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Does my child have asthma? Problems with diagnosis of paediatric asthma


Asthma is one of the most common childhood conditions yet making the diagnosis in younger children (< 5 years) often causes great difficulty to clinicians and families. In many cases this can lead to over and under diagnosis depending on the age group¹,² . This article will focus on tackling the basics of asthma and its diagnosis especially in the younger children under 5 where the ability to perform objective testing such as exhaled nitric oxide (FeNO), peak flow (PEFR) and formal lung function can be limited. 

Asthma attacks still cause numerous deaths in the UK some of which are avoidable. The National Review of Asthma Deaths highlighted that many of these avoidable factors did not require rocket science but just tackling the basics³.

Children with chronic respiratory symptoms fall into 3 categories:

  • The well child with recurrent URTi symptoms (may be up to 10/year) – one of the hardest diagnoses in paediatrics can be the ‘normal’ child.
  • The relatively well child with a treatable underlying condition (asthma, chronic bronchitis)
  • The unwell child with a serious underlying condition (cystic fibrosis, immunodeficiency)
So why does this apparently straight forward disease cause us difficulty in diagnosing?

No one test determines that you have asthma – it requires the health care professional to look at signs and symptoms while excluding other possible diagnoses.

Observational studies suggest one third of all preschool wheezes will go on to develop school aged asthma⁴. 

Case Study


Honey, a 3 year old girl, has a history of frequent wheezy episodes from nine months of age. Following the first episode she was admitted for two days and was treated with prednisolone and an inhaled SABA. She had rhinovirus on her respiratory secretions.

Subsequently, she had wheezy episodes almost every month; the most recent hospital admission was for 10 days and included HDU.

On all these occasions Honey was given prednisolone, oxygen and nebulised bronchodilators. She remained symptom free in between episodes, but whenever she had a cold she seemed to get very severe wheezing illness.

Honey’s parents are non-smokers. Her mother suffers from asthma, but there is no other significant past medical history. Honey was born at full term with no neonatal respiratory or bowel problems.

On previous examination her weight and height were tracking the 50th and 25th centiles respectively. There was no chest deformity; the chest was completely clear and no warning features were found on systemic examination.

Does Honey have asthma?

In between infection she is reported to become easily short of breath and to have a wheeze when active – confirmed in clinic. There is also an associated dry cough, more noticeable at night time. She has frequent sneezing but no runny nose without colds and has moderate eczema. There is no food allergy and no history of discharging ear infections.

Honey is seen in clinic. Treatment is started with inhaled corticosteroid (ICS) via spacer – with good response. Her symptoms improve and dramatic decline in the need for attendance at the ED and admissions. She is given a break from treatment over the summer and is actually able to stay off ICS for the entire summer period. A diagnosis of asthma is made.

Back to basics


Before we can make a diagnosis we must first understand what the term ‘asthma’ is or means. More recently there has been a call to park this umbrella term in preference more accurate descriptions. On multiple occasions I have been requested to write a short, one-page guideline for ‘paediatric asthma’, a difficult task.

I often liken this to writing one for paediatric temperature that encompasses a large number of underlying pathologies. That is what we are faced with in this population. In the < 5 age group all that wheezes isn’t asthma hence the fear of missing an alternative diagnosis can lead to uncertainty. The figure below lists differential diagnosis although detailed assessment of these is beyond the scope of this article. We also don’t want to ‘label’ a child with a diagnosis who may only have occasional episodic wheeze. 
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Figure 1 - Differential diagnosis in the preschool child causing wheeze (author's own work)

Asthma is a chronic inflammatory disorder of the airways characterised by widespread, but variable, airflow obstruction that is often reversible either spontaneously or with treatment.

A careful history-taking of symptomatology, triggers, family history-taking and physical findings is pertinent to the evaluation of a child suspected to have asthma⁵.

Symptoms


Asthma is comprised of symptoms of:

  • Cough
  • Breathlessness
  • Wheeze
The more symptoms are present the more likely the diagnosis. A history of breathlessness is very important to the diagnosis and without any history of it I would think carefully.
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Figure 2: Author's own work

Wheeze is a very common symptom but again before we progress, we must question the history if not evident on examination. Wheeze is probably the most common misinterpreted sounds in medicine. It is caused by dynamic expiration and is a high pitched musical note. As a respiratory paediatrician I have developed a collection of respiratory noises to help clarify this in clinic.  If this is not in your armoury there are a number of online resources e.g. YouTube to help! 

Far too often palpable crackles or snuffling are the cause of the sound not genuine wheeze. We often rely on reported history to guide us so this is crucial. Parental recordings on video phone have helped in recent times.

The reported cough also needs to be analysed. The nature, timing and associated symptoms can help provide clues. A classic nocturnal ‘asthma’ cough is often dry in nature, occurs a couple of hours into sleep, is largely associated with rhinitis or has other obvious triggers. The frequency of URTI s in this age group can make this symptom difficult to interpret. Typically reports include: “he’s always got a cough and runny nose” … Cough in asthma is typically dry6.

Cough variant asthma does exist but is rare. Only 9.6% of children with cough lasting longer than eight weeks were found to have cough variant asthma when all children with chronic cough were evaluated according to the British Thoracic Society guidelines7. Undergraduate teaching often points the nocturnal cough to an asthma picture but apart from a ‘habit’ cough most chronic coughs in paediatrics are worse at night.

If the child has a chronic respiratory noise but has no shortness of breath or any impairment on their daily living there may be no diagnosis to make.

Next Step


If we are happy with the presence of our trilogy of symptoms we must then move onto the pattern. Are they present with just URTIs, the classic ‘episodic wheeze’ or are they present in between – interval symptoms. Early childhood wheezing has been phenotypically categorised as episodic wheeze or multiple-trigger wheeze8. The latter being more like a classic asthma picture.
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Figure 3 - Author's own work

Triggers:

  • Exercise
  • Emotion
  • Change in temperature
  • Certain environments – hay fever, swimming pools
  • Pets
  • Smoking
Severity

Interval symptoms may be mild and not affecting activity of daily living therefore may not warrant treatment. They may also be seasonal and only require treatment at certain times of the year. As a general rule, I tend to say to parents that their child should be:

  • running around normally (keeping up with peers) 
  • thriving
  • uninterrupted sleep
If not as a result of their asthma then we need to act. 

Other factors in the history that may point to asthma:

  • Atopic history, eczema
  • Family history
  • Food allergies
  • Other co-morbidities – upper airway pathologies - rhinitis
Central to diagnosis is the following two principles:

1. Evidence of variable airflow obstruction. In school-age children this may be done with objective testing such as peak flow or spirometry reversibility. In the younger kids reversibility with a SABA is ideally documented.
2. Focused therapeutic trials of treatment are to be performed. Treatment should not be started and left without detailed review. 

Therapeutic trial...a three stage approach


Too often ICS are started without appropriate review. Preferably combined with peak flow measurements (school aged children) at home to document improvement:

  • Initiate treatment beclomethasone equivalent 100-200 µg twice daily
  • Reassess at six weeks; if no benefit then the diagnosis is unlikely to be asthma, stop treatment and consider referral for investigations; 
  • If the symptoms have disappeared, stop treatment and reassess six weeks later
If symptoms have recurred by six weeks, restart inhaled corticosteroid in a low dose (100 µg beclomethasone equivalent twice daily). Adjust dose depending on response.

The therapeutic trial can often lead to issues itself due to the subjective nature and accuracy of reporting. This is often due to the lack of objective tests such as spirometry to rely on. At the start of the trial it is important to run through with the family what markers we are looking to gauge improvement.

For example, number of attacks, use of a SABA, number of nights disturbed sleep. 

This will be individual to the child and needs to be reviewed at the end of the trial.

A further safeguard is to consider the diagnosis of asthma as dynamic

In this age group the cornerstone of treatment has to be appropriate management of an acute attack. Whether the child has episodic wheeze or multi trigger wheeze is nearly irrelevant when the child has acute wheeze. This was emphasised by NRAD where 77% of patients did not have a wheeze plan³.

Indications for referral


  • Diagnosis in doubt
  • Treatment not working
  • GP or family not happy
Although asthma itself can sometimes seem a straight forward illness compared to other parts of medicine, getting the fundamentals right can take time and inevitably save lives. Unpicking each symptom and determining a pattern of illness can take time. Parental education is very important both in management and in symptom detection. This approach is highlighted by the effect of investing in education impacted on survival rates in countries such as Finland9.

Signs/symptoms: Suggesting an alternative diagnosis


  • Symptoms onset from birth
  • Productive cough
  • Faltering growth
  • Failed therapeutic trial
  • Significant abnormal clinical findings , clubbing, heart murmur
  • Underlying neurodevelopmental disease
  • Parental anxiety
  • Symptoms associated with feeds

Conclusion


In the child less than 5, the diagnosis of asthma can rarely be made on one consultation and only after consideration of a number of factors, pattern of illness and symptoms. Careful assessment of symptoms before and after is required when using therapeutic trials. 



References

1. Looijmans-van den Akker I. Over diagnosis of asthma of children in primary care. A retrospective analysis. Br J Gen Pract 2016;66:e52-7
2. Molis WE, Bagniewski S, Weaver AL, et al. Timeliness of diagnosis of asthma in children and its predictors. Allergy. 2008;63:1529–1535.2.
3. Royal college of Physician. National review of asthma deaths. http://www.rcplondon.ac.uk/projects/national-review-asthma-death (last accessed May 2020)
4. Belgrave DCM, Simpson A, Semic-Jusufagic A, Murray CS, Buchan I, Pickles A, et al. Joint modeling of parentally reported and physician-confirmed wheeze identifies children with persistent troublesome wheezing. J Allergy Clin Immunol. 2013;132(3):575–83 e12. Epub 2013/08/03..
5. GINAGlobal Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2018. Available from: ginasthma.org (Accessed May 2020).
6. Akio Niimi. Cough and Asthma Curr Respir Med Rev. 2011 Feb; 7(1): 47–54.
7. Usta Guc B, Asilsoy S, Durmaz C. The assessment and management of chronic cough in children according to the British Thoracic Society guidelines: descriptive, prospective, clinical trial.Clin Respir J 2014 Nov 27.
8. Mark Chung Wai Ng, MMed, FCFP1,2 and Choon How How, MMed, FCFP3. Recurrent wheeze and cough in young children: is it asthma? Singapore Med J. 2014 May; 55(5): 236–241.
9.     Haahtela T, Tuomisto LE, Pietinalho A, et al. A 10 year asthma programme in Finland: major change for the better. Thorax 2006; 61: 663-670. 

Dr Dermot Dalton has received an honorarium from GSK for developing this article/content.

PM-GB-ASU-WCNT-200008 July 2020

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