Asthma's grip tightens on young lungs

MARCH 13 - Heather Line knows the routine perfectly: She sees her 2-year-old's shoulders pulled back, a depressed V at his throat, the way his rib cage looks and his rapid breathing - and she calls for help.

At Rocky Mountain Youth, where they get care, attention is paid, ambulances fly.

The drill that Line has down pat is depressingly familiar to increasing numbers of Denver parents, child-care providers and school nurses. Inexplicably, asthma has increased dramatically in Colorado, as it has worldwide. City kids are particularly hard-hit - more than 2,000 Denver children now have asthma.

Nationally, the prevalence of reported asthma went up 75 percent from 1980 to 1994, according to the Centers for Disease Control and Prevention. The most substantial increase - 160 percent - occurred in children from infancy to 4 years of age.

Death rates from asthma have doubled in Colorado from the mid-1970s to the mid-1990s, from 10.6 per million to 21.3 per million, state epidemiologist Richard Hoffman said. The numbers really hit home when he was at a middle school last year reviewing children's medical histories before giving them antibiotics to prevent meningitis.

"I was quite surprised at the large number of children who were taking asthma medicines," Hoffman said. "It was completely unexpected."

Physicians at Denver Health say hospitalizations and outpatient visits for children with asthma have doubled from 1994 to 1999 and there's no end in sight.

Nobody knows why.

"That's the frustration we all have," said Dr. Richard Johnston at National Jewish Hospital, chairman of the national Institute of Medicine's Committee on Asthma and Indoor Air.

First you have to have the genes to get asthma, Johnston said. Children with one asthmatic parent get asthma at three to six times the rate of other kids; children with two asthmatic parents have 10 times the risk.

But the gene pool hasn't changed that much in the past 20 years.

Johnston said his committee concluded that exposure to dust mites might cause a first episode, but "we don't have them in Colorado, so where do our kids get asthma?" There's almost as much evidence pointing to exposure to tobacco smoke, including exposure in utero, he said.

"There's a second theory, and it's purely a theory," Johnston said, adding that the increase is perhaps related to the massive movement of women to the workplace - leaving children inside and inactive for longer periods of time.

If a child comes home from school in the early afternoon, lets himself in and watches TV for four hours, two things have happened, Johnson said: The child hasn't been expanding his lungs, and he's had a much longer exposure to indoor allergens. Add one more element - better windows. Houses are more tightly sealed than they used to be.

"We need to understand the indoor environment and what might be there that would cause this change in the rates."

National Jewish Hospital pediatric allergist Andy Liu said there are some other things researchers have discovered: "In rural underdeveloped countries, the prevalence remains low. And you can see prevalence go up in populations that move to the city." Liu said it appears the immune system plays a role in developing asthma. If a child has severe asthma and lives with a cat, get rid of the cat and the child improves, Liu said. "But children who were raised with cats in the house from early childhood seem to develop less cat sensitization." When asthma rates were compared in children from the former East and West Germany, it was expected that East German children would have more disease because their air was more polluted, but the opposite turned out to be true.

Liu said that "something about the microbial world might have protected children from developing asthma." A lack of exposure to microbes because of clean water, immunizations, city life removed from farm animals and earth may have affected immune systems.

"There's a tradeoff," he said. "Hygiene is healthful, but we may want to look at what we left behind."

Liu was instrumental in organizing "Allies Against Asthma" last fall, a consortium of more than 40 members that has applied to the Robert Woods Johnson Foundation for a grant to improve care for Denver's asthmatic children.

Liu said it isn't clear if more city children have asthma than suburban or rural children, but asthma is more severe among the inner city poor.

One explanation is poor access to health care, Liu said. Uninsured children tend to get health care in emergency rooms, the worst way to manage a chronic disease. Also, asthma medications and equipment can be very expensive for low-income families.

Pediatrician Carol Siegel at Clinica Campesina in Adams County said she sees asthmatic children who share their medications and nebulizers with cousins and siblings who don't have insurance.

"More often than not, we see adults sharing their children's medication," said pediatrician Larry Wolk, director of Rocky Mountain Youth, a health-care system for low-income children.

That happens when children in working-poor families qualify for Medicaid or Child Health Plan Plus - federally subsidized programs for uninsured children - but there is nothing for their parents, Wolk said.

John Ogle, director of pediatrics at Denver Health said that when families of asthmatic children try to get by on a single prescription, someone usually gets the wrong dosage.

Sharing medication also may mean families run out when a child needs his dose, Ogle said.

"We have seen deaths in children," he said. "We view deaths as tragedies that could be avoided (because) asthma is treatable, and the treatment is effective." It's important for asthmatic children to see the same physician and to see him or her regularly, Ogle said. That physician can help figure out what triggers a particular child's attack and how to avoid the trigger.

Sometimes, it's a much-loved family dog. If the child's asthma is mild, the recommendation might be "when the dog dies, don't get another."

Ogle told of a girl who had to be hospitalized every time she visited her housebound grandmother, a cat lover. Reluctant to tell a child she could no longer visit her grandmother, doctors tried dosing her the day before a visit. It worked.

Cigarette smoke can be lethal, Ogle said. At Denver Health, parents of asthmatics are offered cessation programs, but if they can't quit, they are urged to smoke outside.

Even that's an inadequate solution. Clothing that smells of cigarette smoke can trigger an attack, as can cars in which cigarettes have been smoked, he said.

Liu said the allergens that trigger asthma attacks do not cause asthma in the first place. Besides dust, cigarette smoke and dog and cat dander, those triggers include cockroach proteins and dust mites - but those are more prevalent in cities more humid than Denver.

Some cities have days that fill pediatric wards with wheezing children. Johnston at National Jewish Hospital said fog would do it when he was at Boston Children's Hospital. Liu said that in New Orleans, it happens after thunderstorms that release a mold from the bayous.

But Denver doesn't really have those defining days. Sometimes it happens here in flu season because cold viruses can trigger asthma; sometimes it's spring when trees and grasses are blooming.

City mothers look at hazy horizons and wonder what role pollution plays. The sleep-deprived Heather Line, whose family lives near I-70 and Federal Boulevard said, "I don't know if living near a highway does it." Victoria DeHerrera guesses that in her family it's dust. She's quit smoking, the dogs stay outside, they have no cats. She and her husband, Thomas, have become master managers of asthmatic care. Now they're thinking about moving, or removing the carpet in the house they've got.

Still, 7-year-old Thomas continues to get worse. "He doesn't panic as much as I panic," said DeHerrera, interviewed in the pediatric intensive care unit at Denver Health Medical Center where her son was recovering from another acute attack.

It's a terrible thing to see your child unable to breathe, she said - it's like watching him drown. "Imagine if you're underneath water, clawing to get up. That's pretty much how it is."

About Asthma

• Asthma is a chronic inflammatory condition of the airways of the lungs.

• Symptoms of asthma include repeated episodes of coughing and/or wheezing triggered by a viral upper respiratory infection, allergens, exercise, cold air and passive smoking.

• In Colorado, common allergens that may trigger an asthma attack include pets, seasonal pollen from trees and grasses, and seasonal molds.

• In cities more humid than Denver, cockroach and dust mite proteins are major allergens.