November 24, 2010


My youngest son is age 11 and has rather bad asthma attacks. Up until now we’ve used a Ventolin inhaler, but our doctor is suggesting we add another, called Pulmicort. This, I believe, is a cortisone medication, and we’re quite concerned. Could you give us an overview of this whole situation?
Asthma is a worrisome condition, and we feel an update will be beneficial to our readers as well as to you.
Asthma is a major problem, affecting an estimated 300 million people worldwide. About 7 percent of Americans, or some 21 million, have asthma. It affects all races of people from infancy to old age, with a few more boys than girls dealing with the disease. Interestingly, in adulthood, a few more women than men are affected.
The essential problem is a narrowing of the airway. This causes wheezing, with a prolongation of expiration over inspiration, but also cough and tightness in the chest. A sense of breathlessness causes fear, and the condition can be serious—even life threatening—if not managed successfully.
More recently, management has been divided into the “quick relief” component and the “long-term control.”
2010 1538 page24To properly understand the condition, it helps to understand what’s happening in the airway. The composition of the bronchioles and bronchi involves a lining of mucosa with its mucus-secreting cells, collagen scaffolding, smooth muscle cells, and no cartilage farther down the airway.
Asthmatic people have elements of inflammation, a result of allergy, irritants, or infection that narrows the airway. Inflammatory and allergic cells amass in the tissues of the airway. They cause the capillaries to be more permeable, with the oozing of fluid through them. The fluid and inflammatory cells thicken the airway walls. The inflammatory cells release substances that stimulate smooth muscle contraction with a resulting narrowing of the airway. Repeated contraction builds the bulk of these muscles, further thickening the airway wall. Increased airway secretion of mucus, along with inflammatory cells and cells shed from the lining, builds up in the airway, also interfering with air flow. Breathing “in” tends to open the airway slightly, but breathing “out” permits the airways to collapse more and restrict airflow. This makes for a slightly prolonged expiration over inspiration.
The Ventolin your youngster is using stimulates the receptors, called beta-adrenergic receptors. Stimulation of these receptors causes smooth muscle to relax, which opens up the airway. We use these medications as “quick relief” medicines. For someone who has only an occasional asthma attack, this may be all that’s required. Long-term control is directed to reducing the inflammatory and allergic factors. The agent that has proved most successful in this regard has been an inhaled corticosteroid. In fact, a number of hospitalizations and serious attacks of asthma can be very significantly reduced with daily and regular use of such agents.
There are other medications that can be used in asthma, but the two already discussed form the essential backbone of treatment.
Of course, it’s important to think of other things besides medicine in the management of asthma. Most people with asthma have an allergic predisposition. Such people should not have pets—such as cats, dogs, and birds—that shed skin debris called dander. Fish are pretty safe but not very cuddly.
The dust in our homes is rich in insect protein; much of this is the excreta of mites, cockroaches, and other insect varieties. Damp dusting is recommended to remove—not just stir—the dust. Hardwood floors are preferable to carpet, and synthetic bedding is best. Feather pillows are definitely out!
Food allergies can span the whole gamut of foods and need to be carefully discovered and avoided.
Cold and exercise can stimulate an attack of asthma, though many outstanding athletes continue to excel by using a bronchodilator ahead of the exercise or event.
As children grow up, so does the size of their airway, often resulting in an improvement in the severity of asthma.
We suggest you follow your doctor’s advice, and expect you’ll see marked improvement. Though steroids can have a variety of side effects, using a metered inhaler controls the dosage, and one seldom sees interference with other body functions with what amounts to low-dose local therapy.
Our 8-year-old son still wets the bed at night. My husband is concerned because he also had this problem until he was 11 and felt it gave him low self-esteem.
This is a common but hidden problem. Up to 20 percent of first graders occasionally wet the bed, and some 4 percent wet the bed two or three times a week. Boys are more likely to wet the bed than girls, but while 7 percent of 10-year-old boys wet their bed, some 3 percent of 10-year-old girls do so, as well. Bed-wetting is called enuresis and is classified into primary and secondary forms. The factors involved in bed-wetting have to do with depth of sleep and loss of ability to awaken, as well as bladder capacity.
Some of the children have problems in the daytime that are subtle and may not be readily recognized. They may not drink much during the day, then arrive home thirsty and load up with fluids later in the day. Some of these children may also be constipated. Ultrasound testing shows the bladder size, can assess the bladder wall, and can measure the rectal wall and diameter for constipation.
Enuresis may cause a youngster to feel a lowered self-esteem and interfere with the typical social activities of children their age.
It may be wise to reduce fluid intake after 5:00 p.m. It has not been shown to be beneficial to try to “stretch” the bladder by holding the urine in.
Of the treatment methods that have been studied, there are two that hold promise and have statistical merit. The first is “alarm” therapy. This system awakens the child at the precise moment wetting commences. The mechanism may be the classic-conditioning or avoidance-conditioning effect. In a Cochrane review of some 56 randomized trials, about two thirds of the children were dry within three to six months, and upon stopping the alarm, half remained dry thereafter. If there’s no response after a month, it’s reasonable to stop.
Medications used to stop bed-wetting that have evidence of benefit are desmopressin, anticholinergics, and tricyclic agents. Such medications require prescriptions from your doctor.

In dealing with enuresis, it’s important to review the whole picture, to defuse tension and anxiety about the process, and to maintain the confidence of the child by respecting his or her ?confidentiality.
The condition is stressful enough without compounding the situation with threats or overreaction. Even though the occasional child will have enuresis into adolescence, there are very few who will have this problem postadolescence.
Send your questions to Ask the Doctors, Adventist Review, 12501 Old Columbia Pike, Silver Spring, MD 20904. Or e-mail them to [email protected].
Allan R. Handysides, M.B., CH.B., FRCPC, FRCSC, FACOG, is director of the General Conference Health Ministries Department. Peter N. Landless, M.B., B. CH., M. Med., F.C.P. (SA), F.A.C.C., is ICPA executive director and an associate director of the General Conference Health Ministries Department. This article was published November 25, 2010.