Out of breath

Fiona first realised that there was something wrong with Jessica when she was a baby. She developed a hacking cough that didn't go away, and repeated trips to the doctor only confirmed that she didn't have a chest infection. When Jessica was one, she was choking and not breathing properly, so an ambulance had to be called to take her to hospital in the middle of the night. Despite this emergency, it was only when Jessica was two that the problem was diagnosed as asthma and she was put on medication to help prevent attacks.

At about this time, Jessica started at a private nursery as Fiona worked full-time. Fortunately, the woman who ran the nursery had an asthmatic child herself and knew what to do. Fiona left an inhaler at the nursery and felt confident that it would be used when necessary.

'I feel that the parent of an asthmatic child needs to know that whoever is looking after their child understands that the condition can be serious and acts promptly,' says Fiona. 'Jessica is also atopic and had a severe reaction to something which brought her out in a terrible rash. She was in hospital again for this, and after that we had to avoid certain foods, and also be careful about exposure to bright sunlight. The nursery staff were very helpful in looking after her needs.'

When Jessica started school, Fiona had some anxieties, as the policy there was that the medication was kept locked away and that a child had to ask for it. 'I felt they weren't as concerned as at the nursery, and I didn't want to make a fuss,' says Fiona. 'I was worried that Jessica wouldn't like to ask for her spacer. However, Jessica's asthma has got much better now so there hasn't been a problem.'

On the increase

Jessica is one of just a growing number of children in the UK who suffer from asthma. A study published in the Lancet recently showed that the number of pre-school children who wheeze doubled in the 1990s. Between 1990 and 1998, the proportion of children surveyed who are reported to have wheezed rose from 16 per cent to 29 per cent, and diagnoses of asthma rose from 11 per cent to 19 per cent. The asthma audit 2001 shows that one in eight children are currently being treated for asthma. This means that every school and every nursery is bound to have a number of children who have asthma, and this may vary from mild to quite severe.

A great deal of research has been done to try to find out why asthma is on the increase. It is clear that there is a hereditary predisposition as asthma tends to run in families and researchers are looking for an 'asthma gene'. One theory which has some support from various studies is that as we live in increasingly clean and germ-free environments, the body starts reacting to substances that would not normally be harmful.

One recent study in Australia showed that living on a farm helped reduce the incidence of asthma. Another showed that a diet high in polyunsaturated fats seems to double the risk of asthma, while breastfeeding reduced the risk. One study in the UK showed that obese children - who are increasing in number - are at greater risk of asthma than children of normal weight, while another in Germany showed that children with runny noses - who have repeated viral infections in childhood - seem to have a reduced risk of developing asthma before school age. It is thought that exposure to these infections stimulates the child's immune system.

What to do

Dust and mites: Since several children in a nursery are likely to be affected by asthma, it is a good idea to try to remove potential triggers from the environment. First, it is important that the nursery is kept free of dust. Soft furnishings and curtains that might harbour house dust mites should be kept to a minimum and cleaned regularly.

Cushions and soft toys can be frozen overnight to kill the dust mites and then washed. Some children may not be able to handle animals in the nursery directly.

Drug treatments: Most people working with young children will have seen the inhalers now used to deliver drugs that treat asthma. These are hand-held devices that are put to the mouth as the drug is breathed in, enabling smaller doses of drugs to go straight into the lungs where they are needed. The most common type is a metered dose inhaler (MDI), known as a 'puffer', a pressurised aerosol, although this is not so easy for a small child to use. An MDI can be made simpler to use by adding a spacer. This is a cylinder with a slot for the inhaler at one end and a mouthpiece at the other. For very small children, a face mask can be added.

Most asthmatics use two types of drugs:

* preventers, which are taken every day whether there are symptoms or not, and * relievers, which are used at the first signs of an attack.

The main preventers are steroids, though anti-inflammatory drugs such as sodium cromoglycate are also used. The main relievers are bronchodilators, such as salbutamol or terbutaline, which open constructed airways.

Exercise: Although exercise can bring on an asthma attack, especially if the child runs around in very cold air, it is beneficial for the child. It is even more important that an asthmatic child has regular exercise and is physically fit. Children with asthma should be able to take part in normal exercise at nursery or school, with a few sensible precautions. Taking a couple of puffs of a reliever before exercise can help, or the drug can be given half an hour before exercise. A few short sprints or a proper warm-up before vigorous exercise can also help. The child should always have the reliever at hand during exercise.

Liaising with parents: It is important to liaise with parents over the management of their child's asthma. If the child is repeatedly getting wheezy, it may be a sign that the asthma is not properly under control, and the parents will need to be informed so that, on their doctor's advice, they can adjust the treatment. Many parents of children with asthma may be over-protective, and this may make the child more clingy when being left at nursery. Again, talking to the parents can help get things in proportion, and it may help them relax if they feel the nursery staff know what to do if the child has an asthma attack. NW

For more information contact:

* The National Asthma Campaign,

Providence House,

Providence Place,

London N1 0NT

Tel: 0207 226 2260