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It’s not easy for children to use inhalers, and those who don’t use them properly don’t get the full dose of asthma medication they need. That’s why products like nebulizers and spacers are so popular. Spacers are used along with an inhaler. They hold the child’s medication so that he or she can inhale it in several breathes, instead of just one. But a new study has shown that most parents don’t know how to have their kid properly use a spacer.

169 New York City families with children between 2 and 9 years old participated in the study. The parents were asked to administer asthma medication to a stuffed toy, using an inhaler and spacer. This process is supposed to require 10 steps, 5 of which the researches considered essential—

  1. Shake the inhaler
  2. Form a seal between the spacer and the child’s face
  3. Press down on the inhaler once
  4. Have the child take 6 or more slow, deep breathes
  5. Wait 30 seconds after those six breathes before doing a second actuation

Of the 169 families, only 1 demonstrated all 10 steps and only 6 demonstrated the 5 essential steps. This means most kids weren’t getting all the asthma medication they needed, and were being put at greater risk of an asthma attack. The most common mistakes were not having the child take 6 deep breathes, and not waiting 30 seconds before the second actuation.

The study highlights the need for better asthma education. "A lot of physicians will hand patients prescriptions for… asthma inhalers and not teach them how to use them,” said researcher Dr. Jennifer Appleyard. “Make sure you know how to use these devices properly. It has a huge effect.”