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QUESTIONS ABOUT ASTHMA IN CHILDREN: INJECTIONS, PETS, DIET AND MORE
Are desensitizing injections worth having?
The general answer to this question is no. There are two main reasons: first, they usually consist of eighteen weekly injections which can be painful, no child that I have ever met likes needles and it is unfair to subject anyone to this number; second they often are not effective. Asthma is rarely precipitated by a single allergy, so being desensitized to only one allergen will not prevent attacks occurring. The only possible justification is if your child is particularly sensitive to one animal (perhaps the family dog) and it would cause more heartbreak to give it away than to have the injections.
Can we keep pets?
Pets are one cause of asthma and may be blamed unnecessarily. If you have a child with asthma then I would not buy any new animals. This may sound harsh but it is important to remember that asthma can be a life-threatening condition and it would be reprehensible to place your own child’s life at risk purely for the sake of keeping a cat or dog. If you already have a pet and the asthma attacks are uncontrolled then the only action to take is to give it a holiday with a friend or in kennels. If the asthma decreases greatly then it may be necessary to part with the pet. If there is no change then obviously the asthma is not precipitated by animal dander.
Should my child eat a special diet?
Certainly by boosting the immune system your child will be better able to fight off an impending attack. This means eating a fresh whole-food diet free of additives and taking a daily multivitamin supplement. In asthma there is always the possibility of a food allergy, although in my experience this is usually fairly obvious because the symptoms occur soon after eating or drinking the offending substance. Thus, if your child has a wheezing episode, try to work out what has been recently ingested. Preservatives in food can also cause problems, the commonest of which are tartrazine and monosodium glutamate. These should be avoided wherever possible.
Should we move house to a cleaner area?
There is no indication that moving to a different area makes the slightest difference in the incidence of asthma, unless of course you move to the top of Mont Blanc where there is no dust. Those who do emigrate or try a different area are usually bitterly disappointed at the results and much worse-off financially. Not only that, but there is the inevitable psychological effect on the child at moving to a new school and having to make new friends.
Does my child need a special school?
No. There is absolutely no indication for this and it is vital that any child with asthma should be treated as any other child would be.
Are there any sports that will help asthma?
Swimming is an ideal sport and should be encouraged in every child with asthma. Adrian Moorhouse, the Olympic and Commonwealth gold medalist, had quite severe asthma when a youngster and firmly believes taking up swimming was mainly responsible for the improvement in his condition. Furthermore the warm humid air of swimming baths does not irritate asthmatics and the exercise of swimming, with its breathing control, is of great benefit.
What activities should be avoided?
The answer is probably none, but really it is a matter of common sense. In some children a certain exercise may bring on wheezing. I know one child who was perfectly well controlled except when he went to karate lessons. Since he was quite happy to stop going to these there seemed little point in increasing his preventive medication just for this purpose. If your child is particularly keen to do a certain exercise then it should be possible to control the wheezing but there is no real point in striving for this only to find he or she is not too concerned about giving it up. In my experience cross-country running is the sport most likely to induce an attack and this should not be forced on asthmatic children against their will.
*70/211/5*

Zyrtec-d (Cetirizine-Pseudoephedrine)

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ASTHMA IN CHILDREN: QUESTIONS ABOUT PRECAUTIONS WHILE CHOOSING A CAREER AND MORE
What precautions should be taken when choosing a career?
For the majority of asthmatic children there should be little restriction when planning a future career. There are, however, three important precautions to consider. First, if specific allergies are known to exist, an occupation exposing the asthmatic to these allergens is obviously to be avoided. Those sensitive to pollen shouldn’t become landscape gardeners and there is little point in working in a zoo if attacks are brought on by animals. Second, if asthma is induced by exercise it may be wise to avoid occupations that are particularly strenuous. This is not imperative, however, as it should be possible to control any asthma triggered by exertion. Third, any job where there is smoke, air pollution, irritating fumes or dust should be avoided if possible. This includes such trades as baking and carpentry and working in public houses with their inevitable smoky atmospheres. I have not in any way meant this list to sound restrictive as I am a firm believer that everyone should follow the career they will enjoy the most, and this applies just as much to asthmatics as to anyone else.
Is it safe to wear woolen clothing?
Few special rules need to be made about clothing, unless there is also eczema when irritating fabrics, especially wool, will need to be avoided. Dust fragments trapped in fluffy clothing can irritate the asthmatic child’s airways and chemical detergents used in washing may trigger allergies. The particular allergy which arises from biological washing powders, however, has not been shown to produce a sufficiently strong enough allergic reaction to cause a wheezing attack. Keeping reasonably warm in cold weather is sensible, but there is no evidence that concentrating the warmth about the chest by wearing a thick vest makes the slightest difference in asthma.
Apart from giving all the prescribed medication, what should I do when my child has an attack?
There is nothing more frightening to a child than being unable to breathe so the first rule is to appear calm yourself. Ensure that whatever inhalers you have been advised to give in an attack are administered correctly and at the right time. If the child is too distressed to synchronize the firing of the inhaler then do it for them. Watch the breathing in and out and press the inhaler just as the breath in starts and tell the child to hold their breath for a minute. There is a certain magic to children in inhaling medication and if you reinforce this with reassuring words then the effect will be doubled. Make sure the nebulizer is set up ready for the next treatment so there is no extra distress caused by searching for the bits to it.
Make the child comfortable, sitting upright either in a chair or on the edge of the bed. Encourage him or her to relax and breathe slowly. Remind him or her of breathing exercises they have been taught and make sure they are used. Something to occupy the child’s mind is useful; this might be television, a record, a story or a puzzle. All the time emphasis should be on an outward quiet confidence and an inward alertness.
*71/211/5*

Ventolin (Albuterol)

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TAKING CARE OF ASTHMATIC CHILDREN: AWAY FROM HOME
A difficult situation to face is when your child is asked to stay at a friend’s house or with a relative. Sleeping in another bedroom can carry risks as the amount of dust may be different and the pillows may be feather, both of which increase the allergic response and may produce wheezing. Other questions are: do they have any pets? Will your child become over-excited? Will he or she be too frightened to wake anyone if wheezing develops at night? In reality, if your child’s asthma is well controlled it is most unlikely that any problems will arise. I remember 4 year-old Julie’s parents spending a virtually sleepless night the first time she stayed at a friend’s house. Julie was perfectly alright with not the slightest hint of a wheeze. It is most important to ensure that all the normal medication is sent with the child and whoever is going to be the guardian knows exactly what action to take if wheezing should develop. I have found there is little point in simply telling friends or relatives, as under pressure they often can’t remember what to do. Far better is to write it all down step by step so they have an easy procedure to follow. Furthermore, if you are really worried then make sure you can be contacted if necessary. Simon’s parents were worried because he was booked into an activity camp for a week’s holiday in the summer and they were concerned that he would be out of contact for so long. Once again I advised them to make sure Simon had his inhalers and nebulizer with him and to explain to the nurse at the camp about the potential problem. Simon did have a minor attack half-way through the week but this was easily treated with extra doses of Ventolin and he had a tremendous holiday.
It is always worrying leaving your own child in someone else’s care, but it is vital that an asthmatic child is allowed to lead a normal life. If you prevent them from going then this will cause resentment which may lead to far more stress and tension in the end.
*66/211/5*

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CHILDHOOD ASTHMA: YOUR QUESTIONS ANSWERED
When the doctor tells you that your child has asthma it does come as quite a shock. Many questions crowd the mind at the same time and there is little or no time to ask them. More thoughts will occur to you on the way home or over the subsequent weeks and it isn’t easy to have them answered in the rush of a busy surgery. Even when you have become an ‘expert’ in treating your child’s attacks there will still be situations when you are not sure of the correct action to take.
Is asthma inherited?
Undoubtedly there is often a history of allergy either in the form of hay fever or asthma in one or both parents. So the tendency to develop the condition is at least partly inherited, and is then actually brought on by either infection, pollution, further allergy or stress.
Can babies develop asthma?
Asthma can develop in babies although it is uncommon below the age of twelve months. Many babies develop a sort of wheezy bronchitis which is not true asthma and which is often a ‘one-off event. Croup, which is a throat infection, can mimic asthma but responds to steam inhalation. It is the recurrent nature of the wheeze which tends to confirm asthma in babies, as many will have only a single episode and never wheeze again.
Will my child grow out of her asthma?
It is the increased irritability of the airways that is the root problem in asthma and fortunately this does settle down gradually as the child’s age increases. Many have grown out of the condition by the age of 12 although for some it can take longer. The factor that is most vital is to keep your child free of attacks for as long as possible, to allow the airways to become less sensitive. If there is frequent wheezing, perhaps once or twice a month, then there is little chance of the condition settling spontaneously. This is one of the reasons why it is so important to take preventive medication on a regular basis.
How do I explain to my daughter that she has asthma?
Firstly, always use the word asthma to describe what is wrong with her. It does not help to use vague expressions. Many children, even when very young, will know another child with asthma but will only relate to them if they know that they have it as well.
Explain to your daughter how the air passes from the nose and mouth into the lungs, perhaps likening them to balloons which go up and down as the air goes in and out. I always liken the airways to drinking straws through which the air travels to the lungs. In asthma the problem is that these tubes become narrowed rather like a straw that has been bitten and chewed. This makes it more difficult to drink through and less liquid comes up the straw. In the same way, less air flows out of the lungs or balloons because the airways or straws are narrowed. Medicines need to be taken to make these straws become wider and the most effective way is to use an inhaler or ‘puffer’ which sprays a fine jet of medicine straight on to the straws themselves. Occasionally if the asthma is bad enough this spray has to be breathed in through a mask for ten minutes.
My child has to use inhalers twice a day, every day. Is it safe to do this?
Most definitely. The reason is that the dosage used in medication that is taken straight into the lungs is ten times less than in drugs that are swallowed. Inhaled drugs go straight to the breathing tubes which are the problem area, whereas swallowed drugs have to circulate all round the body, including places like the heart, brain, liver and kidneys. These can produce side-effects in any of these parts, whereas by using inhalers there is negligible absorption into the rest of the body and so side-effects, if they occur at all, are only very slight. This is the reason why I have emphasized the importance of using inhaled medication rather than tablets or medicine.
*67/211/5*

Sterapred (Prednisone)

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Other names: Meticorten

CHILDHOOD ASTHMA: HOLIDAYS AND STAYING AWAY FROM HOME
In my surgery and in the asthma clinic one of the factors that causes great concern to parents is whether it is safe to go on holiday. My answer is invariably ‘yes’, as it is important for a child with asthma to lead as normal a life as possible. I have a young teenage patient who is going to Kenya on her third safari this year! The only time I would recommend staying at home is if the asthma is in an unstable condition. If attacks are coming very frequently it is wise to have the treatment reviewed and appropriate action taken in the stable environment of your own home. Usually this does not take long and hopefully only means a postponement of the holiday rather than a total cancellation. For the vast majority of asthmatics it is perfectly safe to go away but as a precaution you must ensure that you have the means to deal with an attack if one should occur.
Most vital is to remember to take the medication with you! This may sound silly but for three years I worked in a hospital in Blackpool and we once calculated that over half our admissions in summer were people who had forgotten to bring their medicine with them. Inhalers are usually the last to be packed so they can be easily reached and it is amazing how often they are left behind on the bedroom table. Also make sure you have one or two spare inhalers with you as they do have an irritating habit of running out or being lost just when needed most. If you are staying in this country then an attack can almost be as easy to treat as at home. It is well worth remembering to check when you arrive at your destination as to where the local doctor is based and how to make contact in an emergency. Everyone in the United Kingdom is entitled to medical treatment wherever they are staying free on the N.H.S. If you are staying in a hotel – and this applies particularly in London – the staff will often call a doctor privately for you, and the visit plus treatment can take up most of your holiday spending money. You are within your rights to ask for an N.H.S. visit and you should always insist on this. A useful tip is to take your own doctor’s phone number away with you and give him or her a ring first for advice. It is not very often necessary to call a doctor out, especially if you follow the treatment plan.
The first night of a holiday is the one when your child is most likely to suffer an asthma attack as the change of environment throws up different kinds of allergens and also there is all the excitement. So be organized and unpack the medication before you retire to bed.
If you are travelling abroad the situation is slightly more complicated, though if you are well prepared you should have little trouble. First, before you go, make sure you have adequate medical insurance just in case you need it. If you are going to the United States also ensure you have a credit card with sufficient reserve funds on it, as often the hospitals over there want the money before they will give the treatment. The last thing you want at that time is to have the stress of ringing insurance companies to obtain a cash advance.
*64/211/5*

Tavist (Clemastine)

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ASTHMA IN CHILDREN: STAYING AWAY FROM HOME
One of my patients, a little 5 year-old called Victoria, recently had to be admitted to a hospital in Italy with an asthma attack because her parents had not taken her nebulizer with them. I agree it is very bulky and difficult to fit into a suitcase but it does have a carrying handle. To me it is the most vital piece of luggage and must have top priority. Most people take far too many clothes away with them, so leave some behind and take the nebulizer instead.
Taking a nebulizer away with my own children has completely transformed our holidays, as it has taken all the anxiety away over the possibility of being unable to treat an attack. If it is combined with the use of a peak flow meter then it will be rarely necessary to use any local medical facilities. If there is any doubt before you leave about the power supply then it is wise to take a foot pump nebulizer rather than an electric one. These are cheap to buy or often your own doctor will lend you one to take with you. It is no use if your child has an asthma attack and there is nowhere to plug in the nebulizer!
Just one word of warning: always tell the customs office what the machine you are carrying is used for. Eleven year-old James arrived back at Gatwick from Florida with his father carrying the nebulizer. The customs officer must have thought he was a drug smuggler, because he completely stripped the machine down, causing all kinds of damage and rendering it completely unusable.
Equally important to take with you is a course of cortisone tablets, and I would recommend taking them very early in an attack. When you are away from home it is often difficult to tell how severe an attack is going to be and anyway you want to enjoy the holiday. The sooner the attack settles the better for everyone, so it is worth starting the cortisone as soon as the wheezing starts. Using 5mg tablets, a loading dose of two tablets followed by one tablet three times daily is quite adequate. Your own doctor will, I am certain, supply you with these before you go.
Should you by any chance forget to take any of the medication, and then do not despair. Most foreign countries have a much more relaxed approach to selling medicines than here and most are available over the counter. I remember going to Skiathos, a small Greek island, having forgotten to take any cortisone tablets with me. It was before the island had been developed for tourists so I was a little concerned when I sought out the local pharmacy. There was no cause for concern because their stock was larger than most chemists over here and there were several types of cortisone to choose from!
So, when you go on holiday try and keep calm and resist the urge to panic. This is not easy when you are in a foreign land and so many miles from home. If you go well prepared then management should be straightforward. Remember also that it is easy to ring home these days so take your doctor’s phone number with you. Last summer I had calls from Hong Kong and Brazil – unfortunately no one has so far offered to fly me out to treat them!
As a final note on holidays, I am often asked about air travel.
This will only cause problems in those with such severe and disabling asthma that oxygen levels in the blood are already low. A reduction in oxygen in the air in the aircraft cabin occurs at high altitude and at six thousand feet can be as much as 25 per cent. This could cause some embarrassment to the severe asthmatic and increase breathing difficulties. Fortunately oxygen is readily available. I must stress, however, that this will very rarely be needed and I would have no qualms about taking a child with asthma in an airplane.
*65/211/5*

Serevent (Salmeterol)

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CHILDHOOD ASTHMA: EXERCISE AND SPORT
Many renowned sportsmen and women have suffered with asthma in childhood – the cricketer Ian Botham is perhaps the most famous. It should be the aim with all asthmatic children to achieve a degree of control so effective that they are not restricted in any sport they wish to undertake. There are two problems that can arise during exercise, and these are well illustrated by the following two children, both of whom I saw in my asthma clinic recently.
Jayne is a 9 year-old who had suffered with quite severe asthma attacks since the age of 3. She had lived in the middle of Manchester until the age of 8 and I am sure the pollution in the inner city had been mainly responsible for her frequent wheezing episodes. Since moving to a more rural area her asthma had considerably improved and because of this Jayne became rather lax at using her inhalers. Although she no longer had any major attacks Jayne often found that she was short of breath and wheezy when doing games at school. Netball was not too bad but worst of all was cross-country running, which basically consisted of two laps around the school field. The first lap was usually alright but she became very short of breath on the second and usually had to stop and walk.
On checking her peak flow at rest I discovered that it was 325 when her predicted level was 375. During exercise more oxygen is needed by the muscles and therefore the lungs have to work harder. If the breathing tubes are already narrower than they should be, then the lungs have to work even harder to take in the extra oxygen, so the shortness of breath becomes more severe and the wheeze more pronounced. Jayne therefore was an example of a child whose asthma in general was poorly managed and this showed itself when she exercised. All that was needed in her case was to make sure that her preventive inhaler – Becotide 50 – was taken in the correct dose of two puffs twice a day. In fact I noticed from her case records that she had not had a new inhaler for nearly three months, indicating that Jayne had hardly been using it at all. An average inhaler contains 200 puffs and at 4 puffs a day should last 50 days, less than two months. When she went back to the recommended dosage her peak flow rose to 395 which then left her plenty in reserve for when she exercised. She is now able to complete two laps of the school field without any sign of problems.
There is also a specific condition called ‘exercise-induced asthma. Certain asthmatic children, although able to exercise perfectly freely, find they become increasingly wheezy when the exercise has finished. Twelve year-old Neil was typical in that he was very keen on all sport but – particularly after a hard cross-country race at school – he found that his asthma was very troublesome. Everyone becomes short of breath on exertion but this normally settles quickly when the exercise is finished. However Neil found that, instead of being able to relax and ‘get his breath back’, a paroxysm of wheezing would overtake him. This is proof of exercise-induced asthma, as no other form of chest disease is associated with breathlessness which becomes worse immediately after the exercise has finished. With Neil the wheezing reached a peak after a few minutes and could take up to an hour before there was any relief, even when using his inhalers.
During the course of exercise it is difficult to make accurate measurements of the width of the airways. However, the information that is available does suggest that in most people, including asthmatics, the airways actually widen during exercise, i.e. the peak flow increases. It is what happens after that provides the crucial difference. In normal people, the airways quickly revert back to their previous state, but in the asthmatic this is not so. For some reason the airways continue to narrow for up to five minutes, remain at that level for some time and then slowly widen out again. The extent of the change can be quite considerable and certainly this was the case with Neil. His normal resting peak flow reading was 450 but when measured five minutes after the end of a grueling cross-country race at school it had fallen to 220. In other words there was a 50 per cent reduction in lung capacity in just five minutes, so it was not surprising that Neil was so distressed.
*62/211/5*

Singulair (Montelukast)

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EXERCISE FOR ASTHMATIC CHILDREN
Exercise can be taken in many different ways and not all appear to be equally potent stimuli for exercise-induced asthma. In some children simply jumping about in the bedroom is sufficient stimulus and I have known my own son Ross to wheeze after the effort of laughing at a comedy programme on television. Both Jayne and Neil developed it after running and certainly I have found this to be the commonest precipitating cause. Indeed, only six to eight minutes of running is needed to bring on a severe attack of asthma and many will become wheezy in less time than this. Cycling will also produce breathing problems but less consistently, perhaps because only the legs are used. Swimming seems to be the most innocuous of all and can be recommended to everyone with asthma. In everyday life the asthmatic child will find that the severity of wheezing is less with shorter periods of exercise and with light as compared to heavy exertion. Quite hard sports, for example playing football or cricket, can be tolerated by the asthmatic, provided it is in brief bursts with some respite in between.
Almost all asthmatic children have exercise-induced asthma, so what can be done to prevent it? Without becoming too technical, it seems that an attack comes when the muscles of the airways are stimulated by the release of chemical substances. Exercise causes the release of these chemicals, but they have not yet been identified. It is interesting to note that if further exercise is taken within one or two hours then the degree of wheezing produced is much less. This suggests that the first bout of exercise depletes the stores of these chemicals and that it takes some time for them to be replenished.
The prevention of exercise-induced asthma is very simple: as it is caused by muscle spasm a dose of one of the bronchodilator drugs is the treatment of choice. You will remember that this can be given either in the form of Ventolin or Bricanyl through a pressurized inhaler, a turbohaler, a rotahaler or a diskhaler. While it can be given when the child becomes wheezy it is far more effective if given just prior to the exercise starting. Let us consider this in practice with the case of 12 year-old Neil. Neil’s main preventive medication was a Becotide inhaler. It has no real effect on muscle spasm, so increasing the dose would not prevent exercise-induced asthma. His main bronchodilator or anti-spasmodic was Bricanyl and by taking three puffs of this just prior to running Neil found that he was virtually free of wheezing after the race. Unfortunately he found that the Bricanyl, as it does in some children, made his legs feel weak and tired. While this was of no consequence in normal living it reduced his running performance. By switching to a Ventolin inhaler Neil found his running times improved. Ventolin has the side-effect of producing a slight tremor; this is harmless but in school Neil found it affected his writing. It did not, however, make any difference to his running. He was in a situation therefore of using a Bricanyl inhaler for normal wheezing episodes and a Ventolin inhaler for his exercise-induced asthma. Occasionally if it was before an important race he would use Ventolin via a nebulizer before leaving home. Personally I doubt if this is really necessary as the simple inhalers are most effective and I suspect with Neil there was an element of nervous asthma related to the tension of a big event. In summary, the key to preventing exercise-induced asthma is to give a bronchodilator about ten minutes before exercise begins. This sounds easy but in younger children is often forgotten, especially at school. It is important to discuss this carefully with your child’s teacher so your son or daughter does not feel self-conscious or embarrassed about using it. Whichever bronchodilator your child normally uses should be used to prevent the exercise-induced asthma, i.e. it can be a pressurized inhaler, a turbohaler, a rotahaler or a diskhaler. Always remember that exercise is not harmful to an asthmatic child. It is very often frustrating and annoying not to be able to engage in vigorous sports because of shortness of breath. Physical fitness is as beneficial – if not more so – to an asthmatic child as it is to anyone else. For this reason this important aspect of asthma control should never be ignored.
*63/211/5*

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CHILDHOOD ASTHMA: SCHOOL
The parents of an asthmatic child face two important decisions in relation to schooling. One is whether their child is fit to go to school on that particular day, and the other is what precautions need to be taken actually at school.
The individual decision on whether to go or not will depend to a large extent on the index of severity. A child who has been awaken half the night coughing and wheezing is generally in no fit state to go to school the next day. If a cold has led to wheezy bronchitis and the phlegm is turning yellow, it is probably best to allow the child to rest at home. Each mother or father will have their own method of telling; perhaps the speed and ease of washing and dressing, how quickly breakfast is eaten, the sallow tired look, the tinge of blueness in the lips or the pitch of the wheeze. They will know how to balance these criteria against the manipulations of the child. Is homework complete or is there a disliked lesson on that day? Is it games day? If both parents are going out working, then other factors come into play; how will the boss react to another day off? Which parent should stay with the child?
In the end, all these sometimes conflicting forces will result in a decision. Often it will naturally lean towards the side of caution and it will be very irritating on some occasions when the child runs around quite happily all day without much sign of a wheeze. One should remember when this happens that asthma is a potentially life-threatening condition and it is far more important to have a live child than a happy employer! Parents have a built-in protective reflex towards their own children and this should be instinctively followed. If you feel your child isn’t fit to attend school then that is usually the right judgment.
Julie and Simon presented different problems when it came to making a decision about school. Julie was in her first term and was much less able to manage her own asthma than an older child. For this reason it was much better in her case to be cautious and keep her off at the slightest sign of a wheeze. In fact her attacks were relatively infrequent and often Julie had recovered sufficiently by lunchtime to go in for the afternoon.
Simon, being older than Julie, was in a different situation altogether. One of the major causes of his attacks was the stress involved in returning to school after the holidays. His parents were therefore reluctant to let him stay off school as it only seemed to prolong the problem. They asked me if there were any definite guidelines I could give them as to whether it was safe to let him go.
I have stressed the importance of the peak flow meter in monitoring the control of asthma in children. Often a fall in readings precedes the start of an attack and using the meter is the only reliable way of telling how breathless the child is becoming. At rest – perhaps sitting at the breakfast table – the breathing may seem quite normal, but as soon as there is any exertion like walking to school the wheezing may be much more apparent. The peak flow meter will give the true picture more clearly. Simon’s normal level on the scale was 400. Under no circumstances should he be allowed to go to school if his reading fell below 300, more than a 25 per cent reduction. This reading means moving on to the plan for treatment of an attack. If his level was somewhere between 300 and 400 then it would be reasonable to let him attend school, as long as his peak flow is stable. In other words it should be measured three or four times between waking up and leaving the house to ensure it isn’t falling towards the danger level.
*60/211/5*

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Other names: Entocort, Pulmicort Inhaler, Rhinocort

ASTHMATIC CHILDREN AT SCHOOL
I think it is worth stressing that most children with a mild wheeze actually improve at school. This may be partly because they have been removed from an allergic environment but mainly as a result of the increased discipline in the classroom. The child is kept quietly working at a desk, not allowed to become excited and is also not given too much sympathy. Many is the time I have sent my own son Ross to school with a wheeze and spent the day worrying about him only to see him emerge happy and smiling without the slightest sign of any breathing difficulty.
The exception to this rule is the sensitive child who is frightened of a particular teacher and can start to wheeze in advance of certain lessons. Also, undue pressure from parents to do well academically can induce school-time asthma. As the child strives to reach the standards his mother and father expect during the school day a definite episode of wheeziness can develop and this will only ease as the pressure to perform is lifted. I tactfully suggested to Simon’s parents that this could be the case with their son and although they denied it, I am sure it may have been a partial contributory factor.
Equally important as deciding to send your children to school is what action is taken when they are there if a wheezing attack should develop. For a large part of the day they are under someone else’s care and it is vital the teachers are able to handle the situation. If you are lucky then the school will have a proper medical set-up. My son Ross is now in his first term at secondary school which has a sick-bay run by a nursing sister. I have donated a nebulizer to the school so I can rest assured that at least he will be well managed should an attack occur at school. My other children are still at primary school, however and are not so lucky, so what can we do to minimize the risks of problems developing? Parents often complain to me at the asthma clinic that the teachers do not know what to do if a child is wheezy at school. If they are going to be in loco parentis for six to seven hours a day then at least they should have some idea how to look after your child. This is a valid point, but rarely in my experience is it really the teachers’ fault. Teachers are not doctors or nurses and so do not claim to know a great deal about asthma or any other medical condition. At no stage during their training are they given any teaching on simple medical conditions and how to react to them. It is up to you as a parent to protect your child’s health at school and to meet the teacher or nurse and let them know of your child’s asthma. They need to know how often the attacks occur and what brings them on. Are they affected by exercise and is there anything the child should not do? The form teacher should have in writing a list of all the medications that your child takes and how often they should be given. The most vital information is what action should be taken if an attack starts. Remember, while these pocket-sized inhalers will become commonplace to you, most teachers will never even have heard of them, let alone seen one in action, so please go in and show the teachers how they are used. The pressurized bronchodilators like Ventolin and Bricanyl are easy to use and are most effective in stemming an attack. If you leave precise instructions as to how many puffs can be given, and if your child has been properly taught how to use one, then there should be no cause for alarm.
It is essential both for your child’s safety and for the teachers’ peace of mind that they have a telephone number where you can be reached in an emergency. If you do not do this then you have to accept that the limited knowledge of the teacher may not be to the benefit of your child’s condition. If you are unavailable for any reason then it should be made clear that if the school is worried at all, they should be free to take your child to the nearest hospital without fear of criticism. Most school teachers are given little information by parents and are then criticized for not acting correctly when a problem arises. This is hardly fair on the teacher. Seeing a child fighting for breath is very frightening so it is not surprising that teachers tend to panic. I have always found that if you fully explain a plan of action to them that you will have very few problems and your child should have a healthy and happy school life.
*61/211/5*

Periactin (Cyproheptadine)

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ACUPRESSURE FOR TREATMENT OF ASTHMA ATTACK IN CHILDREN
It is a drawback not being able to do acupuncture at home. This works on exactly the same principle as acupuncture, except that the points are massaged instead of needled. This means it will not be as effective as proper acupuncture but it can still be a valuable aid. All that is required is two minutes of firm pressure using either the tip of your fingers or the blunt end of a ball point pen. It is important to remember never to use severe pressure on any of the points – locating the right place is more important than the depth of pressure. As you will be doing it on a child remember you are much stronger than them. Acupuncture points are often very sensitive and it is easy to produce quite marked discomfort.
There are some points described on the abdomen, but I tend to avoid these so there is no risk of damage to the underlying organs. The other important precaution when using acupressure is always to treat children lying down, in case there are reactions such as tiredness or dizziness. Mark, a 9 year-old, found that daily acupressure when he was mildly wheezy was the most effective. Massaging the six points I have described for two minutes at a time takes only a total of twelve minutes, hardly an excessive commitment.
Many doctors now practice acupuncture, and I think it is advisable to go to one wherever possible; he or she will be in a better position to advise when it is possible to use acupuncture or when the wheezing is severe enough to warrant conventional medication.
*57/211/5*

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HOMOEOPATHY AS A NATURAL THERAPY FOR TREATMENT OF ASTHMA ATTACK IN CHILDREN
This is a form of alternative medicine that I particularly like, as it can be used at home and does not involve any disagreeable procedure on the child. (Not that acupuncture is actually unpleasant but it often produces a degree of fear beforehand.) The one vital factor in asthma is to ensure the correct choice of medication, and so it is not possible, other than by luck, to go and buy a preparation yourself from the local health food shop. Homoeopathy treats the whole person, so it is necessary to consider personality and lifestyle as well as the actual asthma. In my experience it is usual to use one of four possible preparations, depending on the particular symptoms:
? Arsenicum Album. When there is great restlessness and exhaustion. The wheezing tends to be worse after midnight and also between one and two in the afternoon. Cold and wet weather is a problem, as is sea air. Arsen. Alb. (the abbreviation) is best suited to children who are excessively tidy, intelligent and precise but also have tendencies to fear and anxiety.
? Ipecacuanha. The preparation I most frequently prescribe. There is usually a loud cough and associated nausea.
Lying down seems to bring on the breathing problems and the child tends to be a worrier.
? Kali Bichromicum. This is used where the symptoms are made worse by noisy surroundings and improve during gentle movement, from warmth, and after nourishment. There is often an associated headache and a loss of voice. The wheezing tends to be worse between three and five in the morning and often leads to nervous exhaustion.
? Aconite. Wheezing occurs after exposure to cold, dry wind and is accompanied by great fear. It is also made worse, strangely, by listening to music. Attacks are sudden, violent and brief with a characteristic dry suffocating cough.
If you do decide to try alternative therapy for asthma it is vital to receive specialist help at the start so the right method is employed. Failure to do this may lead to the wrong choice of preparation which may then not work.
*58/211/5*

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EQUIPMENT TO TREAT SEVERE ASTHMA ATTACK IN CHILDREN: INHALERS, NEBULIZERS
This list of equipment should be kept in a set place in the home and always kept up to date. The inhalers and nebulizer solution can be readily obtained on prescription from your doctor and you should have no problems maintaining your stock of these. The nebulizer has to be bought and is usually ordered through the surgery. The only drawback is the effort required to pump it – and there will be no way your child will be able to do it so it will be down to you!
To my mind every asthmatic child should have access to a nebulizer. Not only has it kept my own children out of hospital but it has made them much more self-confident as they know the treatment will work. If you do decide not to buy one then many doctors’ surgeries now have them available to borrow. The obvious drawback is that many asthma attacks start at night when the surgery is closed and there is the inevitable delay in starting the treatment until your doctor brings the nebulizer. During this time the wheezing may become much worse. Also it is possible that the machine is already on loan to another patient so there is no possibility of using it, or the attack may start when you are away from home. Some children only experience asthma with a change of environment. It is important when the nebulizer first arrives that you are taught the correct way to use it and I am sure your practice nurse will show you this.
The only slight problem you may experience with this list of equipment is obtaining a course of cortisone tablets. Basically, it is a very powerful drug which over a period of time can cause side-effects. However, I have found that to settle an asthma attack it only takes a course of three or four days. Significant side-effects do not occur for about five weeks so there is a wide safety margin. Some doctors argue that they like to see the child before such a strong substance is given, but to my mind this causes delays when further deterioration may occur. Not only that but often if the nebulizer is used as well it may only be necessary to take one or two cortisone tablets. So if your GP is reluctant to give you any, be quietly insistent and I am sure you will be allowed them.
When treating an asthma attack it will obviously depend on how much of this equipment you have at home as to how far down the line you can go. If, for instance, you only have the simple inhalers then you will have to call your doctor as soon as these lose effect, or as soon as the peak flow readings begin to fall through the range of the yellow band.
*53/211/5*

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Other names: Brethaire

NEW ADVANCES STOPPING A STROKE: CHEMICAL/DRUG RESEARCH
When an artery bursts or is clogged, it can’t supply the brain cells with blood, and they die. The injured and dying cells then emit substances that spread the injury to a widening circle of brain cells. Release of these substances allows the entry of excess calcium into the cells, followed by the entry of water, which bloats and destroys the cells. Chemical compounds to reduce the risk to brain cells during stroke are now being tested for human use. They would protect the cells from being flooded with water in this deadly process.
Brain scientists also are testing many chemicals for their ability to dissolve blood clots and stop a stroke in progress. These include streptokinase, an enzyme from bacteria, and TPA, a chemical found in tiny amounts in human blood. Studies show that they destroy clots in the coronary arteries. There is some proof that these chemicals destroy clots in brain arteries.
An experimental anticoagulant called Ancrod comes from the venom of Malaysian pit vipers. It thins the blood, breaks up clots, and has been tested on about 500 persons with some success.
In addition, researchers are focusing on ways to prevent clot formation. Blood clots in the coronary arteries produce heart attacks. Antiplatelet (blood-thinning) drugs, including aspirin and warfarin, are being tested on a large scale to see which ones help prevent stroke. If you have suffered a stroke, the chances are that you will have another. Treatment with blood thinners can extend the life expectancy of stroke patients.
Aspirin therapy – depending on the patient and the dosage – has been found to stop clotting. If you are 50 or older, researchers urge you to consult with your physician about aspirin therapy to help prevent stroke or heart attack.
Warfarin, a prescription drug for humans, is a blood-thinning chemical. It was long known as an ingredient in rat poison. When used to prevent stroke, it requires careful management, including monthly blood tests and adjustments of the dosage, as its effects vary with age.
*7/266/5*

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TREATMENT OF SEVERE ASTHMA ATTACK IN CHILDREN
Treating a mild attack of asthma is easy because there is no tension or stress involved and there is time to consider the best course of action. There are definite indicators to tell you when your child’s condition is worsening and you should take stronger measures to control the attack. The following are the guidelines that I have found to be reliable:
Early Signs
1. No relief is obtained from the usual inhalers.
2. Your child requests more frequent doses of the inhalers.
3. There is a persistent wheeze which seems to be worsening.
Later Signs
1. Constant loud wheeze.
2. Child becoming easily tired.
3. Usual inhalers needed every hour.
4. Marked movement of the abdomen with every breath.
Danger Signals
1. Wheeze lessens due to shallow breathing.
2. Child exhausted.
3. Blue tinge to the lips.
4. Child very restless.
A more accurate guideline is the peak flow meter. This is a small device which is used daily to monitor the progress of asthma by measuring the amount of air which passes through the lungs. Any reduction in the score from the normal, healthy range will reflect deterioration in the asthma. I would suggest that you use the following principles as a guide to the severity of the attack, using a score of 400 as the norm:
1. A score in the region of 300 to 400, i.e. a reduction of up to 25 per cent of normal, is classed as a mild attack.
2. A score between 200 and 300, i.e. a reduction of up to 50 per cent of normal, is a sign that a serious attack may well be building up. You should not put off taking remedial action in the hope that the asthma will improve by itself – usually it does not.
3. Any score of less than 200, i.e. less than 50 per cent of normal, means the asthma is not controlled and has moved into the severe attack range. It should not be accepted under any circumstances and steps must be taken urgently to correct it.
4. A score of 100 or less, i.e. a reduction of 75 per cent or more, requires urgent medical attention. While it may be acceptable to try and see whether the treatment described for a severe attack is effective, you must only try this while waiting for the doctor to arrive. If your GP is unable to call within 30 minutes then your child should be taken to the nearest casualty department. I must stress, however, that this is a most uncommon occurrence and most probably the peak flow readings will never fall as low as this.
This is all very well in theory, but in practice under extreme stress it can still seem too complicated. I have devised a method of marking the peak flow meters of each asthmatic with a colour system whereby the asthmatic child and the parents will know exactly what steps to take without having to work out percentages. The system takes the form of colour bands which are stuck on to the peak flow meter at the appropriate level for each patient. Simple instructions are written on the band as to what is the correct action.
After some experimentation we found that the best method was to use colours in the same manner as traffic lights:
? Anything from the green band or better means ‘Go’. Everything is alright and maintenance therapy should be continued as normal.
? Yellow for ‘Get Ready’ and some remedial action should be taken.
? Orange or Amber means that the attack is severe but should still respond to the treatment without the need to call the doctor.
? Red equals ‘Stop’ and indicates the reading is very low and urgent medical help either from the doctor or at hospital should be sought.
Peak flow meters are vital in the assessment of severity of attacks but it is also imperative to have the right equipment easily to hand at home to deal with any crisis. I have found that all that is needed are the following:
? A bronchodilator inhaler, e.g. Ventolin or Bricanyl.
? A steroid inhaler, e.g. Becotide 50 or Becotide 100.
? A nebulizer, preferably an electric one but a foot-pump nebulizer will do.
? Bronchodilator nebulizer solution, either Ventolin or Bricanyl.
? A course of cortisone tablets.
If you have all these at home then you will be able to deal with virtually every asthma attack. Since introducing this list plus the colour-coded peak flow meter I have not had to send a child on this regime into hospital. I am sure the reason is that as soon as there is deterioration in the peak flow reading suitable action is taken so the level never reaches the red zone.
*52/211/5*

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TREATMENT OF ASTHMA MILD ATTACK IN CHILDREN UNDER AGE OF TWO: DIFFERENT TYPES FOR TREATMENT OF ACUTE ATTACK
Homoeopathy treats the whole person, and so it depends a great deal on character and personality as to which preparation is most suitable. Basically I use four different types for the treatment of an acute attack:
? Arsenicum Album. When the baby is very restless though appears exhausted. The wheeze is usually worse between midnight and two in the morning. The baby is thirsty but will only take small sips of warm fluid.
? Ipecacuanha. The baby is vomiting or obviously nauseous and has a loud cough.
? Kali Carbonicum. Attacks typically occur later in the night, usually between three and five in the morning.
? Aconite. Attacks usually occur after exposure to a cold wind and the baby looks very frightened.
Of all these I tend to find that Ipecacuanha is the one I nearly always prescribe, and if you are in doubt I would suggest trying this first. Homoeopathic remedies are available on prescription, but many GPs will not prescribe them. Fortunately they are very cheap and all of the above can easily be obtained from any health food shop. Although they come in tablet form they are not to be swallowed, but must be allowed to dissolve in the mouth. This is a great advantage in babies, anyway, since there can be a danger of choking with swallowed pills.
Please do take the obvious precautions like always ensuring that your child has his inhaler with him and that it is not empty. A standard pressurized inhaler contains two hundred doses, and although it is impossible to tell accurately how many remain a new one does feel much heavier than an empty one. So when an inhaler seems to be becoming very light make sure you have a spare one, and do not leave it until it is empty before contacting your doctor. In fact it is much safer to have at least one spare inhaler at all times and I know in my own house there are several in different places. For example my own child has one in his bedroom, one at his grandmother’s, another in his trouser pocket and finally a spare one at school! Most GPs are quite happy to give an initial stock of inhalers to the child to ensure they do not run out. Another irritating problem about inhalers is that even a relatively full one can simply stop working.
The powder-containing inhalers – the rotahaler and the disk-haler – obviously have the advantage that there is no guesswork involved about remaining doses. However, it is still necessary to carry around spare disks or capsules and it is amazing how many children I have come across walking around with an empty rotahaler or diskhaler.
In the main children take very well to inhalers and certainly prefer them to tablets and medicine. One 8 year-old called Kirsty commented:
When I had asthma once my dad had broken his arm and it was Christmas time. I felt very tight in my chest and all dizzy and sick. All I could manage to eat was soup and it felt like I was on a diet – especially as everyone else was tucking into Christmas food. Mum started to give me tablets to make my chest better but I hated the taste of them so I hid them around my room. Later when she tidied up my room when I was better, she found them all over the place! She shouted at me saying, ‘I’ve found another? and another? and another?!’ I just went downstairs and laughed to myself.
There are many special situations relating to asthma attacks -during exercise and when on holiday for example.
*49/211/5*

Flovent (Fluticasone Propionate)

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ASTHMA IN CHILDREN: TREATMENT OF A SEVERE ATTACK
This is the time when asthma really hurts, when as parents you experience the pain and torment of seeing your own child suffering terribly in a desperate attempt to breathe. This is the time when an all-consuming panic can set in. You will be well aware that a certain number of children die every year from asthma, and suddenly you realize that your own son or daughter could be one of them. Surely it cannot be happening. Why can it not be like any other Sunday night? Why is it always at a time when the surgery is closed? You will feel desperately lonely and very frightened. ‘Why did I not listen to what the doctor told me and give the inhaler three times a day as advised? I daren’t ring again as I have already rung twice this week and it is a Sunday night.’
All these emotions and more will flash through your mind, and you will try to stay in control as you know that if you panic your child will sense this, and this can make the asthma worse. I know this is what happens as I have experienced these feelings myself with my own children. Perhaps as a doctor I should be better able to deal with the situation but I can assure you it is impossible for anyone to remain detached about their own family!
I remember on one occasion we had just returned from a holiday in Abersoch in Wales, and my son Ross had developed an attack of asthma in the car on the journey home. North Wales does not have that many hospitals, and anyway it wasn’t until the last half an hour that his condition deteriorated rapidly. I rang my own GP and she came over immediately. Ross by this time was worn out with the effort of breathing, and in the middle of his nebulizer treatment he actually slumped into a kind of exhausted sleep and the mouthpiece fell out of his mouth on to the floor. At that moment I glanced at the doctor and saw a look of terror in her eyes – I knew for an instant she thought he had died. Fortunately Ross jerked himself awake and carried on with the treatment but I vowed from that day on that I would always be available to parents if they were struggling with their child’s asthma. It was following that incident I opened an asthma clinic at my surgery, with no appointment needed, so anyone who wanted could come in at any time.
But what if it is at a weekend or when the surgery is closed? When should you call your doctor out? There are specific indications when to do this which I outline in more detail on p. 109. As a general rule you must always contact your GP if you are worried. Do not be concerned about contacting him or her unnecessarily. All doctors know that asthma is a potentially serious condition and that the sooner it is treated the better. Unfortunately there will always be the occasional doctor who will be a bit grumpy and might even infer that the visit was not needed. My advice to you if this happens is to immediately change your doctor to one who is more sympathetic. The vast majority will come out quite willingly even when it is in the middle of the night.
What does irritate doctors is to be called to see little Johnny at three in the morning when he has been ill for two weeks with a cold, or when the call has been left until one in the morning when the parents have returned after a night out!
*50/211/5*

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PHYSICAL RECOVERY AFTER CORONARY BYPASS SURGERY
As you already know, you can expect to feel unfit immediately after your operation. While in hospital, you will start moving around, resuming normal activities and, by the time you go home, you will be able to look after yourself. However, most people still feel weak, insecure and somewhat apprehensive. It is therefore comforting to have someone at home with you for the first day or two.
You will gain confidence by gradually increasing your physical activity, participating in the group exercise sessions and walking each day at home. In time, you should not only have the same physical capacity as before: your physical performance should be better, because you will no longer be limited by chest pain, which is the reason most people have the operation. You will find that you can do more without having to stop or slow down. However, you may need assurance that it is safe to step up your activity at a reasonably fast rate and to push yourself to some extent. You will achieve this confidence if you attend an exercise program recommended by the rehabilitation team.
*6/160/5*

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TREATMENT OF ASTHMA MILD ATTACK IN BABIES AND CHILDREN UNDER AGE OF TWO
Very young children present a special problem when they are wheezy, as they are too young to use any of the conventional inhalers. Many doctors will not recommend them until the age of 3, but I have found with care and patience most children will manage with them quite adequately from the age of 2 onwards. The situation has improved since research has shown there is no possibility of over-dosage, as people always feared. In fact the nebulizers have been shown to deliver up to 50 times the dosage of a conventional pressurized inhaler.
Asthma is uncommon below the age of one, and the reason for this is uncertain. It seems likely that it does take some time for irritability of the airways to develop, and perhaps there is some inherited protection from the mother in the first year of life.
If a baby does develop wheezing it is usually mild and often requires no treatment. However, if it becomes more severe then it may be necessary to give a bronchodilator, either Bricanyl or Ventolin in a syrup form by mouth. This obviously raises the possibility of side-effects, but in babies the dose needed to produce widening of the airways is very small, so it is unlikely that significant unwanted effects will arise. The main problem with medicines at this age is they are very slow to act and may take over an hour to produce any effect at all.
An alternative to medicine – especially in the 1-2 age group – is to use a conventional pressurized inhaler with an inverted paper or plastic cup on the end. Paul was 13 months when he had his first significant wheezing attack. It was not surprising, as both his parents suffered with it and were well versed in the use of the various inhalers. I advised them to give Paul some Ventolin every three hours using the following method. Firstly, a hole should be cut in the bottom of the plastic cup, big enough to fit the mouthpiece of an inhaler. The wide part of the cup is then placed over Paul’s face and nose and four puffs of the inhaler are given into the cup. This manoeuvre allows the spray to stay in the cup long enough to be inhaled a little at a time with each breath without much effort. Paul received instant benefit and his breathing became much more settled.
Alternatively, Ventolin can be given via a nebulizer as described on p. 86. The problem with this method in the very young is that they will not tolerate a mask strapped to the face or a mouthpiece in the mouth. However, it is usually possible to hold the mask near enough to the baby’s face for sufficient of the vapour to be inhaled. You will actually be able to see the baby breathing in the cloud of medication as it comes out of the nebulizer. This can be repeated as necessary, but four hourly is usually adequate. It is worth mentioning here that babies do tend to wheeze for longer than older children, although it often does not cause them any distress. Many is the time in the surgery where I have seen a baby with a slight wheeze who was nevertheless perfectly happy, and it was the parents who wanted something done. With some babies it is wise to allow the wheeze to settle on its own. This is not true, of course, in older children where it is important to bring the wheeze under control as quickly as possible.
I am normally a little reluctant to recommend alternative methods in treating asthma, as it is a condition which can deteriorate so rapidly. However, in young babies asthma is much milder and often responds well to homoeopathy. By using this it may well be possible to avoid the use of conventional medicine by mouth.
*48/211/5*

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TREATMENT OF MILD ATTACKS IN ASTHMATIC CHILDREN
In past years many children had oxygen cylinders in their bedroom, but this had little therapeutic value unless the attack was severe enough to be life threatening. Too much oxygen can actually depress the respiration further.
The anxiety which accompanies difficulty in breathing is also relieved by the presence of a loved one. No asthmatic needs telling that breathing is easier when sitting up, and most children will have their preferred position. This may be propped up in bed with several pillows, or when wheezing it may be easier to breathe if the legs are hanging downwards, so sitting in a chair – providing the child can keep warm – is usually more comfortable. The idea that one must be in bed if ill is a difficult notion to dispel in many parents, but there is no doubt asthma is better managed in an armchair downstairs.
Sleep is always a problem, and I have found at home that the first night of an attack is usually spent downstairs in front of the video recorder. It is much better now that we have all-night television but in the old days when there was no night entertainment the morning often seemed a long time coming. It is important that children with asthma should not be woken for any reason once they have fallen asleep. The audible wheeze always sounds much worse when asleep, but if the breathing deteriorates further it will always make the child wake up anyway. The benefits of going to sleep are very great, as not only does it produce relaxation but also reduces the body’s energy requirements. For this reason I sometimes prescribe a gentle sedative to help induce sleep.
These steps will settle nearly all mild attacks of asthma without recourse to further measures. However, there are a few children where the response to bronchodilator inhalers is less than would be expected. To understand the reason for this we must look again at why the wheeze occurs. Spasm or contraction of the muscles in the walls of the airways is undoubtedly the initial problem but there is also the swelling of the lining of the breathing tubes to take into account. Some children undoubtedly develop much more swelling than others and this can prolong the breathing difficulty Bronchodilator inhalers will relieve the muscle spasm but will not ease the swollen linings.
Debbie was a classic example of this, as although her initial wheeze improved with her bronchodilator inhaler she was left with a persistent cough and some shortness of breath. This was not relieved by increasing either the frequency of the dose or the number of puffs she took. The most effective treatment is to use a cortisone inhaler in which a measured dose of steroid is taken directly into the lungs. Please do not be doubtful about the use of cortisone as insufficient is absorbed into the rest of the body to cause any unwanted effects.
Debbie’s parents asked what exactly steroids are? ‘Steroid’ is a name given to a group of chemical compounds, many of which occur naturally in the body. There is a wide variety with different effects. For example, there are the muscle-building steroids used by some athletes illegally to improve their performance. There are also steroids in contraceptive pills and steroid creams for the treatment of sore, inflamed skin. Cortisone is used in asthma as it is a very powerful anti-inflammatory agent so will relieve the swelling in the affected airways. The preparation I recommend is Becotide and this is available in all the same devices as Ventolin and Bricanyl – a pressurized inhaler, a diskhaler or a rotahaler. Debbie was used to the simple pressurized inhaler, so I prescribed Becotide in a similar form. The dose was two puffs four times daily which we were able to stop after four days when her peak flow had returned to normal. It is important to note that the swelling of the airway lining does not settle anywhere near as dramatically as the spasm, so it may take some time for the child to return fully to normal.
On one occasion when Debbie used a steroid inhaler she noticed her voice became a little husky, and she developed a mild throat infection. This can sometimes happen, but neither effect is serious and both can be prevented or reduced if the mouth is rinsed out after using the inhaler. Should it continue to be a problem then using a spacer device like a volumatic (a chamber into which the inhaler is puffed) will also cut down the problem, by reducing the amount of the drug which lands in the mouth and throat.
*46/211/5*