Wheezing, coughing and the struggle to catch a single breath.

Sounds like asthma, right?

But there may be another cause for respiratory distress in your child: vocal cord dysfunction.

Asthma and vocal cord dysfunction (VCD) seemingly show the same symptoms, especially in adolescents. But what’s the difference between them?

Cook Children’s Emergency Department sees an average of 13,000 children each year exhibiting wheezing and difficulty breathing. The similarity of symptoms between asthma and vocal cord dysfunction may be difficult to differentiate to the eye so it’s important to note the small distinctions.

“Asthma and VCD are quite different even though some of the symptoms can overlap,” Corwin Warmink, M.D., medical director of Emergency Services at Cook Children’s said. “VCD causes difficulty breathing in compared to asthma, which makes it more difficult to breathe out. They also sound different when using a stethoscope to examine a patient.”

Unlike vocal cord dysfunction, asthma is an immune response when the body is exposed to various “triggers,” such as air pollutants, physical activity and airborne particles like pollen and pet dander. When triggered, the bronchial muscles in the airways constrict and the sudden obstruction causes the reaction of an asthma attack.

You may be experiencing an asthma attack if your symptoms include:

• Tightness in the chest

• Difficulty breathing

• Shortness of breath

• Coughing and wheezing

• Excess mucus

Vocal cord dysfunction is the abnormal closing-together of the vocal cords, resulting in the loss of airflow. Unlike asthma, VCD does not involve an immune response or a reaction from the airways. Vocal cord dysfunction makes it more difficult to breathe in than breathe out when symptoms occur.

Children who are active, vocal and use their vocal cords more than usual may have higher tendencies to experience VCD.

“We see VCD most common in female teenage athletes although it does occur in males,” Karen Schultz, M.D., pulmonologist at Cook Children’s said. “Type “A” personalities are at higher risk.”

You may be experiencing vocal cord dysfunction if your symptoms include:

• Tightness in the throat

• Difficulty breathing

• Coughing and wheezing

• Hoarse voice

Asthma and VCD are regularly confused as the symptoms and triggers are similar. Many patients with VCD are originally treated for asthma.

“Patients are diagnosed by history, exam and lung function testing,” Dr. Schultz said. “Lung function testing can be completely normal in both conditions when no symptoms are present. Frequently history alone can differentiate the two. Occasionally lung function testing after exercise can be diagnostic or laryngoscopy after exercise”

Signs you may be experiencing VCD instead of asthma:

• It is more difficult to breathe in than it is to breathe out

• Asthma medications and inhalers do not ease symptoms

The diagnoses for VCD and asthma are different. Asthma requires pulmonary function tests, such as a peak flow and a spirometry test. While a diagnosis for vocal cord dysfunction typically entails results from other pulmonary function tests, such as a laryngoscopy or a spirometry test.

Many children who are diagnosed with vocal cord dysfunction are referred to see a speech pathologist who can assess the degree of dysfunction, and begin a plan of action with different types of breathing and stretching exercises for the vocal cords.

“There are a number of ways we treat different diagnoses, but we will usually start with breathing exercises to make sure air flow is unhindered and the vocal cords can be well supported,” Melanie Van Noy, speech pathologist at Cook Children’s said. “Then we may do simple exercises to lengthen and stretch the vocal cords or exercises to reduce pressure. It depends on the diagnosis and the dysfunction.”

While VCD does not have specific medications to ease symptoms, speech therapy is tailored to allow children and their families learn triggers and how to cope when an attack does occur.

“For kiddos, a large part of our job is helping our young patients to become more aware of their vocal habits and educating not only them but their parents and siblings on how they can help change those habits, Van Noy said. “We also have some sophisticated software programs that help give our kiddos the feedback they need so they can not only hear the difference, but see the difference and the changes they are making as well.”

Speech therapy typically teaches and treats children for three to five sessions. If the child is still showing symptoms, a team of Cook Children’s doctors will begin to assess all the different aspects to their case.

“Our ENTs and pulmonologists work closely together to ensure that if our treatment plateaus or the patient is still showing symptoms despite treatment, we can collaborate on what to do next,” Van Noy said. “That may look like a discussion with the physician regarding compliance and progress of treatment, what other medical intervention strategies are available or maybe just another episode of care, which is what we refer to as our plans of care.”

Whether it’s bottle feeding or breastfeeding, you may have some questions or concerns – things that many other parents have also questioned! If not, or maybe you’re just not sure, speak to your pediatrician about a possible feeding evaluation by a speech-language pathologist (SLP). Build or re-build that bond. There’s lots that can be done to help and it will have lasting effects! Let’s take a look at three of the most common problems moms have and suggestions on what can be done about them.

1. Problem: Baby won’t stay latched during breastfeeding or falls asleep.

The best intervention for saving breastfeeding is the earliest intervention. Getting help from a lactation counselor or consultant before you feel like throwing in the towel will help to alleviate some of the frustration you and baby may be experiencing. Don’t wait - below are some resources you can contact. The WHO’s (World Health Organization) stance is breastfeeding serves a nutritional purpose for children until they’re at least 2 years of age! So keep it up, Mama!

2. Problem: My baby coughs, chokes, and is simply a messy eater.

If a baby is coughing, choking or losing milk from around the bottle when feeding, stop what you’re doing and find a nipple that may flow a little slower. Despite their very new presence in the world, babies are usually very good communicators if we’re really “listening”! They may be telling you that the milk is coming faster than they can swallow it. This might be a really easy fix. However, make sure your feedings are not taking too long and baby is getting enough. If you’re unsure, ask for help.

3. Problem: My baby spits up more than what I feel is normal.

Dr. Smith just wrote a very informative and thorough blog about gastroesophageal reflux and how it impacts feeding. Take a look at what he has to say about it and compare it to what you are seeing in your child. While the majority of cases of reflux resolve on their own around 6 months, as SLPs, we do see infants and children whose eating habits have been severely affected by it. Make sure to make notes about your baby’s behavior and discuss them with your pediatrician!

Learn more from the Tarrant County Breastfeeding Coalition

With so many things to consider how will I know when my baby is ready? Where should my baby sit for feedings? What should I offer my baby to eat first? How do I do this anyway? Should I try the spoon or just go for the squeezy pouches?

As a feeding therapist these are questions we hear a lot. When your baby is ready for the introduction of pureed foods around 4-6 monhts, it's time for the messy fun to begin! If your baby is showing the following signs, it might be time to give it a go:

• Takes a bottle or breast feeds with ease.
• Watches with interest when caregivers eat.
• Brings objects to his mouth.
• Sits comfortably in a bouncy or infant seat.

Here are a few questions you may have when you are ready to take the plunge:

1. Where should my baby sit for the feedings?

• Stable seating is best for your baby. Babies should not be bobbing, leaning or lounging on their back. In the beginning, babies should be in a semi-upright position, like they would sit in a bouncy seat or infant feeding seat. As babies become more stable sitting up, a booster seat or highchair can be used.
• Position baby at caregiver's eye level.
• Remember, as babies grow their seating will need to be adjusted.

2. What should I offer my baby to eat first?

Start with thin baby food cereals. Rice cereal by spoon is a good choice. Gradually increase the thickness of the cereal as your baby tolerates. Alternatively, Stage 1 or homemade single ingredient purees may be offered.

3. How do I offer these foods?

• Show your baby with your expression and tone of voice that this is going to be fun and enjoyable.
• Show the baby the spoon; a small plastic toddler spoon works well.
• Dip the spoon into the puree wiht a small taste on the end of the spoon.
• Offer the spoon slowly. Place small taste on lower lip.
• Caregiver should model smacking lips.
• Continue to give small tastes of puree modeling "Aaahhh" for baby to open mouth and "Mmmm" for baby to close mouth and use lips to clear the spoon.
• Follow the cues of the baby to continue offering more bites and bigger bites. Hint: If he pushes your hand away or turns his head, he's most likely done. However, if he opens his mouth, he's letting you know he's ready for more.
• Keep mealtimes short and sweet. End feeding in a positive way.
• Let baby get messy, messy, messy! While we're at it, don't scrape food off of baby's face during the meal. Save the cleaning up for after all the bites are done and baby is out of the feeding seat. Washing off at the sink works well.

4. Why should I start with the spoon and NOT the pouch?

Here are all of the wonderful things your baby is learning when you offer pureed foods from a spoon:

• Practice getting the tongue and jaw to move in more coordinated and controlled movements getting them ready for harder solids.
• A chance to work on lips clearing the spoon rather than just sealing as they do for breast and bottle.
• A chance for baby to begin working on moving tongue from side to side and biting on a firm object.
• A chance to build a feeding routine that fosters skills and confidence.
• A chance to work on building trust and incidental feeding experiences as they see someone they love and trust offer and explore foods with them.
• A chance to begin working on the co-feeding stage, redefining the parent role and the child role in feeding as babies move toward independence with finger feeding and spoon holding and licking while still needing help from their caregiver.

5. While we are on the subject, how about pureed from pouches?

Pouches are so convenient. They offer parents an easy way to expose their little ones to a variety of flavors, they're easy to transport and easy to offer on the go. For those times when you simply can't pass on the pouch, remember these tips:

• Consider squeezing onto a spoon.
• Remember to get face to face with your baby when using a pouch.
• Offer pouch foods that are more single ingredient or just a few ingredients so that the pouch is an added food, not the whole meal. 
• Offer the pouch when seated in a stable highchair with a tray, offering some of the puree on the tray for the baby to touch and practice licking from the fingers.

About the author

Melissa Smith is a speech pathologist at Cook Children's. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury. Click here to find the closest Cook Children's Rehabilition Services near you.

That question makes me cringe. Not because of the question itself. I understand it. As parents, we all want what’s best for our children. I’m not afraid of the question or looking to evade it. It’s just who is making the choice on what’s “normal.” I use the opportunity to talk to parents. To reframe what may be thought of as normal, go over their concerns and provide perspective.

Here are some basic guidelines that I give to parents on how a child should be developmentally from 1 to 6 years old. Every child is different and this is only a starting point. If you have you concerns, please talk with your pediatrician for a referral to a speech/language pathologist.

• 12 months old - Children usually can say 1-21 words on their own, actively listen, wave bye-bye, look around when asked, "Where is __?" and use real and toy objects to act out common actions, e.g., feeding, cleaning, etc.
• 24 months old - Speak 145-150 words, combine 2-3 words, produce plural - s and - ing words, enjoy nursery rhymes, finger play and songs and put 2-3 actions in symbolic play.
• 30 months old - Say 360-600 words, speak in simple sentences, have his or her speech understood by family members, listen to real stories and start role playing in life experiences, such as going to the doctor.
• 36 months old - Say so many words you can't count them, have his or her speech understood by more than half the people your child meets, use "I, me, my and you" correctly. Answer what, where, when and who questions and retell familiar stories. At this age, children should be asking questions, not learning to read yet, but enjoying books and making friends. 
• 4 years old - Your child should start playing with words and making up stories. Most children at this age will be playing with friends and pretending to be a superhero, a cowboy, a parent or an animal. Children may begin using voices as characters and creating their own costumes and props.
• 5 years old - Most children at this age have started school. They can sit and listen for a whole story. They will start using words such as "know, understand and think." They will talk to ask questions, to explain things and to imagine.
• 6 years old - At this age, most children begin to speak more like grownups, especially at school. They can be polite when talking and know when adults don't understand what they have said. Often times, children will be able to change what they originally said to be better understood. Children at this age should be able to use all of their speech sounds and begin reading.

You know your child better than anyone and of course there will be times when your child just won't pay attention or doesn't feel like reading. But these general guidelines should be taken into account as an overall view of your child's development. I hope this helps give a better understanding of what we observe as speech patholigsts at Cook Children's.

*The vocabulary ranges used in this blog are based on MacArthur-Bates CDI.

About the author

Carol Edley, M.S., CCC-SLP, is a speech/language pathologist at Cook Children's. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury.