In January, during a middle school gym class, 12-year-old Indiyah Rush was carrying her rescue inhaler, as she does every day. The Rowlett girl has asthma; her mom, Monique Rush, says she wants Indiyah to be prepared in case of a debilitating attack. “During an emergency, sometimes you can’t walk down the hall to the nurse’s station.”
In this case, the emergency wasn’t Indiyah’s. When Alexis Kyle, 13, began having an asthma attack, Indiyah didn’t hesitate to share her medication with her classmate.
Although Rush says her daughter thought she was doing the right thing — potentially saving a life — Schrade Middle School didn’t agree. Citing its zero-tolerance policy on sharing controlled substances (prescription asthma medication included), Garland ISD automatically suspended both girls pending an appeals process. The suspensions were lifted within a week, but Rush still has reservations about how the school will react in an emergency. “My fears were, what would have happened to [Alexis] if my daughter hadn’t done what she did?”
Navigating school policies and properly planning for emergencies in the classroom is just one more source of stress for parents of kids with asthma, a chronic disease that inflames and narrows airways in the lungs, making it difficult to breathe. Although asthma’s prevalence has remained relatively constant the past few years, it still has a serious impact on local families, affecting nearly 100,000 North Texas kids. In 2013, more than 1,500 children in the Dallas-Fort Worth area visited hospital emergency rooms or were admitted to a hospital with a primary or secondary diagnosis of asthma. And 54 percent of Texas kids with asthma missed at least one day of school in the past 12 months.
While the exact cause of asthma is unknown, doctors say there is a genetic predisposition for it. People with a family history of asthma or allergies are more prone to developing asthma; other risk factors include obesity, exposure to secondhand smoke and environmental factors such as air pollution. Children from low-income households are more likely to have asthma because of lack of affordable health care, and without access to medications they are more likely to land in the hospital with flare-ups.
Asthmatic kids experience wheezing, tightness in the chest and persistent coughing due to inflammation of lung tissue, tightening of airways and increased mucus production, according to Dr. Sam Foster of the North Texas Allergy & Asthma Center in Denton.
“Symptoms may be worse at night or with more intense activity, like playing sports or running,” he says. “Sometimes just laughing can worsen asthma symptoms.”
Jack Mitchell was only 8 months old when he landed in the emergency room because he couldn’t breathe.
“It was awful,” says mom Emily Mitchell, of Lakewood. “He had a combination of a high fever and wheezing. I remember thinking that he was such a little baby, and I didn’t want other people to touch him because he was already so delicate. It broke my heart that there was nothing I could do.” A year and a half later, Jack was officially diagnosed with asthma.
There’s no cure for asthma, and it can be life threatening if not properly managed. The key to reducing flare-ups is preventive treatment — both knowing and avoiding triggers that cause a reaction — and taking medicine to alleviate symptoms before they get out of control.
THE TRIGGERS AROUND US
While some triggers are present all year long, back-to-school time is especially challenging for children with asthma.
“Kids are getting together in classrooms and passing respiratory viruses around to each other,” explains Dr. Nancy Dambro,medical director of Pulmonary Services at Cook Children’s.
The weather is also partially to blame.
“For children who have pollen allergies as a trigger for asthma, the change in season is a peak period,” adds Dr. Angela Moemeka, medical director, Community Health at Children’s Health in Dallas. “Going from winter to spring or summer to fall can cause an increase in asthma symptoms.”
Exercise triggered Arlington mom Kala Batts’ son Micah’s asthma. The now 8-year-old developed respiratory issues when he was playing sports. “He was my regular active kid up until he was 4½ years old, and all of a sudden he couldn’t breathe right,” she says.
“During soccer he would start this short, shallow cough. He would be running, and then I would physically see his shoulders go up to his ears. He would clutch his shirt, slowly slouch and walk over to the sidelines.”
And that was just the beginning.
“He would freak himself out,” she remembers. “He was struggling to breathe so badly that he got scared. And the more you cry, the more you hyperventilate, so it just made it worse.”
At 5, Micah was diagnosed with activity onset asthma as well as allergy onset asthma.
“Once we found out what triggered him, it was like, ‘Oh my gosh: “He’s got all of these environmental and seasonal threats hitting him and then he’s running, so he’s got the physical activity on top of that. That’s why he can’t breathe! I get this.’”
Micah’s case is typical, say doctors. Kids usually show signs of asthma before age 5. It’s more common in boys before puberty and in girls after puberty, leading some doctors to believe that hormones play a role.
“The diagnosis of asthma is based on symptoms, the number of times a child goes to the doctor’s office or ER and how often he requires certain types of medications to improve his symptoms,” Moemeka says. And even if a child presents with wheezing in the first few years of life due to viral infections, for example, doctors prefer to hold off on an asthma diagnosis. “Everything that wheezes isn’t asthma,” Moemeka says. “That’s part of the reason we wait until a child is 2 or older.”
TAKE YOUR MEDICINE
Experts classify asthma as “intermittent” if a child has an asthmatic episode only once or twice week, and “persistent” if it happens daily. Lung function is measured using a special test called spirometry, which can also help doctors assess a child’s health.
“We use a tier-based treatment algorithm,” Foster says. “People who have infrequent symptoms may only use medications on demand; whereas, more severe and frequent symptoms usually require daily medications.” An albuterol inhaler or treatment administered through a nebulizer breathing machine, for example, is known as a fast-acting “rescue” medicine and used when a child first shows symptoms. However, the first line of defense in a child with persistent asthma is an inhaled steroid or daily oral anti-inflammatory medication.
BREATHING BETTER TOGETHER
That’s what finally worked for Jack, whose asthma is triggered by colds. Today the 4-year-old’s condition is under control, but it’s been a long road to learning how to manage the disease. After a particularly bad cold at age 2 that would not go away — “he started grunting and his chest was like rapid fire because it was working so hard to get oxygen,” Mitchell says. He was admitted to the hospital for several days, officially diagnosed with asthma and prescribed a daily steroid to reduce inflammation and mucus production.
These days he also takes albuterol to open his breathing passages and relax his muscles when a flare-up seems to be coming on. “If I hear a lot of coughing at night, I will start using albuterol because I know where this is going,” Mitchell says. “I finally feel like we’re on top of it — after being afraid of colds for years.”
Batts took a different approach, supplementing traditional nebulizing breathing treatments (which Micah once had to do up to four times a day, including at school) with essential oils. Using natural remedies to help control asthma is controversial at best within the medical community, though Batts claims the combination has been successful for Micah. “You know when your kid needs extra help,” she says. “Moms know their kids best.”
CLEARING THE AIR
And there are certainly many moms trading asthma survival stories in North Texas.
“The city of Dallas has over 1 million people, and like other large cities, asthma’s prevalence is affected by housing stock, type of allergens that exist in the homes and the age of homes in which children are being exposed to allergens,” Moemeka explains.
Add to the equation the fact that the Dallas-Fort Worth area is the 11th most polluted city for ozone, according to the American Lung Association, which can also trigger asthma attacks.
“Ozone pollution is likely due in part to old factories in the area with outdated equipment and infrastructure,” says Cheryl McCarver, executive director of the Health and Wellness Alliance for Children in Dallas, a coalition of community-based organizations. “The pollutants in the air particles are still very high, and the air comes into the area and causes breathing problems.”
Like Moemeka, McCarver emphasizes that there’s more to asthma than the outside environment; what’s inside homes matters as well.
“One of the things we work through is the actual quality of the indoor environment: the carpet, whether children are allergic to pets or insects, mold, things like that,” she says.
So what’s a parent to do if their kid seems to be showing signs? First — and this is critical, Dambro says — is to define the pattern of symptoms.
“The most common thing I see is patients who are defined in the intermittent category and not given preventive medicine. Then they get really sick and land in the intensive care unit,” she says. That’s because parents tend to downplay symptoms to doctors. “There’s an old-fashioned notion that a lot of people didn’t want to be labeled with the diagnosis of asthma,” Dambro explains. But this step is crucial to getting kids the right treatment plan and getting them on the proper medicines.
Second, be informed.
“The patient has to partner with the doctor and be educated about how the illness works and how the medicine works, and they should have a written action plan so that they know what to do when the child gets sick,” Dambro explains.
In fact, developing a written action plan with your doctor is one of the best ways to avoid a visit to the emergency room.
“Writing things down helps a person control and own their disease,” Foster adds. “And it’s enabling for parents. Rather than looking online or talking to Grandma or trying to figure out what to do, they have written instructions.” The plan, which should also be given to schools, day-care providers and after-school programs, details a child’s triggers, what to do during a flare-up — including when and how to give fast-acting rescue medicine — and when to call the doctor or seek emergency care.
In addition to submitting an action plan to your child’s school, familiarize yourself with district resources and policies — which, as Indiyah Rush and Alexis Kyle found out, can be a source of uncertainty. Per the Texas Education Code, students can carry and self-administer prescription asthma medication (with the right documentation), but districts may have differing asthma management programs and emergency protocols, so it’s important to do your homework. Communicate with your school nurse and administrators to learn what paperwork you need to have on file, who can administer your child’s medication and when, what kind of asthma training the teachers and staff have received, and how the school will respond in an emergency.
Third, administer the medicines as prescribed.
“It’s a pretty simple thing to do to give two puffs in the morning and two puffs in the night, but an incredible number of parents forget to give it, don’t give it regularly or stop giving it,” Dambro says. “The rate of people stopping the medicines is very high.”
One of the reasons parents stop is because they start to see fewer symptoms and mistakenly think their child has outgrown the asthma. Unfortunately that can backfire and lead to an even worse attack. Other parents stop giving medicine because they simply don’t want their kids to take pharmaceutical drugs or are wary of the side effects of steroids (although experts in the medical community say small doses of inhaled steroids are generally safe).
Of course, identifying and learning to minimize or avoid triggers is also a big piece of the puzzle in keeping the disease under control.
For Batts, that means not letting Micah sign up for soccer.
“He’s playing baseball right now because there’s less running,” she says. But since he can breathe and actually enjoy himself on the field, he doesn’t mind. “Now that we have his condition under control, he is vibrant again,” Batts says.
Fortunately there are also steps that can be taken on a community-wide level, according to Foster.
“Vaccinate for the flu; it’s a leading cause of hospitalization for children with asthma,” he says. “Encourage exercise and an age-appropriate diet. Breastfeed when possible — it’s believed to reduce the risk.”
But the best solution for now is educating North Texas residents. In addition to teaching parents to create a healthy indoor environment for their kids, groups like the Health and Wellness Alliance for Children examine social determinants that impact families.
“We use uncommon partnerships and link our clinical, social, community, public and philanthropic areas to reduce the burden of childhood asthma in our community,” McCarver says. This is again where socioeconomic factors can come into play. “A lot of children live in poverty, and that affects their family’s ability to fight asthma. We don’t want them to have to choose health over paying bills to keep the lights on.“
Comprehensive approaches may be one reason asthma-related ER visits in the area have declined. “Over the last 10 years or so we have seen decreased rates of hospitalization and fewer deaths in children with asthma,” Foster says. From 2012 to 2015, patient visits for asthma to Children’s Health Emergency Department decreased by 49 percent. Overall there seems to be better management of the disease thanks to education and more access to preventive care. “All of this shows that changes in guidelines and increased awareness in the medical community and community at large is making some strides,” Foster adds.
While experts will be watching to see if this trend continues, there is one thing they can all agree on in the meantime: the importance of the parent’s role in helping doctors diagnose, treat and manage asthma.
“A mom should trust what she knows about her child and to bring that information to the pediatrician,” McCarver says. “Parents are the experts — their instincts and concerns are valid — and they should be eager to share that information to help pediatricians support the well being of their children.”
For Mitchell, it was a matter of not only trusting her instincts but also finding the right care, especially since she has started to see signs of asthma in her 2-year-old daughter Nora as well.
“I am actually thankful for the time Jack was admitted to the hospital,” she says, looking back on her scary experience. “I learned so much. The doctors and the nurses were fantastic. They taught me everything about asthma I needed to know.”