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Wheezing: Tips for Kids Using Inhalers

There are different kinds of metered dose inhalers (“MDI”):

1)      A “rescue inhaler” contains Albuterol or Levalbuterol, which opens up the lungs and reduces inflammation for quick relief. Brand names include Ventolin, ProAir, Proventil, or Xopenex. 6 puffs of these are equivalent to putting 1 vial of Albuterol or Xopenex in a nebulizer and sitting with the mask on your child for 15 minutes. These are usually used on an as-needed basis, up to every 4 hours. If your child needs to use this every 4 hours for more than 24 hours, needs it more often than every 4 hours, or needs this more than twice every week, please call your pediatrician.

2)      Some inhalers are used to prevent asthma, wheezing, and breathing trouble. These are only effective when used every day on a continuous basis. They are not used for fast-acting relief of an acute breathing difficulty, but may help when used during cold or allergy season, or if started right at the beginning of an asthma exacerbation or when a child is exposed to known triggers. Brand names of some of these medicines include Flovent, Qvar, Symbicort, Dullera or Advair. Flovent and Qvar are like using the Pulmicort/Budesonide in the nebulizer. Symbicort, Dulera and Advair also have other medicines in them for stronger asthma prevention. Please discuss if and when you should use these with your physician.

3)      There are also inhalers that contain powder or are not used with a spacer. Some brand names are: Maxair autohaler, Proair RespiClick, Asmanex Twisthaler, or Pulmicort Flexhaler. None of these need a spacer to work effectively, but these are only for older children who can control breathing in the medication and not breathing out into the device.

Please see the “Asthma Education For Kids” playlist from BoosterShotComics on YouTube, especially episode #1: “Iggy & The Inhalers” to better understand the roles of different medications used for wheezing or asthma. Episode 4 explains how to use a spacer with mouthpiece.

There are 4 main brands of spacers. They may be cheaper online than from a pharmacy, but always require a prescription.

1)      Aerochamber with flow-vu. This brand is a clear tube with colored ends and teddy bears on the side. It has a two-way valve (to get the medicine in and air out) and is anti-static (so the kid can inhale all of the medicine and it won’t stick to the sides). The flow-vu allows you to see when a child gets a breath with a good seal. There is a small orange one for infants, yellow medium one for age 1-5 years old, blue one with mask for older children that still need a mask, and blue one with mouth-piece for older kids that can seal their lips around it instead of having to use a mask (more comfortable, kids can usually start doing this around age 6).

2)      Vortex Non-Electrostatic Valved Holding Chamber. This device also has a two-way valve and is anti-static. It is metal, so it is more durable and machine-washable. It comes in 1 size with different sized masks that fit on the end. This has the advantage of only needing one device as the child grows older (you just switch the mask on the end, not the whole device).

3)      Optichamber. The original device is a plastic tube with 1-way valve that most pharmacies try to give our patients. Some versions are NOT anti-static, therefore much of the medicine sticks to the plastic, instead of being inhaled by the child. The single valve can make some children feel suffocated when breathing into the mask. I do NOT recommend this device. However, there is now an Optichamber Diamond version, which is anti-static, has a 2-way valve, and can be used comfortably. It comes with different size masks or a mouth piece, all clear, and very soft.

4)      InspiraChamber. This is a clear, anti-static, valved chamber, with purple ends. It offers very soft masks with a special place in the small mask to fit a pacifier, to calm the child while they inhale. It also has a flap that moves, so you can see if the child is taking a breath with a good seal and getting the medicine.

How to Use Your Inhaler:

Before using a new inhaler for the first time, shake it up, then put it into the spacer and press it 10-15 times to prime the device (e.g. makes sure the medicine is coming out in an even dose, and not just the propellent). The next time you use it, shake it first, but you do not need to prime it.

My son playing with his inhaler and spacer to get used to it

To use a spacer with a mask:

  • Shake the inhaler before each use.
  • Put the inhaler mouthpiece into the spacer.
  • Hold the mask over your child’s nose and mouth and create a good seal. Holding your fingers like the letter C can help. If you’re using a device with flow view, you should see the flap move with each breath the child takes. Otherwise look at the child’s chest to count breaths.
  • Press the inhaler.
  • Have your child breath in and out six times (about 30 seconds).
  • Remove the mask and let your child breath normally for a minute.
  • Repeat if more than one puff was prescribed (most inhalers need 2 puffs per dose, but some use more or less).

While your younger child may not like the spacer and mask being held over his mouth and nose, it will go much quicker than using a nebulizer. Let the child play with it and practice putting it on stuffed animals or family members to make them comfortable. Some children will allow you to use it if they get to be the ones to hold it or press the inhaler (just make sure the seal is tight over their face so they get all of the medicine).

To use a spacer with mouthpiece (older children and adults):

  • Shake the inhaler before each use.
  • Put the inhaler into the spacer.
  • Have your child seal their lips around the mouthpiece and exhale.
  • Press the inhaler.
  • Have your child breath the medicine in and hold their breath for about 30 seconds. If they can’t hold their breath, they can take another breath or 2 in to get more medicine from that puff (any extra medicine should be sitting in the chamber).
  • Take the spacer out of their mouth and have the child breath normally for a minute.
  • Repeat if more than one puff was prescribed.

Keep in mind that while many experts believe that an MDI with a spacer is as good as, or better than, a nebulized treatment, some parents prefer a nebulizer, and that is okay.

If you are not sure if your child is actually wheezing, or what they have, this blog from Dr. Stuppy can help, with descriptions of different kinds of coughs and breathing, along with youtube video links.

If your child does NOT have asthma, reactive airway disease, wheezing, bronchospasm, or difficulty breathing, my post on Coughs, Colds and Croup may be more helpful.

Please note that this guide is NOT intended to diagnose or treat any illness or condition. Always speak to your own physician for advice. 

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Tips for Sensitive Skin & Eczematous Kids

Part of the information is from UpToDate.com, but has been extensively revised by Dr. Shaham.
What is eczema? — Eczema is a skin condition that makes your skin itchy and flaky. Doctors do not know what causes it. Eczema often happens in people who have allergies. Another term for eczema is “atopic dermatitis.”

What are the symptoms of eczema? — The symptoms of eczema can include: intense itching (even before the rash starts), redness, rough patches of skin, small bumps, skin that flakes or skin that forms scales.

What can I do to reduce my symptoms? — Use unscented thick moisturizing creams (ointments preferred) to keep the skin from getting too dry. Also, try to avoid things that can make eczema worse, such as: being too hot or sweating too much, very dry air, stress, sudden temperature changes, harsh soaps or cleaning products, perfumes, wool or synthetic fabrics (like polyester), things that you may be allergic to (often foods for infants or pets for older kids).

Bathing Tips— Use warm water for bathing and washing hands. Use a mild, non-drying cleanser that is fragrance-free, dye-free, and allergy tested. Avoid body sponges and washcloths (friction can make the skin worse).  Gently pat skin dry with a towel, do not rub the skin. Kids with frequent eczema flares or infections can benefit from bleach baths, but ask your pediatrician first if this treatment should be used for your child.

Moisturizing Tips— Apply any special skin medications prescribed for you and then liberally apply a moisturizer. Use a moisturizer within 3 minutes of getting out of the bath, to lock in the moisture. Re-apply moisturizer throughout the day, whenever your skin feels dry or itchy. Regular petroleum jelly works very well for this. A recent study showed applying petroleum jelly 3 times a day to infants who had a family history of eczema helped prevent eczema in those babies.

More Tips— Use dye-free and fragrance-free detergents. Use an extra rinse cycle on laundry to get rid of any soap remnants. Keep fingernails short to avoid scratching. Consider weekly bleach baths if the eczema gets infected often. Check out www.eczemacenter.org  and the national eczema association for more information and videos.

How is eczema treated? — There are treatments that can relieve the symptoms of eczema. But the condition cannot be cured. Even so, about half of children with eczema grow out of it by the time they become adults. The treatments for eczema include:

  • Moisturizing creams or ointments – These products help keep your skin moist. An ointment (such as aquaphor or vaseline) can be soothing, lock-in the moisture and act as a barrier to environmental allergens. Other lotions (such as Cetaphil) help repair your skin’s barrier. These need to be applied at least 3 times per day!
  • Steroid creams and ointments – These medicines are different than the steroids athletes take to build muscle. They go on the skin, and they relieve itching, redness, and inflammation. (In severe cases, you may need to take steroids by mouth, but only under physician supervision).
  • Antihistamine pills – Antihistamines are the medicines people take for allergies and also relieve itching. Many people find that itching is worst at night, which can make it hard to sleep. If you have this problem, talk with your doctor or nurse about it. He or she might recommend an antihistamine that can also help with sleep, such as Children’s Benadryl (aka diphenhydramine HCl).