4 year old with suspected Asthma

[Nsign7]

Have been following the forum with great interest so hoping that I could get some advice for my 4 year old son.

He was first diagnosed with viral-induced wheeze back in February of this year after being admitted to paediatric A&E. He was given a Salbutamol inhaler and a course of prednisolone. We thought it was a one off but then in March he had another episode which started with cold like symptoms which progressed over a few days to wheeze requiring another short course of prednisolone. At this point the GP prescribed clenil modulite (brown preventer inhaler) and sent us on our way under the care of the nurse and diagnosed viral asthma.

I was unsure with his diagnosis as I thought a proper diagnosis should not be made until at least 5 years old. Two months later the nurse reviewed treatment and as there had been no further episodes she stopped the use of the brown inhaler. To be honest we hadn't really followed the 2puffs twice a day plan.

A few weeks later yet another episode which started with a runny nose and progressed to a cough which got worse and needed another 5 day course of prednisolone. GP put us back on the brown inhaler. That was May.

He had another episode in July with another course of Prednisolone while still using the brown inhaler so unsure whether this is actually preventing anything.

August was clear but had another couple of milder episodes in September which were managed with the blue inhaler and didn't require visiting the GP. At this point we were hopeful that symptoms were being controlled with the inhalers.

Unfortunately, in October he had a couple of of episode of cold/coughing without wheeze which were controlled with the inhalers but he got a runny nose/cough/cold lasting a week which has resulted in wheeze and a visit today to the walk in centre and another course of prednisolone......

So first apologies for the long email. 😊

Hoping for some advice on what to do next? There is no history of asthma in the family and none of the typical symptoms like night time coughing, allergies, exercise induced, etc. He has had the symptoms in both the summer and now so doesn't appear to be seasonal.

I'm concerned about the number of times has had to have courses of prednisolone (5 times since Feb) . Whether the brown inhaler is actually doing anything. Whether this is asthma or episodic viral wheeze. I've read that while the symptoms are the same, the prognosis can be different.

Should I review the history with the asthma nurse and decide on the next course of action? If my son is getting episodes every couple of months then his condition is not being controlled with the current medication? Should I request a referral to a respiratory consultant?

Any thoughts or advice would be greatly appreciated.

[Chip_y2kuk]

There are a number of things that pop up here..

The brown inhaler can take 3+ months to work effectively, it basically slowly reverses the built up inflammation in the airways and *tries* to keep it that way.... so being on off on off won't have been much help

There are a number of asthmatics that are only really triggered by viruses/illness (which is my 3 year old daughters main issue, she is diagnosed as asthmatic)

When my daughter is coming down with something we firstly try and get it/keep it under control with her ventolin (4 times a day and extras inbetween if needed) and if it looks like we're on the loosing side we can increase her clenil... after that it's a trip to the doctors for prednisolone

It may also be he needs something else like montelukast or a stronger version of the clenil (they commonly start children on 50mcg but he may need 100mcg)

[Nsign7 in reply to Chip_y2kuk]

Thanks for the feedback.. I'm surprised about the time it takes for the Clenil to start working as the normal trial of treatment period we started with was about 6-8 weeks which suggests that should be sufficient time for the medication to establish in the lungs.

I think another review may be needed..

[Chip_y2kuk in reply to Nsign7]

Yes the trials are 4-8 weeks for it to make a noticeable difference... However there are studies where it has taken some 9 months for patients to gain suitable control

[Nsign7 in reply to Chip_y2kuk]

This article may interest you as your daughter is of preschool age if her trigger is viral. Written by A Bush who leads the paediatric respiratory team at the Royal Brompton...

google.co.uk/url?sa=t&sourc...

[EmmaF91 Community Ambassador]

Hi

Sorry to hear what you and your son have been through so far this year

Like Chip_y2kuk said the preventer takes a while to build up so worth preserving with it if you’re uncertain whether it’s helping or not yet. If you have been and you don’t think it is fully working it may be worth discussing a change of preventer

I’d definitely ask for a resp referral if he’s 4 and been on pred 5 times since feb! Whatever’s going on needs checking out and proper management (tho usually if the blue pump helps it indicates asthma 😞).

If he does have viral asthma it’s both a blessing and a curse. Great because it’ll only be there when he’s already ill, terrible because it’s easy for you, him and docs to forget he has asthma so will forget/stop meds whilst he’s well then suffer for it when he’s ill.

Definitely review his plan with the asthma nurse too. Like you have here write down a timeline of when he had issues, other symptoms he presented with (fever/runny nose/cough/tummy upset etc etc) and how it was treated. Highlight how often he’s been on pred to, as that’s an indication for referral esp at his age.

Good luck and hope you manage to get a plan in place soon x

[Nsign7 in reply to EmmaF91]

Thank you for this..

I have an appointment on Wed with the GP to follow up after the Walk-in visit so will push for a referral.

The brown pump maintenance dose is 1 puff daily (100mcg) stepping up to 2puffs twice a day when we notice him getting a cold. Probably need to review this..

I have all the history going back to 2016 documented in an spreadsheet 😊

[angievere]

We went through all this with my son (now grown up) but there was a history of severe asthma in the family. Colds were the main trigger and worse at this time of year. As well as conventional medication I tried to build up his immune system. Lots of hand washing, bath every evening with few drops of Tea Tree oil, lavender oil on his bedding and extra vitamins/ fish oil. He was diagnosed and treated successfully for severe rhinitis as a teenager, constant running nose and sore throat aggravated his asthma.

It is very hard for you and your son at the moment but things will improve as he gets older.

[Nsign7 in reply to angievere]

Thanks and yes, we try and do the same with diet and extra vitamins. I do hope that he grows out of it over time..

[angievere in reply to Nsign7]

It is a particularly difficult time because colds etc abound with children going back to school and the spread of germs. Hope things improve for you.

[ChrissieMons]

Insist on seeing a consultant. High doses of pred for young children is worrying, especially as he has long periods of being well. You need to find out what triggers this as just having a cough or cold shouldn't have such a dramatic outcome. Many people with asthma just get over these, with perhaps a double dose of the inhalers. I know some suffer dreadfully but your child shouldn't be one of them. The more info you have, the better. In the meantime, talk to the nurse at asthmauk.

[Nsign7 in reply to ChrissieMons]

As there isn't really any continuity of care (we're always seeing different doctors) I do wonder whether they are treating the presented symptoms rather than looking at the bigger picture and history.

I did question whether pred was really necessary as my son presented with wheeze and a slight cough which potentially could have been managed with inhalers. His sats were good and no shortness of breath, etc.

I will certainly insist on a referral and go private if need be..

[Luciespiers]

This sounds exactly like the set of symptoms and frequency of episodes my son gets. We got a referral to a consultant when he was five and they have given him better preventer medication. He still has severe episodes which require pred tablets about 5 times a year but overall his symptoms are much better controlled.

[Nsign7 in reply to Luciespiers]

Really? So at what age did he present and how severe are his symptoms? I do question whether pred is really needed in our case on some of the episodes. The cough is the worst symptom which then results in wheeze but it generally doesn't stop him running around and playing normally. He almost never coughs during the night.

What preventer medication is he now on?

[Luciespiers]

Oh. Well, Sam's symptoms are worse at night. The cough and mucous build up used to be very bad and he would get very distressed. Every kid is different though. Some symptoms are more subtle. I'm glad I have a very loud early warning system with the cough as I know when to gear up for a bad episode. I'm not sure how I would manage a quiet wheezer. Do you monitor peak flow, heart rate and oxygen sats as well? We do. Sam's O2 can be ok but his heart can be doing double time. We started peak flow monitoring aged 4 years. He previously took seretide but now he is on symbicort plus montelukast and avamys nasal spray. He had a full blood panel done to identify allergens which were triggers . Sam can cough for a while before it starts to slow him down. But then he can't eat without choking, his tummy hurts from coughing and he can't sleep for coughing. Only time anyone ever heard him wheeze was when he had a chest infection.

[Nsign7]

Ah, sorry to hear his symptoms are that bad.. It must have been tough to manage before getting the referral.

We do monitor O2, heart rate but not peak flow as the doctors have said he is too young for an accurate reading although I will mention it this week when I take him for his follow up appointment. I even have a stethoscope to listen to his chest for unusual sounds.

Thanks for your feedback, it's really helpful to hear from similar experiences..

[Hidden]

It’s interesting reading these, as one thing that becomes clear is either a change of thinking over the years, or different thinking depending on the GP/nurse.

My younger son developed asthma aged about 3 1/2 years (he’s now 26). To be honest we had been on the watch for it as I developed asthma at that age having had bad eczema for quite a lot of my first year; he showed signs of eczema (though nothing like as badly) at eighteen months.

Because he was so small (even for a three year old) his GP was very reluctant to put him on a steroid inhaler, even though he was as certain as we were that it was asthma. However, as a child (and into my twenties) I had been on IntalCo (a non steroid treatment for asthma). The IntalCo had been discontinued years earlier, but a plain Intal still existed. It was better than nothing (there was nothing like the range of meds available now back then). So we tried that. It didn’t work. Five months later, after four emergency appointments/call outs (resulting in nebulisers and/or pred. - we had a nebuliser on loan for a few days a couple of times) in as many months the GP relented; my son was put a steroid inhaler (can’t remember which one - I have a feeling it was becotide, which, like Clenil, contains Beclometasone). I don’t recall it was ever suggested that we needed to get him seen by a consultant.

The decision changed his life. He was attending nursery by this stage and went from being too unwell to go every couple of weeks to being unwell once every two or three months. He still could be very sick at times (including being blue lighted to hospital on one occasion) and viral infections were definitely one of the main triggers. But at no point did anyone suggest that he should come off his inhalers (he had two - the preventer and the reliever) even when he’d been fine for several months on end. I would certainly have fought any such suggestion had it been made. I can’t remember when he got his first peak flow, but he certainly had one by the time he was ten.

His steroid inhaler did get changed. I can’t remember when it was (apart from the fact that it was before he reached twelve); he got switched to Flixotide (a lower strength version of the medication I take for my asthma). As he got older and his immune system improved his asthma calmed down as well. Now twenty six he hardly ever needs to use his inhalers (though he still has them and needs them if the the circumstances trigger his condition - last occasion was eighteen months ago).

As others have said, if things aren’t working for your son at the moment his meds and his asthma need to be reviewed. If that means seeing a consultant, then push for that. While his asthma isn’t controlled his immune system is likely to be compromised (don’t I know it) and he will more be susceptible to infections, which in turn could well trigger his asthma.

Apols for the length of this. Good luck, and I hope things improve for your son soon.

[Nsign7 in reply to Hidden]

Thank you for taking the time to read and reply to my original post. All really useful insights on how to cope with this condition. Glad to hear that your sons situation is largely controlled without meds. Some children can grow out of it over time, especially if episodic.

Just reviewed meds with the GP. Clenil dosage has been modified, 2 puffs twice a day 100mcg.

Another review in 6 weeks and if the symptoms reappear then a referral to a specialist for sure.

Interestingly, at my request, peak flow was measured at 175 - the highest the GP had seen in a 4 year old and higher than the 150 recorded when he was perfectly well during the last nurse checkup. The expected figure for his height is 130 although they don't ordinarily take peak flow into account until at least 5, apparently.. Appreciate this maybe due to the Ventolin and pred but encouraging nevertheless..

Thank you to you and everyone else who has taken the time to reply. It's hugely appreciated and certainly helpful in our ongoing journey.......

[EmmaF91 Community Ambassador in reply to Nsign7]

I’m glad it went well for you. I hope the new meds work for him. Good luck x