A child coughing at night

A child who coughs most nights, wheezes after running about, or misses school every few weeks with chest trouble is usually treated with repeated antibiotics and cough syrups. Many of these children have asthma — and asthma in children is one of the most treatable conditions in medicine. With the right inhaler, used correctly, the great majority return to normal play, full school attendance and uninterrupted sleep.

The reason it gets missed is that childhood asthma does not always wheeze. In a lot of children the only symptom is coughing at night.

The pattern to look for

Asthma tends to show a pattern rather than a single symptom.

• Cough that returns every month, or with every change of weather
• Cough that is worse at night and in the early morning
• A whistling sound from the chest, especially breathing out
• Breathlessness or chest tightness after running or playing
• Cough or wheeze set off by dust, smoke, cold air, pollen or a pet
• Symptoms between colds, not only during them
• A family history of asthma, allergy, hay fever or eczema
• Needing a nebuliser repeatedly at a clinic or chemist

Two or three of those together make asthma likely enough to test for properly.

Viral wheeze or asthma?

Many young children wheeze only with viral infections and grow out of it by school age. Others have genuine asthma that will persist. The distinction matters because the treatment differs, and it comes from the pattern: symptoms between infections, triggers other than colds, a family history of allergy, and how clearly the child responds to an inhaler. Age matters too — wheeze that is still occurring after five, or that limits activity, leans towards asthma.

An honest answer sometimes takes a few months of observation with a treatment trial. That is a reasonable plan, as long as it is a plan with a review date rather than an indefinite supply of syrup.

What we do

History and examination first, including growth, nasal allergy and eczema, and a careful look at what sets symptoms off at home — bedding, damp, a cooler, incense, mosquito coils, cooking smoke, a pet, or a smoker in the house.

Spirometry in children old enough to perform it reliably, usually from about six, before and after a bronchodilator. It demonstrates reversible airway narrowing objectively instead of inferring it.

Allergy testing where the history points to a trigger. Knowing that it is dust mite rather than, say, a pet changes what the family actually does, and avoiding a known trigger is often worth more than a change of medicine.

A chest X-ray only where something does not fit — a one-sided wheeze, poor growth, finger clubbing, or a history suggesting an inhaled object or recurrent pneumonia in the same place.

Treatment, and the two things that decide whether it works

Childhood asthma is managed with a daily preventer inhaler, usually a low-dose inhaled steroid, plus a reliever for symptoms. The doses used are small, they are inhaled rather than swallowed, and they are far safer than repeated courses of oral steroids for attacks — which is the alternative if the condition is left untreated.

Two things decide whether treatment works:

Technique. A correctly prescribed inhaler used incorrectly delivers almost nothing. Children should use a spacer, every time, with a mask for the youngest. We check the technique in front of you at every visit, and we ask you to show us rather than tell us.

Adherence between attacks. The preventer works by reducing inflammation over weeks. Stopping it as soon as the child seems well is the single commonest reason asthma stays out of control. It is taken when the child is well — that is the point of it.

You will also be given a short written action plan: the usual daily doses, what to do on a bad day, and exactly when to go to hospital.

Questions parents ask most

Will the inhaler affect my child's growth? Low-dose inhaled steroids have a small, early effect on growth rate that largely resolves, and poorly controlled asthma itself suppresses growth. Repeated oral steroid courses for attacks carry far more risk.

Will my child grow out of it? Many do, particularly those whose symptoms are mild and only with infections. That is a reason to treat well now, not a reason to wait.

Is it addictive? No. A reliever inhaler is not habit-forming. Needing it often means the preventer dose needs reviewing, not that the child has become dependent.