By Pat Bass, MD 

 Medically reviewed by Sanja Jelic, MD

Pediatric asthma is a chronic respiratory disease in which a child's bronchi (airways) become inflamed and narrowed, making breathing difficult. While common, childhood asthma can be surprisingly difficult to diagnose.

This is partly because kids may not be able to clearly articulate how they are feeling, but also because children can present with both classic and less-obvious asthma symptoms.1

Verywell / Brianna Gilmartin

Types of Pediatric Asthma

There are several types of asthma with different symptoms and triggers.

Some common types of asthma and asthma-related illnesses diagnosed in children include:

• Allergic asthma: Classic asthma symptoms are brought on by something your child is allergic to, such as pollen, dust, mold, pet dander, or certain foods. The allergy may also cause sneezing, itchy and watery eyes, runny nose, or hives.

• Exercise-induced bronchoconstriction (EIB)*: Symptoms are caused by dehydration of the air passages due to changes in breathing during exertion, especially in cold air. Symptoms may be classic or also include sore throat, upset stomach, and decreased endurance.

• Cough-variant asthma: Some children's only asthma symptom is a dry cough that may wake them up, come on after exercise, get worse in cold and/or dry weather, or worsen after exposure to allergens. In some cases, this may be a sign of early asthma, although only about 30% of people diagnosed with this condition go on to develop classic asthma symptoms.2

While they're less common in children, other possible asthma diagnoses include:

• Non-allergic asthma: Classic asthma symptoms may be triggered by things that irritate the airways, including airborne irritants (pollution, smoke, fumes), acid reflux, cold weather, humidity, stress, and respiratory infections.

• Nocturnal asthma*: Classic symptoms frequently interrupt sleep and may be triggered by allergens or non-allergen irritants in the bedroom, especially when sleeping with a window open. Some children fall back to sleep too quickly to remember waking up, so the telltale symptom is daytime sleepiness.

*EIB and nocturnal asthma may be standalone diagnoses or add-ons to a primary asthma diagnosis.

Pediatric Asthma Symptoms

Children experience the same classic asthma symptoms as adults, brought about by narrowing of the bronchi (bronchoconstriction) due to inflammation and an increase in mucus production, including:

• Wheezing

• Coughing that's worse with a viral infection, occurs during sleep, or comes on while they're being active (especially in cold weather)

• Tightness in the chest

• Shortness of breath or gasping for breath

While it may seem like wheezing is pretty straightforward, a lot of parents have a hard time recognizing it. The younger the child, the harder this can be.

Parents describe the wheezing sound in various ways:

• "Whistling sound in the chest"

• "High pitched sound"

• "Rattling in the chest"

• "Crackly sound in the chest"

• "Squeaky"

• "Noisy breathing"

• "Can't describe it but I can feel it in his back"

A child may also present with more subtle symptoms that are different from the above, which can make diagnosis difficult.

Subtle Asthma Symptoms in Children

These more subtle symptoms may be easy to overlook or attribute to something else. While it's true that there are several potential causes of these symptoms, asthma is certainly one of them.

If you notice these in your child, raise it their pediatrician's attention:

• Slow recovery from respiratory illness: Infections like the flu or the common cold can trigger asthma. When this occurs, swelling and inflammation due to the infection itself is compounded, making recovery more difficult. This can be made even more challenging if lung tissue is already compromised from asthma.3 Because of this, those with asthma have a higher risk of developing pneumonia after a respiratory infection.4

• Fatigue or activity avoidance: You may think your child is just uninterested in playing sometimes. But if they don't seem to take part in what their peers are doing, it may be that they're tired from symptoms disrupting their sleep, or that they're having trouble breathing and don't know how to express it.

• Trouble eating: In an infant, the first symptoms of asthma you observe may be poor feeding, especially if they struggle and grunt while trying to eat. It's easy to mistake this for simple fussiness, lack of hunger, or stomach upset.

While an adult with asthma might say, "I've been wheezing and coughing," a child is more likely to say something vague like, "I don't feel good." That means some detective work is necessary to determine if asthma could be at play.

When to Get Help

Listen to your gut and speak with your child's pediatrician about anything that doesn't seem quite right, even if you or your child can't easily give it a name.

Wheezing, in particular, isn't normal and should never be ignored. Contact a healthcare provider if:

• The wheezing is new

• Wheezing isn't new but is getting worse

• You're otherwise concerned about what's happening with your child

Unfortunately, a breathing emergency may be the first indication that your child has asthma. Get emergency treatment for them right away if:5

• They stop mid-sentence to catch their breath

• Their nostrils widen nostrils when they breathing in

• They're using abdominal muscles to force air in and out

• The abdomen is sucked under the ribs when they inhale

• They're lethargic

• Their lips or skin turn blue

• They complain about discomfort in the chest or trouble breathing but there's no wheezing sound

Causes

An estimated 6-million American children have pediatric asthma. Experts aren't sure why some children develop asthma when others who may have the same risk factors don't. However, they suspect several factors are involved:

• Genetics/family history, including parents with asthma and a genetic tendency to have allergies

• Exposure to air pollution, cigarette smoke, or other environmental irritants

• Respiratory infections in early childhood

Some experts suspect that certain viral infections are more likely than others to lead to asthma, but research suggests it may be the number of early respiratory infections a child has—not the viruses themselves—that increase the likelihood of childhood asthma.6

Risk Factors

A wide range of risk factors for pediatric asthma have been identified, but their role in the disease's development isn't fully understood. Some known risk factors include:7

• Premature/preterm birth: Babies born before 33 weeks gestation are especially likely to develop asthma due to lung immaturity. Even those born at up to 38 weeks gestation have a higher risk of the condition than those born later.8

• Smoke exposure: Having a mother who smokes or is exposed to secondhand smoke during pregnancy ups the risk of a child having asthma, as does exposure to secondhand smoke after birth.

• Eczema: Children who have this allergic skin condition as babies are more likely to be diagnosed with asthma later on.

• Allergies: Children with allergies that cause sneezing or stuffy or a runny nose are more likely to have asthma than children without nasal allergies.

• Bronchiolitis: Research shows that this condition, which is frequently caused in premature babies by respiratory syncytial virus (RSV) and the common cold, may be linked to childhood asthma.

Based on this, if you believe your child is at risk for asthma, be sure their pediatrician is aware of it.

Diagnosis

During your child's appointment, the healthcare provider will ask you a lot of questions about your family history, child's history, symptoms, known triggers, and any other observations you've made.

In children under age 4 or 5, diagnostic tests are often of little help; your pediatrician may diagnose asthma based on a physical exam and the information you provide.

In school-age children, diagnostic tests may include a chest X-ray and pulmonary function tests, which measure the amount of air in your child's lung, how quickly they can exhale it, and how well oxygen moves into the bloodstream.

Your child may also be sent for blood tests and allergy skin testing, depending on symptoms, suspected triggers, and initial test results.

Some research suggests that measuring the amount of certain organic compounds your child breathes out may be helpful for making an asthma diagnosis.6 However, this is a newer test that your healthcare provider may not have access to.

Asthma Severity

Asthma severities are defined as follows:

• Intermittent: Symptoms two or fewer days per week; no impact on normal activity

• Mild persistent: Symptoms more than two days per week; minor limitations on normal activity

• Moderate persistent: Daily symptoms; some limitations on normal activity

• Severe persistent: Symptoms throughout the day; extreme limitations on normal activity

The formal diagnosis will include both the type and severity of your child's asthma. For example, mild persistent allergic asthma or intermittent cough-variant asthma with EIB.

Your pediatrician or asthma specialist will consider both of these factors when deciding what treatment approach is best.

Differential Diagnoses

Many children who wheeze don't have asthma and instead have a viral infection. This is more likely if the wheeze is accompanied by:

• Cough

• Runny nose

• Fever

Bronchioloitis from RSV is especially common in children, especially in the late fall, winter, or early spring.

Another possibility, especially in infants, is reactive airway disease (RAD). Many children diagnosed with RAD will not go on to have asthma. However, if they have multiple wheezing episodes with RAD, it could be a sign that asthma has developed. This is more likely if they have frequent infections and colds seem to "go to their chest," as well as if they have a chronic cough that gets worse at night.

Children with cystic fibrosis may wheeze, cough, and experience shortness of breath, but they also generally have poor growth, which isn't typical of asthma.

Other potential causes of wheezing in your child include:

• Gastroesophageal reflux disease (GERD)

• Irritation from secondhand smoke

• Foreign object in the lung (such as a small toy)

• Respiratory tract infection

The initial tests your healthcare provider performs depend on your child's specific symptoms. More tests, including blood tests and imaging, may be performed as potential causes are ruled out.

Treatment

The goal of asthma treatment is always to prevent or minimize symptoms and exacerbations. Other than differences due to age, the approach to treating childhood asthma is generally the same as for adult asthma.

Identifying and avoiding triggers whenever possible is of paramount importance; however, it's rarely practical to avoid all triggers at all times.9

The first asthma treatment your child is likely to get is a bronchodilator—a rescue inhaler that contains a quick-acting inhaled medication to relax the airways and improve breathing. These medications are classified as short-acting beta agonists (SABAs) and include:

• Albuterol, sold under brand names such as ProAir, Proventil, and Ventolin

• Levalbuterol, sold under the brand name Xopenex

Some people mistakenly believe that asthma attacks are reserved for those with more significant cases. It's true that more severe asthma involves more frequent exacerbations, but children with any type and severity may experience them when symptoms spike. As such, a rescue inhaler is appropriate for anyone with asthma.

You/your child should always have a rescue inhaler handy. If your child is in school, speak to the school nurse about whether a back-up should be stored in the office.

Nebulizers and Inhalers

Kids who are too young to use an inhaler, especially those under age 4, may start out with a nebulizer. This device turns medication into an aerosol that your child can breathe in through a mask. You can see the mist, so you know your child is getting the medication, which is comforting to some parents.

For older children, a dry powder inhaler (DPI) will likely be recommended over a metered-dose inhaler (MDI), due to ease of use. Still, using an inhaler can be challenging for kids, as it requires deep breaths that must be timed with the medication's release.

A spacer can help. This attachment is placed on the inhaler and has a chamber that can trap the medication once it is released. This gives the child the chance to activate the inhaler and then take a breath rather than having to coordinate the two steps.10

(Note that some children under 4 may use an inhaler with a face mask instead of nebulizer treatments. As they get older, they can transition to an inhaler with a spacer.)11

There's no set age at which a child should use one method over another; it depends on what your child is best able to use when. All of these options are effective as long as they're used correctly.11

Once your child is old enough to use an inhaler on their own, you and your healthcare provider should make sure they're well educated on how and when to use it.

Long-Acting Medication

If your child still has frequent symptoms despite use of a rescue medication, they may also be put on a long-acting controller. Many of these are inhaled, but some syrups and other formulations may be available for children who can't yet use an inhaler.

These medications are taken daily, whether or not symptoms are present.

The first-line controller medications are inhaled corticosteroids.9 If those aren't adequate, other medications may be added to them, or your child may be put on a different medication or combination of drugs.

Possible classes of drugs, the appropriateness of which depends on your child's age and the type of asthma being treated, include:

• Long-acting beta agonists (LABAs): Serevent (salmeterol), Foradil (formoterol)

• Leukotriene modifiers: Singulair (motelukast), Accolate (zafirlukast)

• Mast-cell stabilizers: Intal/Gastocrom (cromolyn), Tilade (nedocromil)

• Biologics/immunomodulators (for difficult-to-control cases):9 Dupixent (dupilumab), Xolair (omalizumab)

• Antihistamines

Your healthcare provider will also work with you on an asthma action plan, which gives you instructions for handling asthma attacks. If your healthcare provider doesn't bring up this topic, mention it. This information should be shared with other adults who are in regular contact with your child, such as teachers, caretakers, etc.

If you're having trouble getting your child's asthma under control with the help of their pediatrician, you may want to ask for a referral to a pediatric pulmonologist or allergist.

Monitoring

An important aspect of treating asthma is monitoring how effective current treatments are. For this to work, you'll need to have open communication with both your child and their healthcare provider.

If your child is seeing an allergist or pulmonologist, they may be given regular pulmonary function tests. This isn't something most pediatricians have ready access to, though.

A peak flow meter can help. This small, handheld device measures how much air is exhaled when your child blows into it, and results can flag whether asthma is currently well controlled.

Your healthcare provider may give you a meter or recommend that you buy one. They're available online, at pharmacies, and at medical supply stores for less than $10. Low-range monitors are available for younger children.

It's recommended that the meter be used daily as it can show changes in breathing well before a child may be able to feel them. Record the results and any decreases in asthma control.

Your healthcare provider can instruct you on when your child should use a rescue inhaler based on the readings and when they should be notified about changes. The peak flow record may be what identifies the need for an adjustment in treatment.12

Signs of Poor Asthma Control

Signs that your child's asthma is not well-controlled include:13

• Using a rescue inhaler more than twice a week

• Waking up with symptoms more than twice a month

• Needing their rescue inhaler refilled more than twice a year

Prognosis

Some people develop asthma in childhood and have it into adulthood. Others may experience symptoms for a few years and then "grow out of it." Either way, proper diagnosis and treatment can help them have an active childhood and keep their asthma from progressing.

Even in preemies, who are most likely to have pediatric asthma, about a quarter of them stop having symptoms by age 19.14

Prevention

A lot of parents ask healthcare providers if there's a way to prevent asthma in children. There's no definitive way, but a few things may help lower their risk:

• Breastfeeding, possibly due to impacts on genetic expression, changes to the microbiota of the mouth and gut, or the immune-system benefits of breastmilk15

• Going to daycare, possibly because exposure to pathogens in such settings helps build a strong immune system16

• A diet rich in fruits and vegetables, especially an anti-inflammatory diet17

• Omega-3 fatty acids in the diet, which lower inflammation18

• Vitamin D supplements during pregnancy and early childhood, possibly because vitamin D plays a role in lung development and immune function19

• Avoiding tobacco smoke

• Reducing indoor air pollution

• Avoiding childhood obesity: Added weight can physically restrict breathing and increase inflammation that can influence asthma.20

• Getting them vaccinated, which can prevent respiratory infections that may lead to asthma21

Some expectant mothers wonder if eating or avoiding certain foods during pregnancy could prevent their babies from developing allergies and asthma. So far, there's some early evidence that certain foods in the mother's diet may affect the risk. Foods that appear to be beneficial include:

• Cooked green vegetables (moderate and high intake)

• Raw vegetables (moderate and high intake)

• Eggs (moderate intake)

Meanwhile, high intake of meat before and during pregnancy appear to increase a child's risk of wheezing and allergies.22

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American College of Allergy, Asthma & Immunology. Asthma in children.

Magni C, Chellini E, Zanasi A. Cough variant asthma and atopic cough. Multidiscip Respir Med. 2010;5(2):99-103. doi:10.1186/2049-6958-5-2-99

Kim HJ, Lee J, Kim JH, et al. Factors affecting recovery time of pulmonary function in hospitalized patients with acute asthma exacerbations [published correction appears in Allergy Asthma Immunol Res. 2020 Jul;12(4):743]. Allergy Asthma Immunol Res. 2016;8(6):499-504. doi:10.4168/aair.2016.8.6.499

American Lung Association. Pneumonia and Asthma...Why Should I Worry?

UpToDate. Acute asthma exacerbations in children younger than 12 years: Emergency department management.

de Benedictis FM, Attanasi M. Asthma in childhood. Eur Respir Rev. 2016;25(139):41-47. doi:10.1183/16000617.0082-2015

Zhang J, Ma C, Yang A, Zhang R, Gong J, Mo F. Is preterm birth associated with asthma among children from birth to 17 years old? -A study based on 2011-2012 US National Survey of Children's Health. Ital J Pediatr. 2018;44(1):151. Published 2018 Dec 22. doi:10.1186/s13052-018-0583-9

Goyal NK, Fiks AG, Lorch SA. Association of late-preterm birth with asthma in young children: practice-based study. Pediatrics. 2011;128(4):e830–e838. doi:10.1542/peds.2011-0809

Devonshire AL, Kumar R. Pediatric asthma: Principles and treatment. Allergy Asthma Proc. 2019;40(6):389-392. doi:10.2500/aap.2019.40.4254

Roncada C, Andrade J, Bischoff LC, Pitrez PM. Comparison of two inhalational techniques for bronchodilator administration in children and adolescents with acute asthma crisis: A meta-analysis. Rev Paul Pediatr. 2018;36(3):364-371.doi:10.1590/1984-0462/;2018;36;3;00002

Rady Children's Hospital. Inhaler or nebulizer: Which one should my child use?

Asthma and Allergy Foundation of America. Peak flow meters.

American College of Allergy, Asthma & Immunology: Allergist. Recognizing uncontrolled asthma is your first step in controlling it.

Brewczyński PZ, Brodziak A. Have recent investigations into remission from childhood asthma helped in understanding the pathogenesis of this disease?. Med Sci Monit. 2015;21:570–575. Published 2015 Feb 21. doi:10.12659/MSM.893575

Miliku K, Azad MB. Breastfeeding and the developmental origins of asthma: Current evidence, possible mechanisms, and future research priorities. Nutrients. 2018;10(8):995. Published 2018 Jul 30. doi:10.3390/nu10080995

Rantala AK, Magnus MC, Karlstad Ø, et al. Is the association of early day care attendance with childhood asthma explained by underlying susceptibility?. Epidemiology. 2020;31(3):451-458. doi:10.1097/EDE.0000000000001163

de Castro Mendes F, Paciência I, Cavaleiro Rufo J, et al. The inflammatory potential of diet impacts the association between air pollution and childhood asthma. Pediatr Allergy Immunol. 2020;31(3):290-296. doi:10.1111/pai.13185

Lee-Sarwar KA, Kelly RS, Lasky-Su J, et al. Integrative analysis of the intestinal metabolome of childhood asthma. J Allergy Clin Immunol. 2019;144(2):442-454. doi:10.1016/j.jaci.2019.02.032

Litonjua AA. Vitamin D and childhood asthma: causation and contribution to disease activity. Curr Opin Allergy Clin Immunol. 2019;19(2):126-131. doi:10.1097/ACI.0000000000000509

Rance K, O'Laughlen M. Obesity and Asthma: A Dangerous Link in Children. The Journal for Nurse Practitioners. 2011;7(4):287-292. doi:10.1016/j.nurpra.2010.06.011

Beasley R, Semprini A, Mitchell EA. Risk factors for asthma: is prevention possible?. Lancet. 2015;386(9998):1075-1085. doi:10.1016/S0140-6736(15)00156-7

Baïz N, Just J, Chastang J, et al. Maternal diet before and during pregnancy and risk of asthma and allergic rhinitis in children. Allergy Asthma Clin Immunol. 2019;15:40. Published 2019 Jun 22. doi:10.1186/s13223-019-0353-2

By Pat Bass, MD
Dr. Bass is a board-certified internist, pediatrician, and a Fellow of the American Academy of Pediatrics and the American College of Physicians.