What to Expect the Toddler Years (255 page)

Molds. If your toddler is allergic to molds, control moisture in your home by using a well-maintained dehumidifier (sprayed as needed with a mold inhibitor). Provide adequate ventilation and use an exhaust fan vented to the outside to dispose of steam from the kitchen, laundry, and baths. Areas where molds are likely to grow (garbage cans, refrigerators, shower curtains, bathroom tiles, damp corners) should be cleaned meticulously and frequently with a solution of equal parts of chlorine bleach and water or an anti-mold agent. If you have a self-defrosting refrigerator, don’t forget to regularly empty and clean the drip pan. Paint basements and other potentially damp areas with a mold-inhibiting paint. Don’t allow clothing or shoes to lie around damp or wet. Limit house plants and dried flowers to rooms your child spends little time in, and store firewood outside the house. If you must have a live Christmas tree, which can foster mold, keep it in the house for only a few days. Outdoors, be sure drainage around your home or building is good, that leaves and other plant debris are not allowed to pile up, and that enough sun hits the yard and house to prevent damp areas from spawning mold. If you have a
sandbox, keep it covered at night and when it rains; in good weather, let it bask (and bake dry) in the sunshine.

Bee venom. Keep a toddler who is allergic to bee venom away, as much as possible, from outdoor areas known to have bee or wasp populations (flower gardens, for instance). (For tips on avoiding insects, see page 632.) And be sure that you or any other caregiver (including day-care or preschool staff) always has a bee-sting kit at hand.

Miscellaneous allergens. Many other allergens can be removed, if necessary, from your child’s environment: wool blankets (cover them or use cotton or synthetics) and clothing (cotton sweaters and synthetic-filled parkas will keep your toddler warm); down or feather pillows (when your child is old enough to use one, use foam or hypoallergenic polyester-filled ones); tobacco smoke (allow no smoking in the house at all, and keep your toddler out of smoke-filled rooms, restaurants, and so on, away from home); perfumes (use unscented wipes, sprays, and so on); soaps (use only hypoallergenic types); detergents (switch to a fragrance-free detergent or use Ivory Snow for the laundry).

2. Immunotherapy, or desensitization.
Since an allergic reaction is a hypersensitive (or oversensitive) reaction of the child’s immune system to a foreign substance, desensitization (usually accomplished via gradually increased injected doses of the offending allergen) is sometimes successful in controlling allergies—particularly to pollen, dust, and animal dander. Except in severe cases, however, desensitization is not usually started until a child is at least four years old.

3. Medication.
Antihistamines and steroids may be used to counteract the allergic response and reduce any swelling of mucous membranes.

4. Epinephrine injection
(see page 707).

Prognosis.
About 90% of food allergies (to cow’s milk or citrus, for example) are outgrown by age three or four. Even older children and adults can “outgrow” a food allergy after avoiding the triggering allergen for a year or two. Allergies to nuts, soy, peas, and seafood, however, are usually life-long. While some children outgrow their allergies, others may exchange one allergy (to milk) for another (hay fever).

What is it?
A chronic inflammatory lung disease in which airways are hyper-responsive. On exposure to a particular trigger (see “What causes it?” below), the muscles around the outside of the bronchial tubes tighten and their lining becomes inflamed, swollen, and filled with mucus. The temporarily narrowed air passages restrict air flow to and from the lungs, resulting in shortness of breath, coughing, and/or wheezing (a whistling sound produced by air traveling through the narrowed airways, which can sometimes only be detected by stethoscope but may be felt with a hand on the child’s chest). In severe cases of asthma, you may observe whistling both on exhaling (wheezing) and inhaling (stridor). In young children, the only symptom may be a recurrent croupy, “barky” cough that is worse with activity or at night and may sometimes lead to vomiting. But there may also be rapid and/or noisy breathing, retractions (the skin between the ribs appears to be sucked in with each breath), and chest congestion. Some children experience asthma-related chest tightness or chest pain on exercise. The toddler with asthma may feel apprehensive (because of the occasional difficulty breathing) but not understand why. There may also be restlessness, fatigue, and poor appetite.

Since childhood asthma is different from adult-onset asthma, it may take a
pediatric specialist familiar with the condition to diagnose it (its symptoms can be mistaken for signs of infection) and to differentiate it from other possible lung diseases and conditions (such as cystic fibrosis, bronchiolitis, gastroesophageal reflux, or an inhaled foreign object). The degree of illness also varies from child to child; one child may have only one episode of asthma in a lifetime, another a mild case with just one episode a week or less; yet another may have a moderate or severe case, with several weekly incidents and perhaps several visits to the emergency room a year. It may also vary in the same child from season to season and/or year to year. For some, symptoms may improve with age; in others, they may worsen.

How common is it?
Very. Worldwide, 5% to 10% of the population suffers from asthma. In the United States, estimates for children vary from 4.8% to 7.6%.

Who is susceptible?
Those with a family history, especially with an asthmatic parent (there appears to be an inherited predisposition); children with allergies; those with bronchopulmonary dysplasia. Asthma is slightly more common in black children. About 40% of cases develop by age three, 90% by age ten.

What causes it?
Much is not known about what causes asthma. But it is known that a variety of factors may trigger an episode in a susceptible person. Triggers include: common allergens (such as dust mites, animal dander, molds, cockroach leavings, pollens from trees, grass, and ragweed, and sometimes foods—see page 703 for more on allergies); viral infections; irritants, including tobacco smoke, strong odors (from household cleaners, paints, and varnishes, for example); air pollutants (outdoors and in; see page 630); weather changes (temperature, humidity, barometric pressure) and strong winds; anxiety and stress; strenuous exercise (especially in cold weather or after eating certain foods, including shellfish, celery, and melon); sensitivity to drugs or chemicals (coal and chalk dust, food preservatives, such as sulfites, certain food colorings, and other food ingredients, such as MSG). Middle-of-the-night episodes may be triggered by allergens in the bedroom, by cool nighttime temperatures, or even by gastroesophageal reflux (food sloshing back from the stomach up into the esophagus). The fact that airways constrict slightly at night, even in normal children, may also contribute. Episodes may be worse at certain times of the day or night than others because of a child’s individual body chemistry, which varies throughout a 24-hour period.

Related problems.
Recurrent infections affecting the respiratory tract, including pneumonia.

Treatment/management.
Early detection and pinpointing what it is that triggers an episode (keeping a diary will help you to do this) combined with preventive measures are the best treatment. (The use of a peak flow meter and regular aerobic exercise, which are often recommended for older children with asthma, may not be recommended for your toddler.) Prevention for toddlers includes:

Reducing exposure to triggers—such as allergens (consultation with a pediatric allergist can be very helpful in determining what they are) and stress (see page 173).

Reducing the incidence of respiratory infection with optimum nutrition, annual flu shots, and good hygiene (see page 609).

Warding off possible episodes with the use of carefully selected medication, as prescribed—such prophylaxis can be given daily or before anticipated
exposure to a known trigger. Medication (which may include bronchodilators, anti-inflammatory medications, and possibly adrenaline-like oral beta-agonists; antihistamines, if used at all, must be used with caution) should be tailored to the child, with use limited to the minimum amount needed to achieve control over symptoms. Medications may make a child jittery or “hyper” and interfere with sleep. An opportunity to run around before bedtime may help work off this effect and allow better sleep (for the whole family). Restricting chocolate and caffeinated drinks may help. A nebulizer is often recommended as the best way to get the proper dose of medication into a toddler. A nebulizer is an air compressor that turns medication into cold steam, attached to a clear plastic mask, which fits over the child’s nose and mouth. It may work best to hold the mask up to the child’s face while he or she sits on your lap, rather than to attach the mask with the elastic band. Though you may feel like a mad scientist when you start using a nebulizer, the use of this device may help to avoid many visits to the emergency room.