What Is Infant Asthma?

How to Recognize and Treat Asthma in Babies

In This Article
Table of Contents

While you may expect the signs of asthma to be obvious in infants—with classic sudden attacks of wheezing, coughing, and shortness of breath—they can often be subtle and easily mistaken for a respiratory infection. Because of this, and the fact that little ones can't describe how they are feeling, many parents have no idea that their infant has asthma until the attacks are more severe or overt.

By learning how to differentiate infant asthma from common respiratory illnesses, you can seek early diagnosis and treatment. This may not only improve your baby's quality of life but prevent lung injury that can persist into later years.

According to the Centers for Disease Control and Prevention, more than six million children in the United State have asthma, most of whom develop symptoms before the age of 6.

Types of Infant Asthma

There are many different types of asthma, each with different triggers and outcomes. From a broad perspective, asthma can be classified as either:

  • Allergic asthma, also known as atopic or extrinsic asthma, which is triggered by allergens such as pollen and certain foods
  • Non-allergic asthma, also known as non-atopic or extrinsic asthma, in which symptoms develop in the absence of allergy

The distinction is especially important in infants, the vast majority of whom will develop allergic asthma. As an atopic disorder (meaning one with a genetic tendency toward allergy), allergic asthma is often part of a progression of disorders referred to as the "atopic march."

The atopic march classically begins with the development of atopic dermatitis (eczema), often in the first six months of life. This initial atopy triggers changes in an immature immune system that opens the door to food allergies, which in turn opens the door to allergic rhinitis (hay fever) and, finally, asthma. The progression can either happen slowly over the course of years or rapidly during the first months of life.

With infant asthma, the early onset of symptoms is concerning as it is often predictive of more severe disease later in life. This is especially true when wheezing develops before the age of three.

The severity of asthma is also closely linked to a child's history of eczema. If there was mild eczema during infancy, the symptoms of asthma will also tend to be mild and may resolve fully by puberty. On the other hand, if the eczema was severe, the asthma symptoms will generally be severe and may persist into adulthood.

It's important, to remember, however, that not every infant with eczema will develop asthma, and not every infant with asthma will have had eczema. Asthma is a complex disease for which many factors contribute to both the onset and severity of symptoms.

Infant Asthma Symptoms

The symptoms of asthma in children and adults are more or less the same but can vary from person to person in terms of severity and frequency.

Even so, there are characteristic differences in asthma symptoms in infants (under 1 year of age) and babies (between 1 and 4 years) compared to toddlers and young children (4 to 11 years). This is due in part to differences in airway sizes as well as the overall strength and capacity of the lungs.

Infants and Babies
  • Cough

  • Wheezing

  • Shortness of breath

  • Frequent coughing

  • Nasal flaring

  • Exaggerated belly movements while breathing

  • Sucking in of the ribs while inhaling

  • Interruption in crying or laughing due to breathing difficulty

  • Fatigue and lethargy

  • Reduced activity

Toddlers and Young Children
  • Cough

  • Wheeze

  • Shortness of breath

  • Chest tightness

  • Frequent coughing

  • Attacks (and intensity of attacks) can vary

  • Daytime fatigue and sleepiness due to poor sleep

  • Delayed recovery from colds and other respiratory infections

  • Interruption in play due to breathing problems

Complications

Although infant asthma may spontaneously resolve by puberty in some children, early treatment is vital to preventing injury in still-developing lungs. Ongoing inflammation spurred by untreated asthma can lead to airway remodeling, a common occurrence in older children with asthma.

When this occurs, the smooth muscles of the airways begin to thicken and lose their flexibility, while the goblet cells that produce mucus will grow in size. This can increase the risk of chronic obstructive pulmonary disease (COPD) later in life.

Signs of an Emergency

Call 911 or seek emergency care if your child experiences signs of a severe attack, including: 

  • Wheezing while breathing both in and out
  • Coughing that has become continuous
  • Rapid breathing with retraction
  • Sudden paleness
  • Blue lips or fingernails
  • Inability to eat, talk, or play
  • Abdominal contractions while breathing

Causes

It is unknown what causes asthma in children and adults. The current body of evidence suggests that a genetic predisposition paired with environmental factors alters the body's immune response, increasing airway hyperresponsiveness to environmental and physiologic triggers.

Insofar as infants are concerned, there is evidence that certain factors can increase a child's risk of developing asthma.

  • A family history of asthma is the major risk factor for allergic asthma, more than tripling your risk if another sibling has asthma.
  • Lack of breastfeeding may deprive babies of maternal antibodies that help build a robust immune system.
  • Household dampness and mold can cause an immature immune system to produce defensive antibodies to mold spores in the air, increasing the risk of allergies and allergic asthma.
  • Being born in early autumn more than doubles a child's risk of allergic asthma by exposing an immature immune system to windborne pollen and molds.
  • Secondhand smoke exposes a baby's lungs to inflammatory toxins that may increase the risk of airway hyperresponsiveness.
  • Severe respiratory infections before the age of 2, most especially lower respiratory tract infections, may promote changes in airway tissues that can lead to hyperresponsiveness.
  • Nutrition may also play a role in the development of allergic asthma by preventing egg and milk allergies. The risk of a milk allergy may be reduced with breastfeeding, while feeding babies eggs may reduce the risk of egg allergies.

The American Academy of Pediatrics recommends that infants exclusively receive breastmilk for around the first six months of life, at which time solid foods may be added in complement.

Diagnosis

The diagnosis of asthma in infants and babies is difficult because the central tool used for diagnosis—pulmonary function tests (PFTs)—does not return useful results in most cases. Even a simple exhaled nitric oxide test, which measures the amount of nitric oxide indicative of asthma, is of little use in children under 5 years of age.

To this end, doctors rely heavily on an infant's symptoms, a parent or guardian's observations, and other information to make the diagnosis. The process will involve an extensive interview to assess the child's history of breathing problems.

Questions may include:

  • Does anyone in the family have asthma? A family history of eczema or allergic rhinitis is also predictive of asthma.
  • How often does your child experience wheezing? Although wheezing is common with numerous childhood illnesses, asthma is characterized by recurrence, often for no apparent reason.
  • When does your child experience wheezing? Some caretakers may recall events or patterns that precede the attacks, like being outdoors, being near pets, or drinking milk. Triggers like these may support the diagnosis.
  • What does the wheezing sound like? In some cases, the sound of wheezing can help differentiate the causes. A barking sound, for example, is common with pertussis (whooping cough), while "chesty" wheezing with a mucusy cough is more indicative of a bronchial infection. With asthma, the wheezing will be high-pitched with a dry cough.
  • Does your child cough at night? Nighttime cough and wheezing are among the defining features of asthma in children.
  • Does your child have difficulty feeding? Oftentimes, an infant with asthma will not be able to finish a bottle due to the shortness of breath.
  • Does your child wheeze after laughing or crying? Heavy laughter or crying can trigger an attack by causing hyperventilation and bronchial spasms.

Even though asthma tends to be more obvious in older babies than infants, share whatever information you have to help the doctor better understand the nature of your child's symptoms—even if it seems unrelated or inconsequential.

Other Procedures

The doctor will also perform a physical exam to check for breathing sounds (some of which may suggest an infection or airway obstruction) or atopic skin conditions like eczema.

If a cause is not readily found, a chest X-ray may be ordered. This common imaging study can be performed safely in newborns and infants, although it is better at excluding other causes of wheezing and shortness of breath than confirming asthma.

If allergic asthma is suspected, the doctor may recommend allergy skin testing involving the insertion of tiny amounts of common allergens (such as pet dander) under the skin to see in a reaction occurs. Even so, allergy skin testing is rarely performed in children under 6 months of age.

Differential Diagnoses

Other tests may be ordered, including blood tests and imaging studies, to exclude other causes of your baby's symptoms. Among the conditions commonly included in the differential diagnosis of infant asthma are:

Treatment

If asthma is diagnosed in children under 2 years of age, a doctor may take a wait-and-see approach if the symptoms are mild. This is partly due to the lack of research into the safety of asthma drugs in children this young.

If treatment is needed, many of the same medications used in adults can be considered. The selection would be based on the risk of side effects, the frequency and severity of attacks, the impact of asthma on the child's quality of life, and whether the drug is approved for use in children.

Among the treatments available to children under 4 years of age:

  • Rescue inhalers, used to treat acute attacks, are approved for use in children 2 and over, although minimal use is recommended. The only exception is Xopenex (levalbuterol), which can only be used in children 6 and over.
  • Inhaled corticosteroids may be used for several days or weeks to gain control of asthma symptoms. Of the available options, Pulmicort (budesonide) delivered by a nebulizer is the only inhaled corticosteroid approved for children 1 year of age and older. Others are only approved for children 4 and over.
  • Singulair (montelukast), a leukotriene modifier, may also be considered if inhaled corticosteroids fail to provide relief. The drug is available in granulated form for children 1 year of age and older.
  • Theophylline, an older and less commonly used oral drug, can be added to the treatment plan for children 1 year of age and over if needed.

Among the additional treatments available to toddlers over 4 years of age:

  • Cromolyn sodium, a mast cell stabilizer delivered by nebulization, may be considered if inhaled corticosteroids fail to provide relief. The drug is contraindicated for use in children under 2.
  • Salmeterol, a long-acting beta-agonist (LABA) used daily to control asthma, is reserved for children 4 and older. Other LABAs can only be used in children over 5 or 6.
  • Oral and nasal spray antihistamines may be used to treat allergy symptoms in children with allergic asthma but are generally avoided in children under 4.
  • Immunomodulator drugs, which temper the immune response in people with moderate to severe asthma, are avoided in babies and toddlers. The only option available for children 6 and over is Xolair (omalizumab).

Children diagnosed with severe allergic asthma may be referred to an allergist for allergy shots. Even so, allergy shots are generally not considered until a child is at least 4 years old and ideally older than 5.

Coping

If your infant or baby has been diagnosed with asthma, there are things you can do to reduce the risks of attacks and improve the child's quality of life:

  • Follow the treatment plan: If medications are prescribed, understand how they are used, and use them only as prescribed. Do not experiment with treatment or change dosages without first speaking with your child's doctor.
  • Identify asthma triggers: By doing so, you can take steps to remove them from your home. If you don't know what the triggers are, keep a symptom diary, tracking events, food, activities, and symptoms as they occur. Over time, patterns may emerge that can help pinpoint symptoms.
  • Use an air purifier: If seasonal allergies, pet dander, or dust are problematic for your child, find an air purifier with a multi-filter system (combining a HEPA filter with an activated charcoal filter). Check that the unit is able to service the size of the room in cubic feet.
  • Avoid smoking: If someone in the family smokes, have them do it outdoors. Or better yet, have them speak to their health provider about smoking cessation aids to help quit.
  • Have an action plan: Write down instructions as to how to treat acute symptoms and make sure everyone in the family knows them. You can keep the plan posted on the fridge and have a copy ready for anyone watching your child. Be sure to include a doctor's number and instructions on when to call 911 (including a clear description of the emergency signs and symptoms).

A Word From Verywell

Recognizing asthma in infants can be difficult even for medical professionals. If you believe your child has asthma, keep a record of the symptoms (including dates) and share them with your doctor. If the doctor doesn't have the expertise or experience to diagnose asthma in children, ask for a referral to a pediatric pulmonologist who specializes in respiratory diseases in children.

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