Back-to-school time can be a “triple threat” to children with asthma, says Dr. Shelly Vaziri Flais, a practicing pediatrician and editor-in-chief of the American Academy of Pediatrics (AAP) guidebook, “Caring for Your School-Age Child: Ages 5-12.” “The change in weather with cool nights, the germs spreading in new classrooms and ragweed season starting in mid-August in most areas of the country can mean those kids with viral or environmental asthma triggers have more issues,” she explains.
If your child or one you care for suffers from the chronic respiratory condition, they aren’t alone. Asthma affects more than 6 million children in the United States (about three students in every classroom of 30 kids) and is one of the leading causes of absenteeism in schools.
Managing asthma effectively at school requires careful planning and can be challenging even under the best of circumstances, but in many parts of the country, poor air quality continues to fluctuate due to wildfire smoke and flood dust, exacerbating the symptoms of pre-existing lung conditions like asthma, in both children and adults.
Read on for expert insights, practical tips and a comprehensive checklist for a successful school year with asthma.
Why back-to-school is a key time for asthma diagnosis
Asthma can be challenging to diagnose; there isn’t a one-size-fits all list of symptoms. “You can have asthma without hearing a wheeze,” explains Valerie Jarkovich, a registered respiratory therapist at Hinsdale Hospital in Illinois and mother of a first grader with asthma. “Many kids with asthma will only have a cough that lasts for a long time — it’s how the body tries to get and keep airway tubes open.” Other leading symptoms include shortness of breath, chest tightness and poor sleep.
Although asthma exacerbations can occur at any time during the year, a study in the Journal of Allergy and Clinical Immunology found that the highest rate of exacerbations occur in the fall (28.8%) — followed by spring (19.6%), winter (15.9%) and summer (14.5%). So it stands to reason that asthma diagnoses may pop up as children head back to class.
“We know the month of September — right when kids are back to school — is a peak time when we see kids in the ER with asthma attacks,” says Dr. Flais.
Viral respiratory infections (think colds, flu or RSV) tends to make asthma symptoms worse. Up to 70% of asthma flare-ups or exacerbations are associated with viral infections.
“We know the month of September — right when kids are back to school — is a peak time when we see kids in the ER with asthma attacks.”
— Dr. Shelly Vaziri Flais, a practicing pediatrician
What are common asthma triggers in a school environment?
Every person with asthma has different triggers or things that worsen their condition. The main asthma triggers in a school environment include:
- Dust
- Aerosol cleaning chemicals
- Scented products
- Extreme or changing weather
- Environmental factors like pollen and pollution
- Participation in physical activities (e.g., physical education class)
“We have a lot of agriculture in our area with aerial spraying in the fall,” says Deb Cook, director of health services for Kennett School District in Missouri and certified nurse educator. “We also have a high number of parents in our district who smoke at home, and these things that affect air quality outside and inside the home can make asthma symptoms [at school] worse.”
Last spring, as Canadian wildfire smoke made headlines, many school districts — including those in Baltimore and Washington, D.C. — moved recesses inside and canceled or postponed athletics and extracurricular activities in accordance with air quality safety recommendations from AirNow — a partnership of the U.S. Environmental Protection Agency, National Oceanic and Atmospheric Administration, Centers for Disease Control and Prevention (CDC) and other federal agencies.
The Asthma and Allergy Foundation of America notes many schools have established policies and protocols to manage asthma-related emergencies – and the situation could continue to improve. In January 2021, the School Based Allergies and Asthma Management Program Act (HR 2468) became law and encouraged states to improve asthma care in schools by giving preference for federal grants to states that adopt certain asthma management programs and policies.
As kids grow, Dr. Flais, a mother of four teenagers and young adults, says they should start taking more ownership over their condition and a strong awareness of their asthma symptoms and triggers. “This means self-carrying and self-administering their inhalers or rescue medication during the school day or at after-school activities,” she notes. “It’s a good idea to keep an extra inhaler in a gym bag or backpack; emergencies can happen at any time, it’s always good to be prepared and form good habits early.”
“It’s a good idea to keep an extra inhaler in a gym bag or backpack; emergencies can happen at any time, it’s always good to be prepared and form good habits early.”
— Dr. Shelly Vaziri Flais
What forms does a child who has asthma need for school?
Pediatricians and/or specialists can help prepare written plans for managing asthma symptoms at school and responding to emergencies, fill out the necessary paperwork required for asthma medication to be administered at school, and complete forms permitting information to be shared between the providers and school. While your child’s school may have different policies and forms for medication and consent, here are some resources to get you started.
Asthma action plan
An asthma action plan is a personalized guide that outlines steps to manage asthma symptoms and respond to emergencies. Despite strong research indicating their effectiveness, studies have found only 4% of family physicians reported consistently providing a written asthma action plan and only 2% of patients with asthma reported actually receiving one. If your child doesn’t have one or needs a new one, the Asthma and Allergy Foundation of America has an Asthma Action Plan template you can take to your doctor and fill out together.
Medication permission forms
Medication permission forms include whether a child should be allowed to carry and use their own inhaler independently. All prescription medication must be unexpired and in the original container with the prescription label attached. New York City Public Schools have a sample asthma medication administration form other districts can adapt.
Consent forms
Consent forms (also known as release of information forms) permit a healthcare provider to exchange medical information about a child with the school in accordance with Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA) regulations. UWHealth calls this form an authorization for release of verbal communication and exchange of written information.
“If parents also sign a consent form with the school, we can communicate directly with their provider and sometimes it offers a different perspective on how things are going,” says Cook. “If we see a kid coming in a lot to get their rescue inhaler and their teacher tells us they are coughing a lot in class, we’ll tell the doctor they might need to change their plan.”
After piloting a successful school nurse-led asthma management program in her district, Cook and her colleagues published their model in the Journal of School Health for other districts interested in helping students with asthma. If you’re looking for a resource to bring to your child’s school to streamline communication, consider sharing the program’s Asthma Assessment Communication Tool. It was designed to help staff and healthcare providers easily identify asthma severity and distinguish between current, recommended and new treatment plans. Your child’s health care provider(s) could use the same form to document any changes to their care (e.g., medication changes) and return it to the school.
What kinds of medications help kids with asthma at school?
There are several protocols kids may use for asthma at school.
Quick-relief rescue medicines
Quick-relief rescue medicines such as Albuterol (ProAir, Ventolin, etc.) — called short-acting bronchodilators — provide immediate relief of asthma symptoms and are the most common type of asthma medication kept at school; they are taken with an inhaler or a nebulizer for asthma symptoms such as wheezing, chest tightness and cough.
Daily inhaled corticosteroids
Daily inhaled corticosteroids on the other hand, like fluticasone (Flovent HFA) and budesonide (Pulmicort Flexhaler), are the most commonly prescribed long-term control medications for children with mild persistent to severe persistent asthma.
SMART treatment strategy
If your child is 4 years old or older with mild to persistent asthma, they may be a candidate for a single maintenance and reliever therapy (SMART) – a treatment strategy endorsed by the 2020 updates to the National Asthma Education and Prevention Program (NAEPP) guidelines after extensive study and evaluation showed it can reduce the use of oral steroids, emergency room visits and hospitalizations by 60%. With SMART, one combination inhaler is used once or twice daily and contains both a corticosteroid to help keep asthma under control and a specific long-acting bronchodilator called formoterol to relieve symptoms quickly. If your child struggles to remember taking their daily maintenance medication and needs their rescue inhaler frequently, SMART may be a good option to discuss with your doctor.
“If we see a kid coming in a lot to get their rescue inhaler and their teacher tells us they are coughing a lot in class, we’ll tell the doctor they might need to change their plan.”
— Deb Cook, director of health services for Kennett School District in Missouri and certified nurse educator
What medication issues do parents of children with asthma face during the school year?
Because asthma severity and medication plans often change between early childhood, school-aged years and adolescence, it’s helpful to be aware of potential bumps in the road you and your child might face along the way.
Poor medication adherence and technique
In her nearly 30 years as a school nurse, Cook’s found that school-age children struggle most with medication adherence and medication technique. “Many children don’t use their inhaler correctly or come to school without it entirely,” she says. “It’s very easy for kids (and parents) to stop taking their asthma medications when they’re feeling well and don’t have any symptoms — the same goes for any other preventive health behavior.”
Similarly in the hospital, Jarkovich often sees young children with asthma failing to use a spacer with their inhaler, a tube-like holding chamber that attaches to an inhaler to help deliver the medicine. “Without a spacer, the majority of the medication (80-90%) is hitting the back of the child’s throat and not getting into their airways where it should go,” she explains, noting that part of her role as a respiratory therapist is doing a lot of patient training and education on proper technique. “Generally, we like kids to use a spacer with their inhaler until they’re about 8 years old.”
High out-of-pocket medication costs
Unfortunately, Jarkovich says out-of-pocket costs can stand in the way of a child following the proper medication technique during the school day. “A spacer for the inhaler actually costs more than the Albuterol medication itself, because many insurance plans don’t cover them,” she notes.
In New York, for example, Medicaid and Child Health Plus cover the cost of two or more of these pieces of medical equipment per year, but costs can add up when a child needs to keep separate rescue inhalers at home, school and extracurriculars.
Cook remembers a dad telling her his 5-year-old son needed to be kept inside for recess during the winter. “He told me he couldn’t afford his son’s asthma medication and the ER bills,” she says. “This is a sad reality many in our community face.”
Fortunately, in this case, Cook was able to offer support; part of the role school nurses now play is helping kids and their parents access, understand and use their medications correctly and connect them with programs and resources to reduce asthma medication costs. For instance, if you live in the state of New York, your child can get fluticasone (Flovent) free at school with a prescription. If they have an asthma attack at school, they can also get free Albuterol at school with a prescription.
Lack of health insurance
They are among the more than 87 million people in Medicaid and several million more in the Children’s Health Insurance Program (CHIP) who are having their eligibility checked and facing possible termination of coverage for the first time since the start of the pandemic.
Right now, Cook said her district is focused on helping families navigate this Medicaid renewal process. “We’ve launched campaigns on social media and set up tables at back-to-school events,” she said. “If parents don’t renew, they could possibly lose coverage – and without Medicaid, their children’s medicines will run out.” Already, more than 21,600 low-income Missouri residents lost government-funded health insurance coverage in July – including 10,000 children, according to reporting in the St. Louis Post Dispatch.
“It’s still too early to tell what the implications of this will be for kids in our district,” Cook says. “The reality is, many people won’t realize they’ve lost Medicaid coverage until they actually need it.” That said, now is the time to renew your Medicaid or CHIP coverage. Contact your state Medicaid office for more information as dates of eligibility reviews vary.
A checklist for a successful school year with asthma
To ensure your child’s asthma is well-managed throughout the school year, follow these steps:
- Review your health insurance information. Understand your coverage, including medication benefits, co-payments, and formulary restrictions.
- Schedule an appointment with your pediatrician. Together, create or update your child’s personalized asthma action plan and bring any medication or consent forms for them to sign for school.
- Share your asthma action plan with the school nurse, teachers, and any relevant staff members like the bus driver or school administrator.
- Discuss your child’s participation in physical activities with physical education teachers and coaches. They need to be aware of your child’s asthma and may have additional forms for you to complete.
- Regularly review and update your child’s asthma action plan with the school nurse. Evaluate the effectiveness of interventions and adjust them as needed.
- Educate any additional caregivers about your child’s asthma, triggers, and appropriate emergency responses.
- Advocate for school policies that support asthma management, such as indoor activities during poor air quality days and more education for faculty and staff.
The bottom line on heading back to school with asthma
Ultimately, parents must communicate with the school nurse, their child’s teachers, and school administrators to ensure everyone is up-to-speed and has a copy of their asthma action plan.
“You’ll learn your child’s triggers as they get older,” says Jarkovich. “And once you do, it’s important to be their advocate inside and outside of school – making sure everyone from teachers, bus drivers, babysitters and coaches knows how to recognize the signs of an asthma attack and what to do in an emergency.”
