Hello, and welcome to the "Inhale Exhale" podcast, brought to you by FeNO for me. We're the dedicated FeNO podcast that inhales the knowledge and exhales the answers to all your questions. Every September, as children return to school, hospitals see a sharp rise in asthma attacks, often referred to as the September peak. In fact, around a quarter of all children's asthma hospitalizations occur during this period, making it one of the most challenging times of year for children living with asthma, their families, and healthcare professionals. So why does this happen every year? And perhaps more importantly, what can families and clinicians do to prepare? Joining me today to answer those questions is Bailey Edwards. Bailey is a registered respiratory therapist based in North Carolina and works closely with children and families providing asthma testing, education, and ongoing support, and has previously featured on radio and TV channels across the US to help raise awareness of asthma and FeNO testing. In today's episode, we'll explore why the September peak happens, how families can prepare for the new school year, and the role that asthma education, action plans, and FeNO testing can play in supporting better asthma care. Bailey, welcome to the podcast. Great to have you with us. Please, could you tell us a little bit about yourself and what first led you into pediatric asthma care? Sure. My name is Bailey. I am a registered respiratory therapist, and I started bedside in the hospital, so I was in the pediatric ICU, so intensive care unit, and I also worked with the neonatal population, which is premature babies. But what really led me into pediatric asthma care is while I was in the pediatric ICU, I just saw a ton of kids coming in and who were requiring a lot of intervention for asthma flares. And it just seemed disheartening because I grew up with asthma. I knew it was manageable. I knew that there was more that could be done. And so I learned about other avenues, other programs, other things to be involved on the community side, and decided to make the transition to the community side to get into pediatric asthma to help them before they ever get to the hospital. So one thing about having asthma yourself, it's great that you can actually talk from your own experience, right? Yeah, absolutely. It's a great way to connect to families because sometimes families have never heard of asthma or they have never really met someone who has or have lived to adulthood and are still dealing with asthma. And so it helps you connect with them and ask questions. And a lot of parents want to know, "Will they outgrow this?" And some kids can get better with time. Some kids get worse. It just really depends on the patient. So they're able to relate to me in ways that they probably couldn't if they were talking to someone who didn't have asthma. That doesn't mean people who don't have asthma can't help. They certainly can. It just gives a different perspective and a different connection. So we're able to talk personal experiences when I was growing up, this is what I experienced, and this is how things have changed, and this is what we do now. So parents are really receptive to it. Can you tell us a little bit about your current role in asthma care? So like I said before, my current role in asthma care, I work for a pediatric asthma program, and our sole purpose is to intervene with families and children who have asthma in the community. So we meet them where they are. So within the schools and the clinics, we'll meet them anywhere that works for them. But we want to get to these families and help educate and let them know what asthma is. We want them to understand that it is a disease, and it can be ongoing, and we want them to understand what happens during a flare. We want them to understand what triggers are and what can cause an asthma attack or an exacerbation. So we really focus on community events and working with schools and working one-on-one with families so they truly understand asthma to the point where they can control it themselves. They become empowered. We make sure they have access to resources, so they have access to the right medicines. They know how to take those medicines, and they know to come to us if something's wrong, like, "I can't afford my medicine anymore," or, "I need a new spacer," or, "Can you tell me how to use this again?" We're that resource for them. So do you normally pick up on the asthma at the schools, or is it through the program? It can be both. We work a lot with the schools and the school nurses, and by us doing, we do a lot of education. We'll educate teachers, we'll educate nurses in more rural areas that maybe not have a lot of students with asthma. We educate other clinics and pediatricians and stuff like that. So once the word gets out, sometimes it's like, "Okay, we have an asthma program. I might have a patient who could be borderline asthma. We're not sure of an official diagnosis yet. Could your team help us dive deeper into that?" And so sometimes people come to us who already have asthma, they have already a diagnosis, they just need extra education or case management to help them control their asthma over time. Or it could be someone from a school or a hospital or clinic saying, "Can you work with this family more and report back to me on your findings?" So it can be both. We find asthma anywhere. But it is a lot in the schools because when school starts, especially with September coming, and we're seeing it right now, we have a lot of kids starting to cough. Colds are already starting. They're starting to get sick. And so we see it more in the schools, but it can come from anywhere. Okay, so what does a typical day look like for you? A typical day looks like for us in our program, it can vary throughout the year. Right now, we have officially entered into our busy season. So we are doing clinics. We are doing clinics for asthmatics to come in, in preparation for that September peak, and so we can prepare them for the season change, for entering into new schools, the virus season, weather change, all of that. So right now, we are doing clinics to help them become established and to really be prepared. So they're getting their asthma action plan. They're getting refills on their Albuterol rescue inhalers or their controllers, getting access to paperwork for schools. It really varies throughout the season. So right now, this is what we're going to do for a few months, continuing to prepare these students. And as the season goes on, kids will flare, and we'll intervene and educate families on why this is happening, what's a plan we can do. We're very involved in the community, and we can go to events, community events, holidays are coming up, vendor fair, stuff like that. They want people to be involved. So we go and meet with families out in the community, provide resources, and connect. We do lunch and learns. We go and meet with pediatrician offices, and we give them our resources, tell them what we do, encourage people to refer to us if needed. So it varies throughout the year. So what type of patients do you typically see in a day? We typically see patients anywhere from age zero to 18. And so as long as you're in that pediatric world, we will see you. And it doesn't necessarily mean you have to have a full-blown diagnosis of asthma. You can have reactive airway disease. You can be questionable, do we have asthma? You can have severe asthma. We're anywhere on that spectrum. We welcome them. But we do specifically work with pediatric patients. Is there a patient or family whose story really captures why this program matters so much? Yeah, absolutely. We've been extremely fortunate to have many success stories. We've worked with many families who truly understand what asthma is now. They can answer questions better than we can half the time now, and they've been empowered. They know what to do. They know when the seasons change. So that's been really cool to see. But there's one particular patient that stands out, and she's always stood out to me because her story was just-- It was one of my first stories many years ago when I first started in this program. But I'd gotten a referral from a school nurse, and the school nurse was unsure if she had a diagnosis of asthma. But she just noticed that the child was always in her office, had coughed a lot, just was very quiet, and she just thought something more was there. So we got permission from the parent to be able to meet with the child. Mom actually wanted to come in as well, which we always encourage. Sometimes parents come to the schools with us, sometimes they don't, but we encourage either one. If the parent wants to be involved, we always want them involved, because the more they know, the better they can help their child. But this student, she wouldn't talk above a whisper. She was very withdrawn. And I was able to do FeNO testing, which measures the swelling within the lungs, and she was very high with swelling. And so that was our big red flag right there that this child, her lungs were going through a lot. And so we got her back into the pediatrician's office. We worked with them to create a plan, make sure she had the appropriate medication and documentation paperwork-wise in school, and we started her on a controller. And a controller medicine is basically an inhaled steroid that a patient takes daily over time to control inflammation or swelling in the lungs. And we were able to see her almost come out of her shell and become a whole new student, a whole new kid. She wasn't going to the nurse's office frequently. She'd almost stopped going. She was being a kid again. She was able to run around and play. The key moment that I thought was the coolest thing is that our program used to do asthma camps. We've become so busy with clinic and other avenues that camps have not been as prevalent. But in the beginning, we did a lot of asthma camps, and we did one at an aqua center, so like a swimming pool, indoor swimming pool. And this particular student came. She participated in the camp. She showed up ready. She had her asthma action plan. She had her spacer. She had her rescue medicine, which is that albuterol, which you take when you have symptoms. So like coughing or wheezing, chest tightness, things that come out of the blue almost. That's what you carry around, and she brought that. And being indoors with a pool, it's enclosed, so the smell of the chlorine can't escape. It smells very high in there, that chemical smell. Also exercise, running and jumping in the pool, swimming, laughing, playing with kids, all of those are triggers for asthmatics, or they can be a trigger. And she recognized what her body was doing. She recognized that, "I don't feel so good with my lungs, and I need to take a break and go take my rescue medicine." That's exactly what she did. And I can't forget it to this day. I was able to just watch her process my body, what it's doing. She knew she was empowered. She knew what was happening. Go and take her rescue medicine, give herself a break, and then go back to being a kid. So that's the coolest thing. I carry that story with me. So with that story of the first child finding their voice, that's quite amazing, isn't it? You literally helped them find their voice, which is amazing. Yeah. It was really cool to see because that child could have gone her whole life and just had a different experience. But because one school nurse paid attention and one parent was willing to say yes and be involved, and the child was willing to be compliant and learn, and we were all able to work together, it was a really cool thing. Definitely. And it's about being prepared and being knowledgeable about what you're dealing with, isn't it? Yeah, absolutely. So asthma is one of the most common long-term conditions affecting children. How can asthma affect a child's everyday life, both at school and at home? Yeah. It can affect everyday life no matter where they are. A lot of students tend to do worse during the school season. There's a lot going on. Sometimes it's a rural county, meaning there's not a lot of access. It's an old school building. Old school buildings, say the HVAC or the heat and air was cut off over the summer, and now they're running it again. There could be mold, there could be a lot of dust, and entering into that system can be very triggering for asthmatics. You're going back to school where there's other germs, other viruses, things you haven't been around all summer long, and reminding that you've been outside most of the summer. You haven't been cooped up inside. So you've been not exposed to these certain triggers that are inside school buildings, inside homes. You've been out more where it's out and open. Virus seasons come in hot and heavy. We have what's called ragweed, which is a certain kind of pollen that blooms or starts to come out at the end of summer and runs through October. And so it's not the same kind of pollen that blooms in the spring for us. It's a different kind. So ragweed season is already here for us in North Carolina, and we are already seeing kids being affected by it. So that's another trigger that when you're going back outside, you're going into the schools, that can be very heavy. We also have a lot of things called fairs, meaning that it's like an event where there's rides and there's animals, all that combined. Kids love it. People go on field trips to it. So when you're with the school, when you're doing all of that, those are huge triggers. At home, a lot of families learn what the child's triggers are, and they kind of adapt to it. They know that I can't dust when my child is home. Or we keep our home at a certain temperature because at this temperature, they won't flare. Like it's not too hot or it's not too cold. We're able to use allergy encasements on our bed. We don't have carpet. So in the home environment, it can be controlled a little bit better. And when we have families come to us who don't know the difference in triggers, we're able to educate on the home. So we've even educated as simple as dry dusting versus wet dusting. A family didn't realize, like using a dry duster with not a spray, the dry duster stirs up air into this environment and was triggering the child constantly. And so we made a plan that they were only going to do wet dusting. They were going to spray surfaces and wipe it down so it couldn't resurface into the atmosphere. And then we talked about certain filters, stuff like that. So once they become empowered at home, they can control it. They have more options. But at school, they just don't have quite as many options for control. So environments can vary greatly. Right. It's being aware of what triggers you, isn't it? So in your experience, what are some of the biggest challenges you see children and their families face when managing asthma? The challenges can, it varies from family to family and child to child. Sometimes it's a big challenge that the family, one of the parents who was the holder of the insurance, they've switched jobs or they lost a job, and now insurance isn't covering what the child has always been on, and now we need to make changes. And it's already that prime asthma season, and that can be a challenge for families because it takes time. It takes time to get medicine to go through, to work with insurance companies to make sure that they're on the appropriate medicine. So that can take time. That can be challenging. Another challenge that we see is just compliance. A lot of families don't recognize or understand that, okay, I've done this inhaler, which is the controller inhaler, for a month, and so now my child looks great. They feel great, they sound great, they're not sick, nothing's wrong, so we're going to stop it. A lot of times they don't understand that that medicine is meant to be taken on a longer-term basis, season to season. And they're like, "Well, my child's fine." Well, they don't understand that the steroid that's in the controller inhaler is meant to protect, is meant to prevent. It doesn't act like the rescue medicine, the Albuterol, when you come in contact with triggers and you start to cough and wheeze. It's two different medicines. So that can be a challenge for families to understand. And also just having access to medication and access to resources. Sometimes there's nothing in their area that they can get ahold of, so they rely on our program to really help them with that. So all that can be challenging. So going back to the not noticing that somebody might have asthma, so it's kind of like an invisible disability sometimes, isn't it? If you don't have the obvious signs. It sure can, and we're starting to see it again. I see it every year. A lot of times, people think that a little cough here and there, "Oh, they just cough all the time." A cough can come from many different places, like a postnasal drip, like the back of your nose dripping to your throat a lot with a lot of runny noses and allergies. That can cause a cough. Acid reflux after you eat, that can cause a cough. There's many reasons for a cough. But a lot of people don't understand that one of the number one signs of uncontrolled asthma is a constant cough. And although a child may seem well, they can function just fine, but that cough is still there, and you kind of get used to it. So a lot of times they don't recognize that that is a symptom. They think it's just natural, kids always cough. Another thing is a lot of kids take breaks from their medicine over the summer, which is totally fine. We actually encountered a family the other day at our clinic, and you can tell Mom was hesitant to talk about it because she didn't want to say yes or no. And we explained, "You're not in trouble for taking a break from your medicine. It's actually a good thing to see." And what we were able to see was the child, they had gone on vacation, the child had done really well for the last month, but now that she was back preparing for school, we did the pheno testing that measures the swelling in the lungs, and we saw that her swelling in the lungs was already starting to go up. So we were almost to that borderline. We're getting kind of high in swelling. So she was still in an environment that was well controlled, meaning she was home. She's not in the school. So a child looks really good in the home environment when the family keeps it at bay, there's no triggers exposed to the child, so the swelling in the lungs isn't exacerbated. But this child's about to enter into a season where it's going to be extreme, and a lot of triggers are going to be coming her way. So we were able to educate that family. Although she looks really good right now, things are coming, and her lungs are already responding. So it's almost, it's silent right now, but it's going to get very loud if we didn't restart that controller. And we explained to that family, sometimes it's good to see, can we come off this controller? Because if her swelling hadn't reoccurred and she had been doing really, really well, well, maybe you don't need this additional medicine anymore. So we encourage families, it's okay. We'd rather you be honest with us because then we know, do we just need to restart what you were on, or do we need to be aggressive and change? And families become responsive to that because we want to build that trust. We never want to play a blame game or anything like that. So, that's how we point out where the invisibility lies. So it's cool to see the light bulbs go off in parents' brains, like, "Oh, okay, so asthma is coming back. My child still suffers from this. We're not outgrowing it yet," kind of thing. So that's been neat to see. Definitely. It's having a plan and working to that plan, isn't it? And being aware of things. So are there any misconceptions or myths about childhood asthma that you hear particularly often? Yeah, there's a couple. A lot of times people tell us, "Oh, he had it when he was five. He outgrew it. He's eight now." And a lot of times, once you're diagnosed with asthma, it's an official diagnosis. You have that diagnosis for life. But asthma can change. It's based off hormones. It's based off environment. Everyone's different, and how people are developing is different, and what they're exposed to is different. So we like to tell parents that asthma can almost go to sleep, or it can take a break, but it's never completely gone. So we like to keep them aware of the signs and symptoms like coughing, wheezing, chest tightness, shortness of breath. We want them to understand that if a child gets sick and they're sick for a couple of days and they're able to bounce back without any intervention, meaning I didn't have to go to the doctor, I didn't have to take any medicine from a prescription, I was able to take over-the-counter cold medicine, those are all normal things. But if your child is getting sick to the point where they are coughing for weeks on end, that's your sign that asthma's probably not gone away, and the lungs are still very angry from that virus. So that's been hard for everyone to understand, so I've seen that misconception or myth a lot. Another myth is that my child has asthma, they can't go outside and play, or they can't go to PE. We never want a child not to have access to exercise just because they have asthma. We just have to be strategic. We have to have the right plan in place for school. We have to educate the school, so the school nurse, the teacher, whoever the physical education teacher is, we want them to know, yes, this child has asthma, but if you allow them to take certain medicines at a certain time, they can participate. They may not be able to do the same certain level of a sport as this child, but they can still participate. We want their lungs still growing. We want their lungs active. We don't want them to decondition. So that's a big myth we see is that my child has asthma, they can't go and play. We never want a child not to be able to play. There's been actual studies that have shown children need to be active. You're actually doing them a disservice, so as they continue to grow and get older, their lungs are actually deconditioned. They have less lung capacity. It's just setting them up for failure later. Now, that's not me saying you're going to run out and do your own thing. Work with your doctor. Work with a pulmonologist. Work with whatever team you have to come up with a plan so your child can be safe while they exercise. Okay. That's good to know. Thank you. When asthma is well controlled, what difference can it make to a child's confidence and ability to enjoy everyday life, whether that's sports, school, or spending time with friends? It's a big difference. When a child can run and play without the fear, the anxiety, when they can actually feel a difference in their lungs and in their body, and they can keep up with their friends and they're not stopping to go and have a coughing spell or they're tight in their chest, they get to be a kid. They forget that they're a little different from other people. So their confidence is high. They're willing to try new stuff. That fear's not there. So when we empower children and their families that, yes, you can do these things, but let's be smart about it. Let's take the medicine at home that we need. Let's have our rescue medicine in our book bag or in our pocket just in case. So when we empower them and when they really listen and take their medicine as prescribed and their lungs are healthy, these children experience a whole different outlook. They're not as worried. And then when something does happen, they have the confidence to go and get that medicine and speak up for themselves. And there's a lot of times when we go into the schools and see children, I specifically ask them, "If these things happen, who are you going to go talk to? Who do you go report this to?" And we ask, "If you're at school, who do you go talk to?" And they say, "My teacher or the school nurse." And then we ask them, "What are you going to tell them?" So we want to give them that voice to be empowered of what do you do, who do you go talk to, and how are you going to advocate for yourself? So that makes their confidence skyrocket. So you mentioned testing and particularly pheno testing. Could you tell us a bit more about the pheno testing? Sure. FENO is F-E-N-O. It stands for fractional exhaled nitric oxide. Nitric oxide is a gas that we naturally breathe off anyway. Asthmatics tend to run higher in that gas. And we have a device, it's like a breathing machine that you can breathe through, and you take a big breath in and blow out, and this device is going to measure that gas. It's going to give us a number at the end. The test is actually very quick. Either you do six seconds or 10 seconds with a child of them breathing in and out, and then we wait about a minute or so, and we get those results. And based off those results, we're able to tell, is the child well-controlled, there's no swelling in the lungs, or do they have some mild swelling, moderate, severe? And we're able to respond with medicine and a plan based off what we find. Parents also react very positively to this device and this test. And so do kids. They love playing the game. They're like, "Miss Bailey, can I play that game again?" I was like, "Well, in one month when I come back and repeat your test, you sure can." And they almost make it a goal for themselves to make that number better or just continue on what they're doing. So it's extremely portable. We take it everywhere. We take it to schools. We take it to clinics. We just pack it up in our case and we go, and it's quick, it's easy. Parents understand it, kids understand it. So it's a really cool resource. That's great. It's very quick, isn't it? And very accessible. So that's amazing. Yes, it is. It's extremely quick and extremely accessible. It differs from other tests by this one is very quick. It's not this big, big blow, blow, blow like spirometry or pulmonary function test that you have to go somewhere for, and we can carry it wherever. September is often described as the peak month for asthma flare-ups in children, with emergency admissions rising dramatically after school return. Interestingly, this trend is seen across both the US and the UK. Why does this happen every single year? Yes. September is peak month, and the third week in September is peak asthma week. And parents actually ask us this all the time, like, "My child has done great all summer long. Why when this month comes or when we come into this season, my child struggles? What's going on?" And September is like the perfect storm of triggers. In North Carolina, where we are, and it varies by state, we have very high humidity levels, meaning it is very wet and it is very hot. And we are in hurricane season. We are going to have massive storms come our way. And after those massive storms come through, everything gets a little flooded, and flooding and wet environments leads to mold. Like I stated before, we are in ragweed season. That is the type of pollen that is blooming right now that people struggle with. And we are already in the virus season. I have come across many people who are already getting a cold. We already got the crud or the coughing, the wheezing. It's already happening. And now these students are entering into school again. And going back to school, you're in an enclosed environment and a place you haven't been in a few months with other germs you haven't been exposed to, with other viruses you haven't been exposed to. Stress, anxiety, are you getting enough sleep at night? All of these things play into this one month, and it can be very detrimental. It can land you in the emergency room. It can land you into the hospital. You can be admitted for asthma. You can be admitted on a general pediatric floor, or you can be all the way to an ICU on the maximum care. It really depends on how someone's body responds. So it's very important to learn why this month is so peculiar and what to do in preparation for it. Okay. So is it just children who are affected by this or adults as well? No, it's definitely both. Children and adults are affected by this peak. Children may be affected more quickly, and they may be that front line. They're the ones entering back in school. They're the ones interacting with other kids and all that. But then they're bringing it home. They're bringing it home to the adults, and they're bringing it home to other siblings. And you can have siblings at different schools. Different schools experience different viruses at different rates. So when you've got a combo of that coming home, adults can be affected as well. And some adults, they're just simply affected by the weather change or the pollen season that's different. I know I'm in my season right now. I've restarted my own medicine. I've got another pulmonologist appointment coming up. So me, as an adult whose asthma came back later, I'm preparing right now myself. So it definitely can affect children and adults. So this September peak, is this something parents should be worried about, or is it something they can prepare for? Both. I think worry leads to preparation. I think when you are worried about something or you know something can be harmful to a child or to yourself, you're going to prepare for it. So yes, you can prepare. You can get ready for this month in advance. We always encourage at the beginning of August, give yourself a month to get back in routine. Give yourself pediatrician offices and pulmonary and allergy, all those offices, they stay packed with appointments. It's hard to get in. So it's wise to go ahead and have your appointments in place right now, and so you have time to get access to paperwork for school. You need an asthma action plan, a med form, which is like an order for the school to be able to give the Albuterol, the rescue medicine, have refills on your inhalers, have access to spacers. And when you go to your appointments, have those discussions of, "I feel like this happens during this month with my asthma." And have them tested, have the FENO test, have spirometry testing. So there's a lot of preparation that can be done to lessen that worry. Right. And have the right inhalers. Absolutely. We have a lot of kids who, and a lot of families just assume, we've heard the joke, Albuterol is called Al-Betterol. Albuterol helps a lot, but it has a stopping point. And if Albuterol is the only medicine that you're using and you're still having a lot of breakthrough, meaning I'm still coughing, I'm still wheezing, I still get winded, short of breath, I'm still noticing I'm not where I could be. And so maybe a different inhaler needs to be involved in your plan of care. And I specifically tell families all the time, "Just because we give you this inhaler does not necessarily mean that it's going to be the best inhaler. So I want you to really use it, be compliant, meaning take it when it's prescribed. And if it's not working, let's work together to find something else." Because there are many different inhalers and allergy medicines out there now that we can tailor to fit that person. So I never want a family or child to think that, "Well, this is all they gave me." No, we're willing to work with you to figure out what works best for you. And then we also explain that sometimes you could have been on a medicine for six months and it had worked really well, or you could've been on it for a couple of years and it worked really well, but now your body's not really responding to it anymore. Let's make that change. Let's get you on the right one. So absolutely, it matters. What's the best things parents can do to prepare their children ahead of this peak? The best things are prepare, make the appointment. And I know it sounds like a broken record, I'm saying the same things, but it sounds simple, but it's so important. You're making that appointment with your pediatrician, and you're making sure when you call the pediatrician's office or the pulmonologist or the allergist, whoever does your child's plan of care going back to school for asthma, you're making sure they're aware of this is back to school, and I want to be sure we have enough time to talk. Because different appointments have different time levels. So I tell families, "When you call, tell them why you're coming. Say, 'I'm here for an asthma checkup for my child, and I want them to have time to fill out the paperwork and have time to be tested and to make sure everything looks good before we enter into school.'" So just be that advocate. Make the appointment, get the refills from the pharmacy. If you don't have the spacers and stuff that you need to take with the inhaler, find that resource. Get those things back into play so your child's prepared for the school year. So these care plans are really important, aren't they, to keep the school informed and keep everybody in the loop? Yes. The asthma action plan, care plan, it's extremely important. We create our own asthma action plan. We've modified it to fit new therapies, like smart therapy. It's a new therapy that uses different inhalers and different technique and all that. So we make sure we have an asthma plan that fits any child, and we make copies of this. So the family has one at home, it's on the fridge. If I go to grandma's house after school, grandma has a copy. If I, when I go to school, school has a copy. If I have an after-school program or I'm part of sports, they have a copy. So people know what to do when something's happening with this child. Sometimes those who go into an asthma flare or an exacerbation, they may not be able to speak in complete sentences. They may not be able to fully tell you what's really happening, and it's not up to them to necessarily explain to you, "I need all these things." So if you have a plan in place, and we give out carry bags where you can put the plan in it with the spacer and the inhaler, so it's all right there. And then we give enough copies of stuff that they can hand out. So we want the plan very clear. We want the plan readable, so people understand what zone is this and what to do in it. And we want that child to be empowered so they know what to do in it as well. So the plans are very important. And not only is the plan important, a lot of times these schools need an order from a doctor that, yes, this child has asthma, and yes, they can have albuterol or whatever is their rescue medicine at school. So then that covers that school for either the school nurse to give it, the teacher to give it, or the child to self-administer for them to take it themselves. So it's extremely important. And following on from that, how important is taking preventive medication consistently over the summer holidays? It truly depends on the child. I know I touched on it a little bit earlier. A family had gone on vacation over the summer. The child had not taken their controller. She was doing really well. And sometimes summer is not their trigger season. It's not their asthma season. They do well off of it, and that's a good thing. It's okay to take breaks. It's okay to take a break from medicine that you took for the last six months. And what we tell families, if you come off of it, just be mindful of changes. And if the child's old enough, we really empower them, too. And I'm talking, if they're one or two, you can only do so much with empowerment. But we talk to the family, too, and the child, like, "If you start to experience more coughing, you feel chest tightness, when you lay down at night or first thing in the morning, or if it's super hot that day versus the average summer day, how are your lungs doing? Are you able to function? Are you able to go outside and play? Are you able to sleep through the night? Or do you have these symptoms starting to creep back in? If you're noticing symptoms come back in, that might be a red flag sign to restart that controller." But we do have many kids who do well in the summer. I'm an adult who does well in the summer. I don't need my Symbicort, my controller. I do now going into this fall season because I can tell my triggers are here. But it just depends, and there's nothing wrong with advocating and empowering. As long as they understand what to do and when to do it and then get prepared for the next season, then they should have that freedom to do that. Are there any warning signs that parents should look out for before school starts? Yeah. Like I said before, just noticing those subtle symptoms, that constant little cough that slip back in. Is my child, are they active as they normally are? Some kids can go, go, go, and then when asthma starts to kind of flare up a little bit, maybe they're not as active. Maybe they're sleeping more. Maybe they're just more fatigued, exhausted. Asthma can really take a toll on someone's body. It's just looking for those really subtle changes, and sometimes it takes time to recognize those. It can be hard, but when you're that person, that child's parent, it's a little different because you know them. You're watching them all the time. And so you're just really looking for small, subtle signs of-- I think the family that came in who took a vacation for just a vacation and then who also took a break from their controller, she was very quiet and we did ask, "Is your child normally this quiet?" They're like, "Not really." And then we did the FeNO test, and her swelling was already starting to go back up. So stuff like that is just kind of like, okay, just those really small signs that you can look for. You've worked with many families over the years. What separates the children who stay well during September from those who tend to struggle? Those who prepare versus those who don't. Now, I'm not saying that I didn't prepare because I didn't know. Not those families because if you don't know what to do and you've never had a bad experience during September, and then all of a sudden asthma starts to kind of rear its ugly head. Sometimes kids are not outright, the first five years of life was great. Now I'm six years old, and things are changing. Things can change at any time. So those who don't know, they just don't know. But when you do know, you can prepare, and you can do better. So when you are prepared for September, your lungs have a medicine in them because you've been taking that controller medicine as you're supposed to, morning and night. And your lungs are, they have that protection in it. You have access to your rescue inhaler. So as the weather changes or you're getting sick, you have access to a medicine right then and there to go ahead and start. You're not waiting for the cold to set in three days later and then go to the doctor and then get something. So those who prepare and get access early and start things early, they fare better. You're not having the big old ED visit, the emergency room, or the hospital admission. You're still going to get sick. It's the time of year. But it should be manageable at home, or you can work with your pediatrician to get something if you were to need it and be managed at home versus the big hospital. Great. Thank you. When you're trying to understand whether a child's asthma is well controlled, what information are you looking for beyond simply asking about symptoms? Yeah. So we've covered the symptoms, cough, wheeze, chest tightness, shortness of breath. And most, when we ask the children, "Do you have those?" They're like, "No, I'm fine." And then we're like, "Okay, so symptoms are not something that's bothering you right now. Well, what is bothering you? When you go to sleep at night, are you sleeping through the night, or do you feel yourself waking up? I know we've asked you, do you have a cough?" But sometimes kids or families, they don't think about all the different times of day or night that these symptoms could arise. "So are you waking up to cough?" They're like, "Yeah, but I just need a sip of water." "Okay. Well, how often does that happen during a week, during a month? Are you coughing, waking up for a sip of water a few times a month?" They go, "Actually, yeah." That's probably your asthma in the night not doing well. And so sometimes they pair certain symptoms with different outcomes, and sometimes we have to remind them, you're an asthmatic. This is what we need to be thinking about. We ask them your activity level. Do you typically play sports? Do you typically go on walks? Are you able to keep up with your peers? Are you able to do the things that those around you are doing? When you go up a flight of stairs, can you walk up a flight of stairs and just kind of keep walking, or are you stopping when you get up there? You're kind of trying to pinpoint their day-to-day life. So sometimes it's really talking about their environment. What do you do when you get up? Because the more we learn about them and what they're doing, then we can ask, "Well, how do you feel during that scenario? How do you feel when you go to the beach? Or how do you feel when you're on the playground?" And it makes a difference in a family. And when we really get to understand what's happening, then we're looking beyond the symptoms. And then we actually recognize you're probably having symptoms. They're just so subtle that you don't put two and two together during those times. So it's all about awareness and having those conversations and keeping each other informed, isn't it? Absolutely. If a child comes to see you before the school term starts, what does that appointment typically involve? So those appointments can be pretty lengthy. And I prepare families for that because a lot of times these families are running in. They're like, "I just need this paperwork filled out." And I was like, "Well, let's make sure that we're prepared." A piece of paper is a great thing to have, but if you don't know how to read it and you don't know how to educate those other people in your family, in your school on this is what this means for my child, it's not going to do a whole lot. So sure, we can fill out paperwork pretty quick, but those appointments need to involve testing. We need to involve FeNO testing, if possible, spirometry testing. We want to listen to that child's lungs. How do your lungs sound after a whole summer? What are your vital signs? How's your heart rate? What's your oxygen saturation? How are things going? We want to really educate, again, on what medicines are you taking and why. I'm human. I forget my own controller sometimes. So if someone, me, with the knowledge I have, am still forgetful because I'm human, I know kids are, too, and their families. It's fine. But this is our time to reiterate. Now's the time to really get a routine back. It's really important to get back on those controllers if that's what that child needs. It's really important to have inhalers in place at school, at sports practice, at home. So those appointments are not going to be 15 minutes. They could be anywhere from 30 minutes to an hour, depending on what clinic you're at and what time framings they offer. So I like to prepare parents that when you come in, we're going to take time, and we're going to get it right because once we do it right in the beginning, we're setting you up for success for the whole school year. And a lot of people are very receptive to that. It's just talking. It's just being very open and honest. So schedule the appointment, make sure you're verbal and advocating, saying, "These are the things I need for my child." And also, we're encouraging the family to go to the school. We want them to know their school policies. What does your school say? Because we cover a multitude of counties, meaning we cover many different school systems, and every school system has their own set of rules. And we want that family to know, what does your school system allow? Can you have a nebulizer in that school? If not, then you need access to a nebulizer, this machine is a different way to give a rescue medicine. A lot of places don't allow those, so then we need to make sure that family knows how to take an inhaler with a spacer, and they need to know when to take it. So all those things we're going to go over in that appointment. Bring it back to your program. How has FeNO benefited your patients? FeNO has been a game changer. Well, the program I'm part of, I think they have used it for a decade or longer. I have personally used it for the last eight years with families. And when we are able to use FeNO and let the child test and then get that result, that number, and then explain what that number means to the family and the parent and the doctor, we are able to get appropriate medicines on board. And I know I've covered it or said it, that a lot of times when your child looks good, they feel good, they're not sick, families don't want to give medicine. And I can't blame them. Why would I going to give my child something that may not be indicated? So sometimes it's hard to convince people that, yes, your child has asthma, and yes, it can be silent, and yes, there's actually something going on in the lungs, although it may not be visible to the eye. So with FeNO testing, we're able to see that level of swelling, put that level of swelling in perspective to the parent, and then that compliance just goes way up. And a lot of times when maybe the child just had a really rough month, they weren't as compliant as they could be, and their FeNO it got a little better, and we're like, "How often are we really taking it?" It's like, "You're not in trouble. This is something that we are working towards together." I never want a child to feel like they're in trouble. And because when you tell them, "Why haven't you been doing this?" They automatically shut down. That's not something we ever want. We want to explain to them that they're human. They're trying to juggle school, homework, and sports, but at the same time, we have to be taking care of our lungs and our asthma. So the FeNO is a tool to be able to use to find out what's going on and open that conversation for the family. So it's an extremely important part of the process. Older children and teenagers present different challenges compared with younger children? Yeah, teenagers do. Older kids do. They're more stubborn. They can be harder to convince, and they think they know everything. They're like, "I feel fine. I don't need this. I don't care what that number says." Not all teenagers are like that. They're hit or miss, but it just takes more convincing. So I try to find something on their level. Especially my athletes, my boys, who they're like, "I'm not taking that. I'm not having that in my book bag. I'm not using a spacer with that." Some of them will take the little inhaler and discreetly try to hide it, so people can't see that they have asthma or they're using their pump, which is also the MDI, the inhaler. There's many names for it. So, a company got smart, and it has a little mini spacer. So instead of the big spacer that you use with your inhaler, they create a little mini spacer where it's clear. It's a pocket size. My older teenage boys, they'll agree. They'll be like, "Well, can you at least use this one?" And they're like, "Yes, Miss Ada, that's fine. I can try that one." And I was like, "Okay. Well, if you can do that one, can you do the big one at home when you're all by yourself?" And so, you have a bigger spacer, and you've got two options. If you get on their level and you work with them, they're more open. So if they are playing sports, I'm like, "I bet you're really good. You look really athletic. You look strong. And I can tell you love the sport." And they're like, "Yes, I do. I want to go pro," or, "I want to play in college." "That's great. That's a great goal. But I bet you you could play, you're here, you're at this level playing. I bet you could play at this level. I bet you could play even harder, stronger, longer. And then maybe you really do have that chance to go play at a college level." And then they start listening to me. And then I remind them, sometimes it takes homework on us, looking up what Olympic athlete has asthma, what someone they look up to, they can relate to, and put that in perspective like, "Well, you know this NBA basketball player or this football player, they have asthma, and they have to take this medicine for them to be eligible to play, for them to be protected." And then they start listening to you because you care about what they like, and then we're getting on the same page. Is it always that easy? No, but it's worth a shot. It's really encouraging to hear that clinicians are making those changes to accommodate teenagers, and changing the format so they don't feel so conspicuous, say, to use the inhalers. That's brilliant. How do those conversations change as children become more independent? The conversation shifts from just talking to the parent and the parent being very controlling over that conversation. So sometimes when I recognize that child is older and I look at them and they don't say anything, and I'll say, "You know I'm talking to you because we're getting a little bit older and we're getting more independent, and we have to start being that person to put it in play." Like, "Okay, I'm going to take my medicine this morning. I'm not waiting for mom to remind me," or, "I'm going to do these things." I remind them, "Yes, you're still very much a kid, and we don't expect you to do everything, but we need to start practicing that independence. We need to start practicing that responsibility." Because once practice is in play and they can understand what they're doing and why, and it becomes routine, then they're going to be empowered. They're going to be like, "I got this. I can do this." And so sometimes it just means shifting that conversation and that really respecting that child and understanding how they feel. I have point blank asked children, those who are old enough to be more independent, "How do you feel about this plan?" And normally I ask the parent that, "Is this something that you're capable of doing?" Because if a plan is not going to fit a family's lifestyle, then it's not worth giving to them. We want to make sure that this fits their lifestyle, this fits what they can do day to day, and then they're going to be able to comply with their medicines and comply with their plan. So I ask the child that. "Can you do this plan? Is this something you can do every day? Can you set an alarm on your phone, or can you put it somewhere in your room or your bathroom or your kitchen that's going to remind you?" So you're just setting up them to be more independent and empowering them on their level that they feel comfortable. Thank you for that. After everything you've seen throughout your career, what keeps you optimistic about the future of asthma care for children? What keeps me optimistic is that asthma is always going to be here. It's not going anywhere. But the advocacy and the advancement in technology has just come so far. Even as a child, and I remember even in high school, I had issues with asthma and going to the doctor and getting inhalers. It has changed so much. There's so many more resources now. There's so many more conversations being had. There's access to different medicines. There's access to different resources. And we're really tailoring these plans to each individual. And when you have that knowledge and power to say, "This is working, or this isn't working, or I read about this device." There's tons of studies happening. A lot of different agencies, they really want to understand asthma on so many different levels because asthma is not a one size fits all, and it can be paired with other things. It can be paired with allergies or GI issues. And you really want to be a part of these groups who understand your body and your lungs and your system. So it just keeps me extremely optimistic that the advocacy and the care about this population is not going away. It's only getting stronger and louder. Thank you. That's really encouraging, and it must be really comforting for asthma sufferers to hear as well. Thank you so much. That concludes our first segment. So we've had some listeners write in with their own questions about their asthma, and this is our next part, exhaling the answers to your questions. So the first question is, my child wants to take part in sports, but they have asthma. Should they still take part in the sport? Absolutely. With a caution. So a recent study had come out that big myth of children or people with asthma should not exercise. Well, that has finally come out and that's wrong. We really want these children to exercise because we're still growing. You don't want to decondition. You don't want to go backwards. You don't want to be weak. You want those lungs to be healthy. You want them at max capacity of growing, and you don't want to limit that if possible. And kids are meant to play. They have a lot of energy. They want to go do stuff. And being a part of a sports team goes beyond just health. It's that bond with friends. It's that bond with a coach. It's experiencing something different. Sports can have a very, very positive impact on families and kids. And so in preparation for that, just figure out what works. Can my child run track? Maybe not. But is there something else my child could do? There's plenty of asthmatics that can run track, that can swim, that can play football. But if you like, "I'm an asthmatic who recognizes my limits. Maybe I can't play this sport, but I can play this sport." That is okay. You can pick and choose. And don't become discouraged because one sport may not be an option. Or is that sport and that environment not an option? I recognize when I was growing up, I played basketball and tennis and I could not play, or I could play, but not without protection. There was a certain gym that was very, very old, like a basketball gym, that was full of mold. And you went to the school and people automatically knew, "Oh, we're going to be smelling like mold after." It's since been renovated and torn down. But when I was in high school, I struggled every time I went to that gym, but I prepared my lungs with my controller. I had my rescue, and then I learned that playing tennis outside during the fall season was perfect conditions for my asthma. So it just depends on what environment works best, what level of sport works best, and what plan is going to protect your child. So absolutely, please explore those options. Work with your doctor. So the basic answer is yes, but just find out what works for you. And the second question is: how do I know if my child's asthma is well controlled if they don't complain about anything? Just really getting to know your child on an observation level, it really helps. Is my child, are they sleeping in longer or because they're getting poor sleep? When they wake up in the morning, do they just feel congested? Are things just being slow to move? If they already are playing sports, are they playing at the level they were playing before? It's just really looking at their body language, their behavior. A lot of kids don't complain, or they may complain very subtly and say, "Something feels different," or, "Something feels weird," or, "Something feels off." Listen to them, because kids don't just typically complain to complain. They're not going to say something feels weird just because. Normally, they don't have the words for it, or they're unsure of what it is. So sometimes it helps to just have that conversation instead of just brushing them off saying, "Oh, you're fine." They may be fine, but sometimes if you know your child has asthma, it's worth exploring. And then maybe just make an appointment with your doctor. Bailey, thank you so much for joining us today and for sharing your experience. We've covered why the September peak happens, how families can prepare ahead of the new school year, and the importance of good asthma management through regular reviews, asthma action plans, and tools like FeNO testing. It's been really insightful hearing your perspective from working so closely with children and families. I've certainly learnt a lot today, and I hope our listeners have, too. To end the episode today, I have one final question for you. If every family listening today remembered just three things before the new school term starts with regards to asthma, what would you want those three things to be? Well, in preparation for school and the September peak, the three things that immediately come to my mind are the three things we have covered repeatedly in this conversation. You want to prepare. You want to prepare, and you want to prepare. You want to make that appointment. You want to get access to medicines and the spacers and the paperwork, and you want that plan. And you want to check that box. And then you want to educate. So yeah, me and my child went to the doctor. Well, have that conversation with your child on the way home from the doctor. When you get home and over dinner, have the conversation with the family. On the way to school, say, "Okay, if this happens today, what are you going to do? How are you going to advocate for yourself? What are you going to tell your teacher? Where do you keep your inhaler?" Have those sessions with your child. Really educate them, because then you're going to empower them. So you've prepared them, you've educated, and you've empowered them. And then you want to practice what's on that plan. So sometimes it just takes going down the plan and really saying, "If this happens, what are you going to do?" Because you don't want that child scrambling for the plan to read it in an asthma exacerbation, because that's just not the time. You want them to know what it says, and then that child can say to the teacher, "I need my pump. Go read my plan. This is what I have to do." So you want to prepare, you want to educate, and you want to practice. I love that. Thank you so much. Has this podcast interested you or made you think about your respiratory health? If it has, and you have your own questions for our experts, email us at hello@inhaleexhalepodcast.com or submit a question on our website at inhaleexhalepodcast.com. Thank you so much for listening. Bye for now.