Signs of Asthma in Children: What Parents Notice First

Common early signs that may suggest asthma

Asthma rarely announces itself with a single dramatic episode. Parents often notice a pattern over months or years before a diagnosis is made 2Ref 2American Academy of Pediatrics (2024).Asthma.Asthma symptom patterns in children; triggers; difficulty of diagnosis in young children; controller and rescue medications; Asthma Action Plan; school and sports participation:

• Cough that won't go away, especially at night or early morning — this is frequently the main or only symptom in young children
• Coughing or wheezing with exercise or play — a child who runs and then starts coughing or complains of chest tightness may be having exercise-related bronchoconstriction
• Every cold seems to go to the chest — repeated episodes where an ordinary cold causes significant wheezing or a prolonged cough
• Wheezing — a whistling or musical sound on breathing out, though not all children with asthma wheeze
• Chest tightness — older children may say their chest feels "tight" or it's hard to take a deep breath
• Shortness of breath with activities that shouldn't be very strenuous
• Symptoms triggered by specific exposures: pets, grass, cigarette smoke, cold air, strong scents, mold

Why asthma can be hard to diagnose in young children

Standard breathing tests (spirometry — measuring how fast and how much air the lungs can move) require cooperation and are most reliable in children aged 5 and older 2Ref 2American Academy of Pediatrics (2024).Asthma.Asthma symptom patterns in children; triggers; difficulty of diagnosis in young children; controller and rescue medications; Asthma Action Plan; school and sports participation. In younger children, the diagnosis is often made based on the pattern of symptoms over time, response to a trial of bronchodilator medication (a "breathing treatment" that relaxes the airways), and ruling out other causes.

Many toddlers wheeze with respiratory infections without going on to develop true asthma — this is called "recurrent viral-induced wheeze" and may or may not develop into persistent asthma. A provider tracks the pattern over time to make this distinction 2Ref 2American Academy of Pediatrics (2024).Asthma.Asthma symptom patterns in children; triggers; difficulty of diagnosis in young children; controller and rescue medications; Asthma Action Plan; school and sports participation.

Common asthma triggers

A trigger is something that makes a sensitive airway tighten up or become more inflamed. Common triggers in children include:

• Respiratory viruses (colds are the most common trigger in children)
• Allergens: pollen, pet dander, dust mites, mold, cockroach allergens
• Exercise or vigorous play
• Cold air
• Cigarette smoke (including secondhand smoke)
• Air pollution or strong odors
• Changes in weather

Identifying a child's personal triggers helps create an effective management plan. Not every child will have the same triggers 2Ref 2American Academy of Pediatrics (2024).Asthma.Asthma symptom patterns in children; triggers; difficulty of diagnosis in young children; controller and rescue medications; Asthma Action Plan; school and sports participation.

How asthma is evaluated and diagnosed

A provider who suspects asthma will typically 2Ref 2American Academy of Pediatrics (2024).Asthma.Asthma symptom patterns in children; triggers; difficulty of diagnosis in young children; controller and rescue medications; Asthma Action Plan; school and sports participation3Ref 3National Heart, Lung, and Blood Institute (2020).Asthma Management Guidelines 2020 Updates — Frequently Asked Questions.FeNO testing recommendation for uncertain asthma diagnosis in children 5 and older; inhaled corticosteroid stepping strategy; LABA addition for children under 12 with inadequately controlled asthma:

• Ask detailed questions about the pattern and timing of symptoms (night vs. day, with exercise, with colds)
• Listen to breathing and look for signs of chest hyperinflation or prolonged exhalation
• Consider a trial of bronchodilator medication — if a child's wheeze clearly improves with a breathing treatment, this supports an asthma diagnosis
• For children aged 5 and older, lung function testing (spirometry) may be done — and often repeated after a bronchodilator
• Consider allergy testing when allergic triggers are suspected

The diagnosis is clinical — based on the whole picture, not a single test. The 2020 NHLBI Asthma Management Guideline updates recommend FeNO (fractional exhaled nitric oxide) testing for children 5 and older when the diagnosis or treatment approach is uncertain 3Ref 3National Heart, Lung, and Blood Institute (2020).Asthma Management Guidelines 2020 Updates — Frequently Asked Questions.FeNO testing recommendation for uncertain asthma diagnosis in children 5 and older; inhaled corticosteroid stepping strategy; LABA addition for children under 12 with inadequately controlled asthma.

Living with asthma: controllers and relievers

Asthma management typically involves two types of medication 3Ref 3National Heart, Lung, and Blood Institute (2020).Asthma Management Guidelines 2020 Updates — Frequently Asked Questions.FeNO testing recommendation for uncertain asthma diagnosis in children 5 and older; inhaled corticosteroid stepping strategy; LABA addition for children under 12 with inadequately controlled asthma:

• Quick-relief (rescue) inhalers: taken when symptoms appear or worsen, they relax airway muscles quickly. A child with asthma should have one accessible at all times (including at school)
• Controller medications: inhaled corticosteroids (such as fluticasone or budesonide) taken daily to reduce the underlying airway inflammation. Not every child needs a daily controller — this depends on how frequent and severe the symptoms are

A written Asthma Action Plan from the child's provider helps parents and schools know what to do at each level of severity. Regular follow-up visits allow the plan to be adjusted as the child grows.

Asthma and school and sports

Children with asthma can and do participate fully in school and sports with well-controlled disease. Schools typically require an Asthma Action Plan on file and may keep a rescue inhaler in the nurse's office. Some states allow children to carry their own inhalers once they can use them properly. A provider can provide the documentation schools need 2Ref 2American Academy of Pediatrics (2024).Asthma.Asthma symptom patterns in children; triggers; difficulty of diagnosis in young children; controller and rescue medications; Asthma Action Plan; school and sports participation.