Nocturnal asthma. Many parents know all too well the coughing, choking, wheezing and congestion that can keep their children – and the rest of the family – awake at night.
“When my 3-year-old’s asthma acts up, it definitely disrupts his sleep and mine,” says AANMA member Rachel Gerke. “I know it is bothering him when he is really restless at night, crying or moaning and hitting the sides of the bed when rolling. And when I go in to listen to him he is either breathing faster, usually from his belly, his chest not rising, or I hear a whistle at the end of his breaths.”
Rachel’s family is not alone. More than 20 million Americans are affected by nocturnal asthma – also called nighttime or sleep-related asthma. The condition has been reported in medical literature for centuries.
AANMA consulted sleep experts – including parents! – for advice to help you and your family get a good night’s sleep.
Why We’re Losing Sleep
When you breathe in, the lungs transport oxygen into the bloodstream, where it’s carried to the rest of the body. When you breathe out, they transport the waste product – carbon dioxide – out of the bloodstream. How well this process works varies throughout the day as part of the body’s natural circadian rhythm – an internal clock that regulates body mechanics over a 24-hour period. Lungs work best during the day, with peak lung function at about 4 p.m. Several studies show that 12 hours later – around 4 a.m. – lung function is at its lowest. The fluctuation is usually less than 10 percent. However, people with asthma can have up to a 50 percent difference between daytime and nighttime lung function.
In addition to rhythmic fluctuations, other factors contribute to worsening asthma symptoms during sleep. According to Eli Meltzer, MD, of the Allergy and Asthma Medical Group and Research Center in San Diego, California, “These factors include changes in the degree of inflammation, the amount of allergen exposure and the responsiveness patients have to their medications. Not only do short-acting bronchodilators wear off while patients are asleep, their effect over the 4-6 hours of their activity is less at night than in the day. These conditions result in patients waking up short of breath because they need to take another dose.”
Gastroesophageal reflux (often called acid reflux or reflux), a back-wash of stomach acid into the esophagus, is also a contributing factor to sleep disturbance. AANMA member Carol O’Leary found reflux to be the cause of her son’s sleep problems. “After two and a half years of sleepless nights, my son’s acid reflux was finally diagnosed and treated. An effective treatment plan helped our whole family start sleeping better.”
Researchers aren’t sure exactly how reflux and asthma interact, but they do see a connection – adult studies suggest as many as 75 percent of adults with asthma also have reflux. Reflux can set off asthma symptoms. Because reflux is more common when a person is lying down, people with asthma may have more difficulty during sleep.
Another sleep-related condition that can worsen nighttime asthma is sleep apnea. This sleep disorder causes repeated pauses in breathing throughout the night – a serious problem in itself, but also one that can set off or worsen asthma symptoms. A recent study by the Cincinnati Children’s Hospital Medical Center showed that women with asthma are twice as likely to have symptoms of sleep apnea as women without asthma.
“Please don’t rule out sleep apnea as a cause of poor sleep – even in children!” says AANMA member Laurie Soares. “My 10-year-old son has asthma and allergies. He snored, was a mouth breather at night, was tired a lot and had poor height and weight growth. His father has sleep apnea, so with all those factors present we had my son’s tonsils and adenoids removed. Since then, he sleeps quietly, is gaining weight and reports that he now has dreams!”
Allergens – like pollen or mold that cause allergic reactions – can also play a role in sleep problems. Exposure to allergens during the day may set off a chain reaction in the immune system that produces symptoms hours later, as can allergens in the bedroom like dust mites or animal dander.
Studies show that postnasal drip and congestion from allergies can cause multiple nighttime “micro-arousals.” These awakenings are so brief that the sleeper doesn’t even remember them, but they affect alertness the following day.
The Next Day
The effects of nighttime asthma and allergy symptoms reach beyond the bedroom. Children with nighttime asthma miss more time from school – and their parents more time from work – than healthy children. School and work performance can suffer when the family can’t sleep. Children whose rest is disturbed by asthma symptoms have a higher incidence of psychological problems and poor school performance. Studies show that these children score lower on memory and time-limited tests. The most obvious signs that asthma is disturbing someone’s sleep are fatigue, irritability and reduced alertness the following day. According to Dr. Meltzer, other signs to look for include morning headaches, depression and impaired concentration.
Doctors use the term “allergic fatigue” to describe the tiredness and general lack of energy experienced by people with nasal allergies. This condition is often blamed on antihistamine medications, many of which cause sedation. But recent studies show that, in addition to other factors, poor sleep quality contributes to the exhaustion people with allergies may feel all day long.
Eliminating allergens and potential asthma triggers in the bedroom can make a big difference in your child’s quality of sleep. Allergy testing, combined with your child’s symptom history, will help your doctor determine which specific allergens are triggering your child’s asthma or allergy symptoms. Then you can focus your efforts on eliminating exposure to those specific allergens.
AANMA member Rachel Clarke reports, “We were amazed at the huge difference in our children’s quality of sleep once we removed our carpeting and installed wooden floors. It was expensive – but well worth it.”
Jan Frey concurs. After finding out her son was allergic to dust mites and mold, she says, “We ripped out carpeting, removed drapes and stuffed animals and got rid of the clutter that collects dust. We allergy-proofed not only his bed but also his brother’s bed in the same room and our bed. We were amazed at the immediate improvement. His nightly wheezing and asthma flare-ups cleared and he now sleeps more deeply and soundly.”
Christine Noriega took a multi-step approach to helping her son get a good night’s sleep. “My son’s eczema would flare up and keep him scratching all night and his asthma would get worse. First, we found out he had food allergies and eliminated those foods. This helped calm his eczema. We also found he was allergic to dust mites. We put dust mite covers on his mattress and pillows, wash his bedding frequently in HOT water and put a HEPA filter in his room. When he comes in after playing outdoors, we get him into the bath right away to get rid of the pollen and other allergens. Then we rub Vaseline all over his body and put on cotton pajamas. This helps his eczema. All of these steps are helping calm his asthma and he’s finally getting a good night’s sleep.”
If cleaning up the bedroom isn’t enough to curb allergy symptoms, work with an allergist on treatment options, including immunotherapy (allergy shots), oral and nasal antihistamines and nasal corticosteroids. Children 12 and older can also be tested to see if they qualify for a medication that reduces the number of antibodies responsible for allergic reactions.
If you think your child is having trouble sleeping due to asthma or allergies, monitor his symptoms, encourage him to report any problems to you and keep a sleep journal (this can be part of his daily symptom diary). Talk to your child’s doctor about nighttime problems. “We need to control asthma both during the day and at night to maximize a patient’s health-related quality of life,” emphasizes Dr. Meltzer. If you notice excessive napping or drowsiness, school problems, hyperactivity or distractibility, ask your doctor to assess your child’s nighttime symptoms. Talk about your child’s sleep schedule, sleep environment, sleep-related symptoms and behavioral issues. You should also carefully monitor your child’s use of medication: Is he taking all doses on time? Adept at using a metered-dose inhaler or nebulizer? Check his inhaler technique at the next medical appointment and talk to the doctor about other medical conditions – like reflux and sleep apnea – that could be contributing to sleep problems.
Rachel Gerke says, “It has taken us all three years of his life, but we’ve finally started to get my son’s asthma symptoms under control.” Rachel makes regular appointments for her son with his allergist and asthma program coordinator. “He’s had fewer asthma symptoms now that we fine-tuned his medication plan, put wood flooring in his room, removed all stuffed animals, started washing his bedding frequently and put dust mite-proof covers on his mattress and pillow cases. I also think that it made a difference to take the diaper wipes warmer out of his room – it gave off a scent from the wipes that I believe irritated his airways. It is all those little things that a lot of people don’t think about doing in their sleeping environment that make a world of difference.”
Asthma and allergies don’t have to keep your family from getting the sleep you need. Work with your child’s medical care team to determine what’s causing sleep problems and how you can solve them.
Dealing With Dust Mites
Most children and even teenagers have well-loved stuffed animals that are full of dust mites. How do you get rid of those dust mites? You could turn the hot water heater up to 130° F on laundry day. Or you can make your child’s stuffed animals “allergy friendly” by sticking them in the freezer overnight. This tip was first reported by AANMA president and founder Nancy Sander in “A Parent’s Guide to Asthma” in 1989. After the deep freeze, wash and dry the stuffed animals to get rid of dust mite body parts and fecal pellets.
What’s On Your Bed?
With all the mattress and pillow options available today, are some better than others for people with asthma and allergies? It depends on what’s causing your sneezing and wheezing.
If you have dust mite allergy, the keys to a good night’s sleep are using mattress and pillow encasements and monitoring humidity levels. Dust mites need two things to thrive: water (which they absorb from the air) and food (which they get from you in the form of dead skin cells). Keeping your bedroom’s humidity below 50 percent will deprive dust mites of their water source, and a special cover over your mattress and pillow will deprive them of food. The mattress and pillow encasements will also protect you from allergens in mite body parts and poop.
A word about mattress and pillow encasements: Old-style pillow and mattress encasements were made of plastic; they didn’t allow air to flow through, so you’d end up sweaty, and they made a lot of noise when you rolled over. New encasements are made of tightly woven fabric that’s soft and silent. Small pores allow air to pass through but are too small for dust mites and allergens to get through. When shopping for encasements, look for bound seams and a pore size (the amount of space between fabric threads) of 10 microns or less. Avoid coatings or lamination that can wear off in the wash.
New allergy-free and hypoallergenic pillows may not solve your slumber problems. According to the American Academy of Allergy, Asthma and Immunology, both synthetic pillows and feather pillows promote dust mite growth. And allergy to feathers is actually very rare. So select the pillow that’s most comfortable for you and use a tightly woven pillow encasement.
First published: Allergy & Asthma Today, Winter 2007
Updated: February 2009