You’ve crawled into bed and are just drifting blissfully off to sleep, when you hear the dreaded sound: wheezing.

Thirty minutes and several albuterol treatments later, your child’s wheezing has only gotten worse.

Is it time to seek emergency care, or is there something else you could try at home? What made your child’s asthma flare up, seemingly out of nowhere?

Dr. Puja Rajani, a pediatric allergy and immunology physician at Novant Health Pediatric Allergy & Immunology - Carmel in Charlotte, answers your questions, with help from colleague Dr. Marc Chester from Novant Health Pediatric Pulmonology - Carmel.

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Spring triggers asthma attacks. Why is that?

Dr. Puja Rajani

One of the most common triggers for asthma is allergies. In fact, “allergic asthma” (when asthma symptoms start after exposure to an allergen) is the most common type of asthma.

You wouldn’t think this, but allergy season starts around Valentine’s Day here in the Carolinas. People tend to address their child’s allergies when their symptoms are flaring in March and April, but by then it’s too late. If your child is allergic to something and reacts with inflammation in their upper airways (like their nose and throat), it can lead to inflammation in their lower airways — and asthma attacks.

When we get our first break from the winter weather, everyone wants to go outside and enjoy it. But if your child has allergic asthma, they’re being exposed to their allergens.

I’m not keeping my kids inside 24/7. Is there anything else I can do?

Dr. Marc Chester

If you know your child has allergies, and you know what helps them, start their allergy medications before or on Valentine's Day. Some of the medications take a while to start working, so this allows you to get ahead of it before everything starts blooming in March.

OK, that’s good to know for next year. What should parents do during this year’s allergy season?

Antihistamines (like Claritin, Allegra, Xyzal, and Zyrtec and their much-cheaper generic versions) work quickly and are a great place to start for relief. I also really like over-the-counter intranasal steroid sprays like Flonase, Nasacort and Nasonex, although they take a while to build up in your system. I like them because the steroid spray treats the inflammation in the upper airway, reducing lower airway symptoms. In theory, this can prevent some asthma attacks.

I also have to mention the coolest treatment for kids age 5 and older: allergy shots. Using tiny needles, we give children small doses of what they’re allergic to, desensitizing their body and teaching it not to react to the allergen. It's the only treatment we have that doesn't just put a Band-Aid on symptoms. It actually changes the natural course of the disease.

They’re a serious time commitment — your child will have to visit the office for a shot every two to 10 days for at least a year, with several years of maintenance visits after that — and shots won’t reduce their allergy symptoms right away. But if you start allergy shots this year, next year’s allergy season will be much better.

What is actually happening inside my child’s body when they’re having an asthma attack?

A trigger inflames your child’s airways, causing them to swell. The muscles in your child’s airways get tighter (also known as “constricting,”) more mucus is produced, and your child’s breathing starts to be obstructed.

Kids describe it as chest tightness or chest pain. They’ll say it's hard to breathe. Parents notice a high-pitched whistling sound as they are breathing out, or a tight-sounding cough (different from a “wet” cough that brings up mucus or phlegm).

The coughing and wheezing can eventually lead to very labored breathing if we don’t relax and open up the airways again with medication.

When I hear my child start wheezing, what do I do?

An asthma doctor can create an asthma action plan that is personalized for your child, but generally, think of a traffic light. In the “green zone,” your child has no symptoms.

In the “yellow zone,” your child has begun to have some symptoms like coughing or wheezing, so use albuterol through an inhaler or in a nebulizer depending on your child’s age. I highly recommend using something called a “spacer” along with the inhaler; it makes sure more of the medication gets in your child’s lungs. We usually recommend two to four puffs every four to six hours, but check with your child’s asthma doctor.

What about the red zone? Is that when I need to seek emergency care?

In the “red zone,” your child is having significant symptoms that are not improving with albuterol in the yellow zone. At minimum, call your doctor’s nurse line for guidance, and be ready to seek emergency treatment if you see the following:

  • If you look at your child’s stomach and their skin is getting sucked up into their ribs when they’re breathing (called “retractions”)
  • If your child’s nostrils are flaring
  • If your child is leaning forward on their elbows to help open up their airways to get better air in (called “tripoding”)
  • If your child is turning pale or blue/purple
  • If they're having significant wheezing that isn't improving
  • If they’re having difficulty talking
  • If your child has taken more than the allotted amount of albuterol in the yellow zone and still isn’t improving

Should I go to urgent care or the emergency room?

Go to whichever one is closest (many urgent care clinics are not open 24/7, so pay attention to operating hours). One caveat: if your child has history of hospitalization for breathing issues, and especially if their breathing issues have landed them in the intensive care unit before, go to the emergency room or dial 911 immediately.

Dr. Chester — what will happen to my child when we get there?

Your child will be given medications and supportive therapies to try to prevent the asthma exacerbation from worsening. Your child’s vital signs and work of breathing will be monitored closely. Lab work and imaging may be performed to help rule out other causes as triggers.

Typically, increased amounts of albuterol will be given along with systemic steroids (either by mouth or by IV) to help open the airways and reduce inflammation quickly. Sometimes additional emergency IV medications that help reduce airway muscle tone are required, such as magnesium and terbutaline.

If your child does not stabilize in the emergency room with good oxygenation levels and normal work of breathing, they may require admission to the hospital’s pediatric department for more intensive management.

Do I need to follow up with my child’s doctor after an asthma attack?

If your child was in the “yellow zone” but responded to albuterol, you may not need to follow up with your pediatrician or asthma doctor. However, if “yellow zone” episodes are happening more frequently, or are more significant or severe, this may be a sign that your child’s asthma is not as well-controlled at baseline as it should be, and follow up with your child’s asthma doctor should be scheduled.

Additionally, after any “red zone” experience that led to an emergency visit or hospitalization, a follow-up with your child’s asthma doctor should be set up to discuss whether any changes to chronic asthma management need to be made and to review any changes that were made in the ER or hospital.

Most kids go home from their emergency visit on prednisone or a similar steroid. These are very effective at keeping inflammation at bay as your child tries to get over whatever caused their asthma attack.

It’s normal for your child to need albuterol treatments for a few days after an attack. But if you’re not seeing consistent and steady improvement in your child’s symptoms and energy, let your child’s doctor know.

When is it time for my child to see an asthma doctor instead of their primary care doctor for asthma management?

Steroids suppress your child’s immune system, and can impact their long-term health. We want to limit using them. So if your child has needed steroids at least one time due to an asthma attack, or if they’re taking combined therapy (which combines “reliever” medication for acute symptoms with “controller” medication that works slowly over time), it’s time to see an asthma specialist.

We are familiar with drugs like biologics that your child’s pediatrician usually won’t prescribe, and can do advanced tests and monitoring.

Before your appointment, it’s very helpful if you can track your child’s symptoms, the time of day they occurred, and any possible triggers like illness, weather, exercise, allergens, scents or chemicals, or humidity that happened before the symptoms. Also note how often they’re taking albuterol and how many doses it takes to bring symptoms under control.

Kids know when they’re not breathing well, and it can be scary for them and limit their activities. Our goal is to help your child get back to playing, having fun and just being a kid.