Article Figures & Data
Tables
1. A history of ≥4 wheezing episodes with ≥1 physician's diagnosis. 2. In addition, the child must meet ≥1 of the following major criteria or ≥2 of the following minor criteria: Major Criteria Modified API Original API Parental history of asthma Parental history of asthma Doctor-diagnosed atopic dermatitis Doctor-diagnosed atopic dermatitis Allergic sensitization to ≥1 aeroallergen Minor Criteria Modified API Original API Allergic sensitization to milk, egg, or peanut Doctor-diagnosed allergic rhinitis Wheezing unrelated to colds Blood eosinophils ≥4% Blood eosinophils ≥4% ↵* Differences between indices are shown in boldface.
Reprinted with permission from Bacharier and Gilbert.20
Condition Relative Frequency of Occurrence Infancy Childhood Adolescence Asthma + +++ +++ Airway malacia ++ + − Cystic fibrosis +++ + ± Foreign body ++ +++ ± Airway infection +++ ++ + Bronchopulmonary dysplasia +++ + − Primary ciliary dyskinesia + ++ + Bronchiectasis + + + Congenital anomalies (vascular ring) +++ + − Vocal cord dysfunction − ± ++ Tumors ± ± ± Aspiration syndromes (including gastroesophogeal reflux) + ± ± Pulmonary edema + + + −, Unlikely to present in this age group; +, likely to present in this age group.
Reprinted from Bacharier and Gilbert20 and Bacharier54; originally modified from Bierman and Pearlman.55
Taking a careful patient and parental history is critical in the diagnostic process. When assessing for asthma, a child's physical symptoms and history fall into one of the following categories: (1) not asthma; (2) possibly asthma; or (3) definitely asthma. You don't have to make a diagnosis in one visit. Ask about symptoms and use of preventive therapies at every visit. Relevant information can be obtained at every visit. Younger children with viral-induced asthma respond well to leukotriene receptor antagonist therapy. Follow-up and control assessment is as important as blood pressure measurement. Diagnosing the type of asthma affects management (intermittent/viral or persistent/seasonal). Of children with persistent asthma, 50% have symptoms (i.e., are uncontrolled). Of children who have respiratory syncytial virus, 50% <2 years old will develop asthma. The mainstay of prevention for children is low-dose inhaled steroids, but the vast majority of children never need a combination of inhaled glucocorticosteroids and long-acting bronchodilators. - Table 4. Situations in Which Specialist Referral Should be Considered When Asthma Diagnosis is Inconclusive
When a child <1 year old has recurrent episodes of wheezing, at which time congenital causes of wheezing, rather than asthma, are more common. When diagnosis is in doubt, especially in the early wheezer. If asthma is difficult to control, consider other diagnoses or referral. When a child with suspected asthma does not respond to inhaled corticosteroids after 8 weeks of good adherence. Refer children ≥5 years old with persistent type asthma for diagnostic spirometry at a local facility if this is not reliably available in the practice. Spirometry for younger children (>3 years old) can be modified and often is useful in aiding diagnosis. Refer to a allergy specialist for skin testing if a specific allergen is not obvious from the history and clinical allergy assessment. Refer to an asthma educator for assistance in control assessment (as well as instruction in action plans and inhaler technique). Topic Description Vitamin D supplementation Some convincing data of a possible link between maternal vitamin D intake during pregnancy and subsequent risk of wheeze have emerged.24,64,65 Vitamin D supplementation during pregnancy may therefore be a very real option for achieving a primary preventive strategy for early onset wheeze. Before this is formally undertaken, however, studies investigating the mechanism of action of vitamin D are needed, as any potential harmful effects of supplementation during pregnancy should be known.24 RCPCH care pathway Asthma and rhinitis are conditions that commonly coexist. The Royal College of Paediatrics and Child Health Science and Research Department developed a national asthma/rhinitis care pathway for children with allergies, commissioned by the Department of Health. These conditions have remarkably similar immunopathology; therefore an integrated long-term management approach has been shown to improve symptom control and quality of life.54 Link between gut microbiota, method of birth/delivery, and asthma The disruption of the gut microbiota during caesarean delivery and formula feeding has been linked to an increasing number of diseases, including asthma. These long-term health consequences may be partially attributable to the disruption of gut microbiota.66 By understanding birth history, clinicians may be better able to understand factors that contribute to asthma during childhood. - Table 6. Educational Resources for Physicians and Parents Caring for Preschool Children with Asthma
Resource Description URL Family physicians Pocket Guide for Asthma Management and Prevention in Children 5 Years and Younger: A Pocket Guide for Physicians and Nurses Global Initiative for Asthma (GINA) 2009, based on the full Global Strategy for Asthma Management and Prevention in Children 5 Years and Younger http://www.ginasthma.org The National Coalition for Health Professional Education in Genetics A summary of available family history tools and educational aids http://www.nchpeg.org/index.php?option=com_content&view=article&id=61&Itemid=74 Canadian Lung Association A comprehensive site with resources to aid in pediatric diagnosis http://www.lung.ca/home-accueil_e.php Resources for patients and caregivers Bubblioboo (GINA) An interactive asthma information resource and educational game for young children http://www.ginasthma.org/Patients iCAN Control Asthma at the University of Calgary, Canada Links to an Asthma Diagnosis Checklist that patients and their families can fill out before their next doctor's appointment http://www.ucalgary.ca/icancontrolasthma Lungtropolis provided by the American Lung Association and ORCAS A new and interactive learning site for children and the parents of children with asthma http://www.lungtropolis.com/ asthmakids.ca by the Asthma Society of Canada Provides an interactive, child-friendly site with a comprehensive compilation of education resources and games http://www.asthmakids.ca/global/aboutUs.php Asthma UK A nonprofit charitable organization that provides links to a variety of free online resources for parents with young children who have suspected asthma or have been recently diagnosed http://www.asthma.org.uk/advice-is-it-asthma
In this issue
Jump to section
Related Articles
Cited By...
- Improving the global diagnosis and management of asthma in children
- Developing core economic outcome sets for asthma studies: a protocol for a systematic review
- Comparative effectiveness of inhaled corticosteroids for paediatric asthma: protocol for a systematic review and Bayesian network meta-analysis
- Context and Trade-offs in Family Medicine