Roughly 8.4% of U.S. children have asthma making it the leading cause of chronic disease for this population. While asthma attacks in kids declined between 2001 and 2020, in 2021 almost 40% of kids with asthma reported having at least one asthma attack in the previous year, and up to 50% didn’t have their asthma under control. When asthma isn’t controlled, it can limit a child’s ability to participate in their normal and extracurricular activities but can also lead to serious complications like obstructive sleep apnea, pneumonia, gastroesophageal reflux, and even death.

Fortunately, there are many conventional treatments for keeping pediatric asthma under control. A functional medicine approach to pediatric asthma includes using conventional therapies but also personalizing natural options like diet and lifestyle to target the underlying causes of the disease. A root-cause approach combining the best of both modalities may be more effective, have fewer side effects, help reduce reliance on prescription medications, and lead to better long-term outcomes.

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What is Pediatric Asthma?

Asthma is a reversible chronic inflammatory airway disease that can develop at any time during the life cycle, but most commonly begins in childhood. Before puberty, asthma is more common in boys than girls but as testosterone levels rise, airway swelling may decline, so this trend begins to reverse in the teen years. African American and Hispanic kids may be disproportionately impacted by asthma and about 5–15% of kids with asthma have severe symptoms.

During an asthma attack, a trigger stimulates the immune system to flood the airway with inflammatory cells, mast cells are activated, and the cells lining the respiratory tract are damaged. This inflammation leads to swelling of the airway, increased mucus secretion, and bronchoconstriction all of which impede airflow and cause asthma symptoms. While each child will experience it differently, common asthma symptoms include:

• Coughing
• Wheezing
• Chest tightness
• Shortness of breath

During a physical exam, kids with well-controlled asthma may appear completely normal but could have increased nasal discharge, swelling of the nasal mucous membranes, nasal polyps, and atopic dermatitis (eczema).

Asthma is traditionally treated by avoiding potential triggers like second-hand tobacco smoke, ensuring an adequate vitamin D level, and STEP therapy. STEP therapy involves using various pharmaceuticals (like bronchodilators and inhaled corticosteroids) designed to manage intermittent and persistent asthma. Additionally, personalized action plans are created for each patient that addresses treatment for periods when the child is well, when symptoms are getting worse, and for acute exacerbations. While conventional treatment can be very effective, it may come with undesirable side effects like weight gain and metabolic dysfunction, and may not always target the root causes of asthma. By identifying asthma triggers and underlying causes, a functional medicine approach takes asthma treatment to the next level.

Identifying Triggers and Underlying Root Causes of Asthma

The above overview of pediatric asthma highlighted the need for identifying potential asthma triggers and underlying causes for each child. When triggers and causes are known, providers can develop a more comprehensive treatment plan.

The Root Causes of Asthma

While the exact cause of asthma isn’t well understood, like other chronic inflammatory diseases, both genetics and environmental exposures seem to combine to increase risk. Prenatal exposures may be a significant contributor to childhood asthma. Mothers who smoke during pregnancy may greatly increase the likelihood that their child will develop asthma. Additional prenatal factors that may increase childhood asthma risk include mom’s diet (high sugar diets during pregnancy specifically), overall nutritional status, stress level, and antibiotic use.

Outside of prenatal influences, there are a wide variety of potential underlying causes including:

• Exposure to tobacco smoke, dust mites, mold, and cockroaches
• Preterm birth
• Low birth weight
• Birth by cesarean section
• Exposure to medications like antibiotics or fever-reducers
• Exposure to a chronically stressful environment

Additionally, having IgE antibodies to specific allergens is also highly predictive of asthma development. Examples include the "atopic march", which describes the progression from infant eczema to allergic rhinitis and eventually asthma, and food allergy. Food allergies impact 2–3% of healthy kids across the globe but approximately 25% of all kids with asthma have food allergies. IgE food allergy testing or an elimination diet can help providers identify specific foods that could be triggering asthma symptoms.

Asthma Triggers

Each child will have their triggers for an acute asthma exacerbation, but allergic and non-allergic asthma triggers include:

• Environmental allergens like tobacco smoke, animal dander, pollen, mold, dust, and cockroaches
• Food-related allergies like peanuts, soy, egg, dairy, wheat, and food dyes
• Air pollution
• Upper respiratory tract infections
• Weather
• Cleaning solutions
• Exercise
• Stress
• Acid reflux
• Medications like non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin

The Role of Gut Health in Asthma 

Over the past several decades, research has solidified the connection between the gut and the rest of the body, so it’s probably no surprise that this holds for the lungs too. The so-called “gut-lung axis” refers to the bidirectional relationship between the gastrointestinal tract and the lungs. While it would seem that these two distinct organ systems operate independently, they communicate with each other. When gut health is in balance, lung health is positively influenced, but trouble in the gut can spell trouble for the lungs. For example, lower gut microbiome diversity in infancy and gut microbiome alterations from childhood antibiotic use both increase the risk of asthma development.

The majority of the body’s immune cells reside in the GI tract (mainly the small intestine). When there’s an imbalance of bacteria in the gut (dysbiosis), patients can experience increased intestinal permeability, triggering an exaggerated immune system response and chronic inflammation.

Functional medicine providers place priority on restoring gut health in asthma treatment as a way to target root causes. The 5R protocol for gut restoration is one option for addressing the gut-lung axis in pediatric asthma:

• Remove what’s damaging the intestinal barrier: food allergens, ultra-processed foods, food additives and dyes, unmanaged stress, environmental toxins, and pathogens
• Replace what’s missing: digestive secretions (hydrochloric acid, pancreatic enzymes, and bile) and nutrients
• Reinoculate the gut: pre- and probiotic-rich foods or supplements
• Repair the gut lining: L-glutamine, omega-3 fatty acids, and vitamin D
• Rebalance the lifestyle to maintain gut barrier integrity: Anti-inflammatory meal plan, stress management techniques, movement, time in nature, and restorative sleep

Principles of Functional Medicine in Asthma Management 

While a conventional approach to pediatric asthma can be very effective, kids may still be faced with multiple asthma attacks, continuous medication use, and the development of other chronic conditions as they age. The holistic management of pediatric asthma involves identifying all the factors that could be underlying or triggering asthma in a specific child and then developing a personalized plan to target those factors with nutrition, lifestyle, and environmental strategies, as well as complementary and alternative options.

Functional medicine principles in asthma include the assessment of six core physiological processes in the body:

• Assimilation (digestion, absorption, microbiota)
• Defense and repair (immune, inflammation, cellular renewal)
• Bioenergetics (mitochondrial function, cellular energy transport, tissue-specific energetics)
• Transport (cardiovascular, hematological, respiratory, and lymphatic functions)
• Communications (endocrine, neurotransmitters, signal transduction processes)
• Structural integrity (subcellular membrane barriers to musculoskeletal function)

Kids with asthma may have significant dysfunction in both the assimilation and defense and repair processes. By using all the tools in the toolbox to target and correct imbalances in these areas, functional medicine providers may help patients achieve greater success in asthma control, improve quality of life, and reduce medication burden. In other words, functional medicine providers don’t just help patients manage symptoms, they personalize treatments to reverse the underlying dysfunction contributing to asthma development and asthma symptoms to optimize the outcome.

Nutritional Interventions in Asthma Management

Nutrition for pediatric asthma is often not straightforward. There’s no one perfect nutrition plan, rather dietary interventions in asthma management should be personalized based on the needs of the patient. Since food allergies and sensitivities may contribute to pediatric asthma, it’s important to identify specific foods your child may need to avoid. IgE food allergy testing, such as the IgE Food Allergy Advanced Test by Mosaic Diagnostics, is considered the gold standard for identifying type 1 adverse food reactions, but children can also have reactions to foods that won’t show up with IgE testing. An elimination diet with food reintroduction can help identify other types of adverse food reactions.

Elimination Diet

An elimination diet may restrict the top nine food allergens including wheat, eggs, soy, milk, fish, shellfish, sesame, tree nuts, and peanuts. Additional items that may be removed include citrus fruits, corn, nightshades (white potatoes, bell peppers, eggplant, and tomato), ultra-processed foods, and food additives like dyes, non-nutritive sweeteners, thickeners, and preservatives. These foods and additives are typically removed for 4–8 weeks and then reintroduced one at a time while symptoms are observed. If no symptoms occur when a food is added back, then it can be kept in the maintenance meal plan and the next food can be reintroduced. Foods that increase asthma symptoms would again be removed and tried at a later time. An elimination diet is ideally directed by a professional and it’s important to remember that this type of diet is temporary and not meant to be followed long-term. While kids with asthma need to avoid IgE food allergies indefinitely, they will likely be able to reintroduce many of the eliminated foods. Once IgE food allergy testing and the elimination process have been completed, the provider can tailor a maintenance anti-inflammatory meal plan.

Anti-Inflammatory Meal Plan

Food can significantly impact the levels of inflammation in the body as well as gut bacteria balance. A Western-type diet that’s high in ultra-processed foods, sugar, and inflammatory oils, and low in nutrient-dense foods is known to increase the levels of inflammatory markers and contribute to gut dysbiosis. However, an anti-inflammatory diet may impart protection against inflammation and support gut microbiome diversity and balance. A Mediterranean diet may help to prevent asthma development but has also been found to improve outcomes in children with asthma. Providers should tailor the maintenance anti-inflammatory meal plan based on individual food allergies and sensitivities.

Lifestyle Modifications and Environmental Controls

In addition to a personalized anti-inflammatory diet, patients with asthma will benefit from lifestyle and environmental strategies.

Environmental control in asthma management involves avoiding or removing known asthma triggers like tobacco smoke, pet dander, dust mites, pollutants, and medications. However, as root causes (like poor gut health) are addressed and immune system function is optimized, asthma sufferers may be less impacted by environmental triggers.

In addition to avoiding known triggers, lifestyle changes for asthma may also improve asthma control and symptoms:

• Stress management. Kids who are exposed to stressful environments are at increased risk of asthma and may have worse asthma control. Likewise, kids with poor asthma control may be at greater risk of anxiety and depression. Of course, removing unnecessary stressors is extremely important but a daily stress management technique like yoga may help improve mental health symptoms as well as lung function in children with asthma. 
• Restful sleep. Kids with uncontrolled asthma tend to have more sleep-related disturbances when compared to healthy kids, and there’s an association between sleep apnea and asthma in older kids and teenagers. Helping kids create a consistent bedtime routine that allows for an adequate amount of sleep for their age group, limiting screen time before bed, ensuring wholesome nutrition, and early morning natural light exposure can all help to optimize sleep.
• Physical activity. While exercise may be a trigger for some kids with asthma, physical activity is important for combating mental health symptoms and improving quality of life, sleep, gut health, obesity, and inflammation. In one study, ten weeks of aerobic exercise in kids with asthma improved quality of life, as well as lung function and VO2 max. In general, physical activity is safe for kids who have their asthma under control. Kids ages 3–5 need to participate in active play throughout the day and those 6 and up should aim for 60 minutes of activity every day.

Integrative Therapies and Complementary Treatments

Overall, integrative and complementary treatments in pediatric asthma haven’t been well-studied, so it’s difficult to draw firm conclusions. Acupuncture does have some limited data to support its use in the pediatric population though. In one randomized controlled trial, kids with asthma received 10 acupuncture treatments over three months while a control group did not. After three months, the kids receiving acupuncture relied less on inhaled steroids and had greater improvement in asthma symptoms. A 2019 review looking at conventional asthma treatment plus acupuncture found adolescents receiving acupuncture experienced greater symptom improvement but no change in lung function compared to controls. Acupuncture by a qualified practitioner is considered to be safe for children.

Other integrative therapies for asthma such as breathing exercises and herbal remedies don’t have enough quality research to support their use yet. Various breathing techniques did improve quality of life and hyperventilation symptoms in adults but studies looking at the impact of breathing exercises in children have been inconclusive. Likewise, there’s just not enough evidence to recommend the use of herbal remedies for children with asthma. It’s important to remember that integrative and complementary therapies on their own will likely not lead to significant asthma improvement and over-the-counter herbal products marketed for asthma may pose risks for kids.

Patient and Family Education in Asthma Management

Asthma is a chronic disease that can have life-threatening consequences if not well-controlled. Empowering families in asthma care can significantly improve the quality of life and disease course for kids. Patients and families need to know that lung function can be improved and asthma exacerbations can be prevented with a comprehensive treatment plan. Education in asthma management may incorporate four important messages.

Take Control

Patients and families should understand the process of inflammation and that it’s not just limited to lung function. Provide information on how lifestyle factors like diet, sleep, stress, and environmental exposures may contribute to inflammation and poor asthma control. Give patients practical tips about how they can assess whether inflammation is getting out of control. For example, have patients keep track of how many times they experience symptoms during the day, how often they wake up coughing at night, and how many times they have to replace their rescue inhaler. Patients can also use a peak flow meter; a reduction of 20–30% or more from their best reading may indicate an impending exacerbation.

Develop an Action Plan

When patients and families notice an uptick in symptoms, they need to have a plan in place for managing the exacerbation. Here’s a sample action plan from the CDC:

• Doing well: If you don’t have a cough, wheezing, chest tightness, or trouble breathing at any time; if you can do all the things you usually do; when you use a peak flow meter and your peak flow is more than 80 percent of your best peak flow, then continue taking your long-term control medicine.
• Asthma is getting worse: If you have some cough, wheezing, chest tightness, or trouble breathing; or wake up at night because of your asthma; or you can’t do some of the things you usually do; or when you use a peak flow meter and your peak flow is half to three-quarters of your best peak flow; add your quick-relief medicine and continue your long-term control medicine. If your symptoms get better after an hour, keep checking them and continue your long-term control medicine.
• Medical alert: You have a lot of trouble breathing, or your quick-relief medicines don’t help, or you can’t do any of the things you usually do, or you were in the “asthma is getting worse” zone for 24 hours and you’re not getting better; or when you use a peak flow meter and your peak flow is less than half of your best peak flow, then add the other medicines your doctor has prescribed and call your doctor. If your symptoms don’t get better and you can’t reach your doctor, go to the hospital.

Address Triggers

Patients and families should be educated about potential triggers like tobacco smoke, dust mites, and mold and a plan to eliminate or reduce the child’s exposure at home and school should be put in place.

Be Informed About Medications

Asthma medications generally either bring fast relief from airway tightening or are used long-term to control inflammation. Patients and families should be educated on the purpose and specific use of each medication, as well as drug interactions. For example, beta-blockers may decrease the effectiveness of inhalers. Patients need to be able to demonstrate or verbally confirm their understanding of proper medication management.

Challenges and Considerations in Functional Medicine for Asthma 

A comprehensive approach can lead to significant improvement, nevertheless, there are challenges in functional asthma treatment. Changing eating habits and focusing on lifestyle interventions may be difficult, especially for younger children. It’s important to get kids involved in the treatment planning process to empower them to take control of their health as they grow. 

Nutrition-Related Considerations

Implementing an elimination diet and maintaining an anti-inflammatory meal plan for kids and teens can be tricky. An elimination diet should be directed by a qualified professional who will educate the child and family on the process, explaining why certain foods need to be avoided and how long the process will last. A wall calendar for marking off the days during an elimination diet can be a helpful tool.

Once it’s time to move on to the anti-inflammatory meal plan, it’s important to get kids involved in the meal planning and cooking process. Help kids find anti-inflammatory recipes online or in kid or teen-friendly cookbooks. Additional tips for helping kids with asthma follow an anti-inflammatory meal plan include:

• Encourage the whole family to follow an anti-inflammatory meal plan
• Take a cooking class as a family, either virtually or in person
• Introduce new anti-inflammatory foods one at a time
• Provide options when asking children to try new foods
• Learn how to make anti-inflammatory versions of favorite foods
• Avoid eating out
• Avoid all-or-nothing thinking when it comes to food

Lifestyle-Related Considerations

Lifestyle considerations in pediatric asthma care have the potential to significantly improve asthma outcomes. However kids may struggle with poor sleep, stress related to their illness, and have a hard time staying active if asthma isn’t well-controlled. It’s important to educate children on how optimizing lifestyle factors can help them have fewer asthma attacks and possibly reduce their need for medication. Additional tips for helping kids follow lifestyle strategies for asthma include:

• Practicing kid-friendly yoga sessions as a family
• Educating kids on the amount of sleep they need for their age and picking an appropriate bedtime together
• Creating a relaxing sleep routine by encouraging reading or listening to music before bed
• Planning active play for younger children and encouraging older kids to get involved in organized sports
• Avoiding rigid or perfectionistic thinking

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Functional Medicine for Pediatric Asthma: Key Takeaways

Asthma is a chronic inflammatory disease that can significantly decrease a child’s quality of life and limit their ability to participate in their favorite activities. Conventional asthma treatment including trigger avoidance, medication management, and implementing a personalized action plan can be very effective but may not address the root causes of asthma. Tailoring integrative therapies like nutrition, lifestyle, and acupuncture for kids with asthma may help to target the underlying causes of inflammation to improve outcomes and offer a better quality of life.