A Breath of Safety for Your Child

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Q: I work in a daycare center where several children have asthma. The medication says, “As needed,” but we have two parents who want their children to get their rescue inhaler on a daily basis-even though they show no symptoms of asthma. Do we give it to them anyway?

A: Yes. Please follow the parents' instructions, as they know the treatment plan. However, you raise a good point—those types of inhalers are usually recommended when asthma symptoms flare, or prior to exercise in those with a form of asthma known as exercise induced bronchospasm. Needless to say, to clear up any questions or confusion, it is important their parents bring a doctor's note detailing each child's current state of asthma control, the medications they require (if any) on a regular basis, as well as when (specific symptoms, prior to exercise, etc.) and how often to use the “rescue” inhaler.

That said, prior to implementing a treatment plan it is necessary for their physician to get a sense of the child's current level of asthma severity. This is determined by factors such as the frequency (how many times per year) and risk for asthma exacerbations requiring oral steroids (prednisone, others), as well as the degree of impairment such as:

Asthma symptoms (days per week and how often per day)
Nighttime awakenings (times per month)
Days per week requiring the use of rescue medications known as short-acting beta-2 agonists (albuterol, pirbuterol, terbutaline, levalbuterol, others)
Interference with daily activities (none, minor, some or a great deal)
Results of a lung function test (in those ages 5 and older).

Once the above information is obtained, a classification system of their asthma severity is determined (intermittent, mild persistent, moderate persistent and severely persistent). Then, a treatment plan is designed using medications in a step-wise manor (occasional use of a short-acting beta-2 agonist, low-dose inhaled corticosteroid, leukotriene receptor antagonist, etc.) until the right combination is determined that will enable the child to live an active lifestyle with little or no symptoms.

Returning to your question, ensuring children have a safe journey in daycare (school, camp, etc.) requires good communication between parents and daytime guardians. This can be summarized in a written asthma action plan that all parents should personally deliver to and discuss with those in charge of their child's safety while they are away. Contents of this plan should include:

Their child’s current asthma control situation (well-controlled, occasional or frequent use of “as needed” medications)
Current medication dosage schedule, as well as potential side-effects (jittery feeling, dry throat or nose, etc.)
An individualized list of symptoms (cough, anxious look, sweating, wheezing, chest tightness, etc.) provided by the parents that warn of a potential asthmatic attack in their child. This is especially important since symptoms are variable and may be confused with other conditions (nervousness, post-nasal drip, others)
A list of their child's asthma triggers (stuffed animals, certain perfumes, preservatives in deli meats, exercise, allergies, molds, tobacco smoke, others)
When to keep the child inside (hot and humid days, cold weather, high winds, etc.), as well as warning symptoms that would exclude them from exercise (coughing, wheezing, etc.)
Instructions on which additional medications to give in case they are needed, as well as an on-call number (mobile, beeper, work, etc.) to get a hold of the parent right away
Whether the child can personally administer medications, or if it should be given by the designated caretaker

Emergency contact numbers of other adults, including the child's physician and local hospital, in case the parent cannot be reached or an emergency arises.

Additionally, the child's medications should be labeled with their name, instructions for use (how many puffs, how often and time of day to be given, the proper use of the inhaler, dosing schedule of any liquids or pills, etc), as well as physically located in a secure area within easy access in case of a medical urgency. And, in my opinion, every daycare center (or any facility) caring for children with asthma should have the following:

At least one person on-site trained in recognizing the signs and symptoms of asthma
An educational in-service for all caretakers regarding asthma triggers and ways to decrease the problem (dry erase markers, smoke-free environment, dehumidifiers, others)
An emergency plan (ambulance contact number, knowledge in administering the child's inhalers, etc.) to handle breathing difficulties should they arise.

For more information, please check out KidsHealth (www.kidshealth.org) and the American Lung Association (www.lungusa.org), as well as the National Jewish Medical and Research Center (www.njc.org)

More Asthma Advice From Dr. Rob:

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Robert Danoff, D.O., M.S., is a family physician and program director of The Family Practice Residency, as well as the combined Family Practice/Emergency Medicine Residency programs at Frankford Hospitals, Jefferson Health System, Philadelphia, Pa. He is the medical correspondent for CN8, The Comcast Network, a regular contributor to Discovery Health Online and a contributing writer to The New York Times Special Features. (Read his full bio.)