stunting of growth. Inhaled steroids, if used in low dosages are much safer. They act locally and very little is absorbed and thus systemic side effects are greatly reduced. If the child uses a spacer device and rinses the mouth after inhalation, local effects like white spots (thrush) in the mouth and hoarseness of voice can be prevented.

Oral steroids such as Prednisolone, Dhasolone and Dexamethasone should be used sparingly and reserved for acute severe asthma and those with chronic asthma who fail to respond to other anti-asthma medicines. Usually the use of oral steroids is only short-term for acute asthma. Any child requiring regular oral steroids must be seen by a specialist.

Inhaled steroids include Beclomethasone (Beclotide, Becloforte, Beclomet), Budesonide (Pulmicort, Inflammide) and Fluticasone (Flixotide). They can be given as a dry powder (turbuhaler, accuhaler or diskhaler) or metered dose inhaler. Generally, inhaled steroids take 1 - 4 weeks to reach their full effect. The dosage should be titrated according to the response and stepped down slowly when there is good response.

Anti-Leukotrienes (Montelukast)

Montelukast (Singulair) is a new drug that was recently marketed for use in asthma. Short term clinical studies have shown that there are very few side effects. Overall, it is not as useful as inhaled steroids as a preventive medicine. However, it appears to be particularly useful in young children with viral induced wheezing.

Combination Therapy (Long acting reliever and inhaled steroids)

This new combination has made treatment of problematic asthma easier. Seretide (Salmeterol / Fluticasone) and Symbicort (Formoterol / Budesonide) are 2-in-1 inhalers and hence easy to use and faciliate compliance. Like other preventers, they have to be used on a daily basis. Only Symbicort can be used as a quick reliever because of the rapid onset of action of reliever component, Formoterol.

Others

Other medicines like Ketotifen are generally not useful in troublesome asthma, but are effective in treating allergic rhinitis. Cough mixtures and antibiotics are not helpful in the treatment of asthma.

How Does The Doctor Decide Which Asthma Medicine Is Best For The Child?

The doctor will formulate a management plan based on the severity of the asthmatic condition. The child will be reviewed regularly to determine the progress. Medicine will be reduced when the child is better and the doctor will advise on when to stop the medicine. If the response is not optimal, treatment will be stepped up.

A child with mild intermittent asthma only requires a bronchodilator when there are symptoms or when the child is exposed to a known trigger like a viral infection or exercise. An inhaled beta-adrenergic is the medicine of choice here.

On the other hand, a child with frequent asthma symptoms may require a preventive medicine to prevent further attacks of asthma. Oftentimes, a 6-12 month course of sodium cromoglycate or low dose inhaled steroids will suffice to modify the underlying disease. Intermittently, an inhaled bronchodilator may be used when the child is facing additional triggers e.g. when the child is suffering from a respiratory infection.

Long term treatment will be necessary for children with severe chronic asthma. They will usually need a combination of bronchodilator and a preventive medicine to reduce symptoms and allow the child to participate in normal activities and not miss school. They may be on high dose inhaled steroids. Your doctor will advise you on the best option for your child. Fortunately, only a minority of children with asthma need long term treatment.

Discuss with your doctor how, when, and how frequently to use asthma medicines especially bronchodilators, during an acute episode of asthma. Request for a written asthma action plan for your child. This will help you to intervene early and prevent a severe asthma attack.

How Do You Know If Your Child Has An Attack?

Asthmatic children have acute asthma episodes from time to time. Episodes caused by viral infections usually occur slowly over a few days, whereas those brought on by allergens and exercise develop very rapidly.

What Are The Signs That Your Child Is Getting Troubled With Asthma?

• Wheezing or a high pitched whistling sound is heard when the child breathes out.
• Retractions. The soft tissue of the chest wall is sucked in as the child breathes in. It is best seen below the rib cage, between the ribs or above the breast bone and collar bones.
• Difficulty in breathing. Breathing out becomes prolonged and laboured.
• Rapid breathing. The child breathes faster than normal, he appears short of breath and has difficulty in speaking in full sentences or is unable to eat, sleep or play.
• Persistent cough may also be a sign of acute asthma.

What Can Parents Do When The Child Has Acute Asthma Symptoms?

As the parent of a child with asthma, it is necessary that you know how to manage an acute episode at home and know when and where medical assistance is available when needed.

• Stay calm. Stay with the child all the time.
• Refer to the written asthma action plan.
• Use the inhaled bronchodilator e.g. Salbutamol 2-4 (or as advised by your doctor) puffs immediately. Improvement will be noticed within minutes. If there is no relief within 5 minutes, give another 2-4 puffs (or as advised).
• In older children, let them sit up, leaning forward, keeping the back straight with the arms resting on the knees, table or firm surface for support. If a young child is having breathing difficulties, he will be more comfortable sleeping propped up with pillows.
• Loosen any tight clothing around the neck. If it is very warm, open a window and let in some fresh air.
• If the asthma attack is not relieved or wheezing returns within 4 hours, seek immediate help from the nearest hospital or clinic. Meantime, repeat another 4 puffs of inhaled bronchodilator before travelling to the hospital or clinic.
• If the child improves, the inhaler (2 - 4 puffs) can be continued until the symptoms improve.

Your doctor may advise you to increase the dose of the preventive medicine or to take another additional bronchodilator e.g. add an oral steroid or theophylline when the child has acute asthma symptoms.

It is wise to inform school teachers that your child has asthma so that they can respond quickly and calmly to an asthma episode. It is important to make sure that your child has his reliever inhaler in the school bag.

When Is Urgent Medical Attention Needed For An Acute Asthma Episode?

The general rule is that whenever you are worried, you should seek medical assistance as early as possible.

The following are some guidelines that may be useful:

• Based on your past experiences, you know that this is a severe attack.
• Peak flow readings fall and your child is not responding to the medicine you are giving.
• Your child needs an inhalation of bronchodilator more often than 4 hourly.
• The child is restless, refuses to eat, unable to sleep or speak properly because of difficulty in breathing.
• Your child looks blue or exhausted from the effort of breathing or is not fully alert. This is an emergency! Call the ambulance immediately. Always try to get help before this late stage.

How Can Parents Be Of Help To The Doctor In Accurately Monitoring The Child's Progress?

Doctors are very dependent on the parents' report of their children's progress. This unfortunately is often deficient because of the problem in recall. Parents can help by keeping a diary record of symptoms, triggers and medications used.

Inhalation Techniques

Wet Aerosol (Metered-Dose Inhaler)

What is a metered-does inhaler?

It is a device that contains a small aerosol canister filled with medication. The inhaler dispenses precisely measured doses of medications as small "puffs". Inhalers deliver these drugs directly to the lungs. Inhalers are portable and can be carried around easily.

Instructions

1. Remove cap from the mouthpiece of inhaler. Shake the inhaler.
2. Breathe out as hard as you can.
3. Close lips tightly around the mouthpiece of inhaler.
4. Breathe in slowly and deeply; at the same time, firmly press down the top of the canister once.
5. Hold your breath for about 10 sec, then breathe out slowly.
6. If taking > 1 puff, wait 1 min before the 2nd puff and repeat the above steps.

After finishing, wipe the mouthpiece and replace the cap.

Do a regular check on the use-by date. Inhalers need to be replaced before the expiry date. Always ensure that there is a spare new inhaler before you suddenly run out of medication. Inhalers should always have their caps on when not in use.

Most children are unable to handle a metered-dose inhaler well especially during an acute attack and the use of a spacer device is helpful.

Metered Dose Inhalers With Spacer Devices

A spacer is a large plastic container that serves as a reservoir for the drug released from the inhaler. The use of a spacer delivers aerosol with less force than a metered-dose inhaler alone. The drug is less likely to be deposited at the back of the throat and swallowed. Moreover the child does not have to coordinate breathing in with the activation of the aerosol.

Instructions

• Remove cap from the inhaler and shake the inhaler.
• Insert inhaler into the spacer. Close mouth over the mouthpiece.
• Make sure there is a tight fit.
• Spray in 1 puff. Breathe through the mouthpiece of the spacer for 5 - 6 times. Do not inhale through the nose. You should hear a soft click sound as the child breathes in and out.
• Wait for 1 min before the 2nd puff.

Maintenance of Spacer

• Clean once a week
• Rinse spacer with water
• Do not use scrub or tissue paper
• Air-dry the spacer

Metered-Dose Inhalers And Spacer With Facemask

Spacer with facemask is particularly suitable for young children who cannot use the mouthpiece of a spacer.

Instructions

1. Remove cap from the inhaler and shake the inhaler. 2. Insert inhaler into the spacer. Place mask over the mouth and nose.
2. Make sure there is a tight fit.
3. Spray in 1 puff. Hold mask firmly to face for 5 - 6 times.
4. Wait for 1 min before the 2nd puff.

Maintenance of Spacer with facemask

• Clean once a week
• Rinse spacer with water
• Do not use scrub or tissue paper
• Air-dry the spacer

Wet Aerosol Inhaler (Autohaler)

If the child uses a breath-actuated metered-dose inhaler, the inhaler will automatically discharge the medicine as the child breathes in. There is no need to inhale at the same time as actuation.

Instructions

• Remove the mouthpiece cover by unclipping from the back.
• Keeping the inhaler upright, push the grey lever up. Shake the device well.
• Breathe out normally.
• Place mouthpiece into the mouth and close lips firmly around. Make sure that the hand is not blocking the air entry holes at the bottom of the device.
• Breathe in slowly and deeply. Hold breath for 10 sec or for as long as possible. Breathe out slowly. Take the device out of your mouth and push the lever down.
• If another dose is needed, wait for 1 min and repeat the above steps.

Asthma FAQs

No One In The Family Has Asthma, Can A Child Have Asthma?

Asthma may occur in a child who has no family history of asthma, although it is much more likely to occur in one who has a family history of asthma.

Very often, careful questioning usually reveals a close relative who has trivial childhood asthma or asthma related allergic conditions e.g. eczema, allergic rhinitis.

Do Children Grow Out Of Asthma?

Most children do. About 50% of children, particularly those with mild asthma, will be attack free by adolescence. Of those who continue to have attacks, they become less frequent ad milder. Only a very small number continue to have chronic problems as an adult.

Do Children Die From Asthma?

Yes it can happen. Those at risk are children who do not receive proper and adequate treatment or those who have delayed seeking medical assistance in an acute asthma episode. Most deaths can be prevented and avoided.

Does Asthma Have Any Permanent Consequences?

Children with severe chronic asthma may have permanent growth retardation and damage to the lungs may be permanent.

Cigarette smoke is harmful to children's lungs especially those with asthma. Children should be brought up in cigarette smoke-free environment to prevent lung damage.

Which Doctor Should Look After My Child's Asthma?

Your family doctor will be the most important person to help you in your child's asthma management. He will refer children with frequent attacks or chronic symptoms to the specialist for advice.

What Are The Effects Of Inhaled Steroids On Children? Are Steroids Dangerous?

Inhaled steroids are safe especially at low doses, as very little gets into the bloodstream to cause side effects. Doctors and parents have to weigh the potential side effects against the severity of the child's asthma.

Should Children With Asthma Take Part In Sports?

Physical well being is particularly important in asthmatic children. In the event that the child develops a severe acute asthma, only a child who is physically healthy will be able to cope well. Participating in sports is important for peer acceptance and hence for the child's psychological well being too.

Children with exercise induced asthma should use an inhalation of Salbutamol or Terbutaline 15 minutes before starting exercises. If wheezing occurs when the exercise finishes, the reliever inhaler can be used again. Warming up exercises help to reduce asthma symptoms especially during cold weather. When the environment is polluted e.g. when PSI>100, asthmatic children should avoid strenuous outdoor activities.

It is helpful for parents to inform teachers of the child's asthma and his need for inhaler before exercise. In the event that the child experiences breathing difficulties, the teacher can supervise the child using his inhaler before getting medical assistance. Teachers are very important in helping asthmatic children achieve normal physical activity. They can encourage the children to start with light exercises to build up their confidence and physical well being. As the condition of the children improve, they can opt for other more strenuous exercises. Teachers can also assist the children in choosing the best form of exercise for them. Exercises that are less likely to induce asthma should be encouraged. Swimming and leisure cycling are less likely to cause symptoms than jogging and running.

Should Any Food Be Restricted?

Our tradition is filled with food taboos in asthma. However, there is little scientific evidence to show that certain foods cause asthma, and food allergy as the main cause of asthma is rare. Unless you have observed that your child always gets asthma after eating a particular food, there is no reason to restrict food. We have seen several children who develop eye-swelling and difficulty in breathing after consuming bird's nest.

Foods that contain known allergens like artificial colouring and preservatives should naturally be avoided. Citrus fruits tend to worsen cough and should be avoided during an acute illness.

Is There Any Food Which Will Strengthen The Child's Lungs?

Again, there is no scientific evidence that certain foods can modify the underlying lung problem. The importance of a balanced diet in promoting good health cannot be over emphasised. A balanced diet makes healthy children and healthy children have better resistance to infections and hence less asthma symptoms.

Is It Alright To Keep Pets At Home?

Pets are best avoided as some children do develop asthma after contact with pets. It may be difficult to remove the pet without causing emotional trauma as the child may be very attached to the pet. Hence, if there is already one at home which you cannot remove, then the next alternative is to keep the pet out of the house, or at least out of the child's bedroom.

What Are The Anti Dust Measures Which May Be Helpful?

House dust mites thrive well in house dust, especially in humid climate. They are found in bedding, carpets, furniture, and soft toys. The following anti dust measures are helpful in removing one of the most important triggers of asthma:

• Clean the air conditioner filters on a frequent basis. Avoid dampness, keep room airy and well ventilated.
• Remove carpets, fluffy toys, and upholstered furniture from the child's bedroom
• Enclose mattress in zippered vinyl covers which can be cleaned frequently with a damp cloth
• Do not use feathered pillows and woollen blankets
• Wash bed linens in hot water
• Use a damp cloth or wet mop to clean the bedroom
• Vacuum, rather than sweep the house. Air cleaning devices may be helpful during the haze to filter the fine particles in the air.
• Do not do any high dusting in the presence of the child.

Can The Child Sleep In A Room With Air Conditioning?

There is no contra-indication to sleeping in a room where the temperature can be controlled to a cool comfort. However, it must be serviced regularly to avoid dust collection.

Can My Child Travel By Air?

Do not travel when the child is unwell. The stress of air travel may precipitate an asthma attack. You should prepare for the flight by requesting a seat far away from the smoking section. Keep the bronchodilator medication with you in a hand carrier at all times.

Are There Other Ways To Treat Asthma?

Many other treatment modules have been tried with very little success, especially in children. Allergic shots have been tried with little success and can be dangerous if it is done by untrained personnel.

Hypnosis and acupuncture have been used with little sustained benefits.