Diagnosing and managing asthma is particularly challenging in children, and an incorrect diagnosis can have a significant effect on quality of life and future lifestyle choices.
Although the diagnosis of asthma needs to be kept in context, it is worth remembering that asthma kills and these deaths are mainly preventable. In most cases - if the diagnosis of asthma is robust - effective treatment will improve symptoms.
The BTS/SIGN guidance recommends that if a healthcare professional suspects asthma, a structured clinical assessment should be undertaken with a combination of history, examination and tests to assess the probability of asthma.1 This should start with an assessment of the child’s symptoms.
Most children with asthma have symptoms before five years of age.2 However, remember that most children under the age of five years who have asthma symptoms do not have asthma in adolescence or adult life. In very young children, it can be difficult to determine whether presenting symptoms are caused by asthma or another condition. Infants, toddlers and preschool children have small, narrow airways. Head colds, chest colds and other illnesses can irritate and inflame the airway, causing noticeable symptoms. Infants and young children have frequent colds which can make them cough and wheeze
Symptoms of paediatric asthma range from a nagging cough that can linger for days or weeks to a sudden breathing emergency. The most sensitive symptom of asthma in young children is wheeze.1 The likelihood of asthma in a young child who is not wheezing is only 7%. See box below for common symptoms of asthma in children.
|Common symptoms of asthma in children|
Important! The most sensitive symptom of asthma in young children is wheeze.
Recurrent symptoms are a clue that a child might have asthma. Also consider whether symptoms worsen when the child is around asthma triggers, including irritants such as smoke or strong odours, perfume, scented candles, air fresheners (especially plug-ins) and household cleaning agents; or allergens such as pollen, pet dander and dust mites.
Important! Irritants include smoke or strong odours, perfume, scented candles and air fresheners.
Asthma is a variable condition for which there is no one definitive diagnostic test so diagnosis is based on probability. Guidance suggests that objective testing can be useful but that it needs to take place in the context of a structured consultation.1 A one-off consultation cannot always differentiate between asthma and, for example, viral wheeze in infants.
In all patients, bronchial hyper-responsiveness and airway inflammation are the fundamental components of asthma.3
As with adults, we are encouraged to think of children as having a high, intermediate or low probability of asthma. If asthma is suspected, it is important to explain this to parents, but recognise that most children with symptoms will not progress to asthma.
Those with a high probability of asthma will have symptoms - more than one of, wheeze, breathlessness, chest tightness, cough, and variable airflow obstruction.
It is important to document if a wheeze has been heard, although this must be distinguished from a rattly cough or stridor in children. Document the duration of inspiratory or expiratory wheeze and ideally take a peak flow meter reading. A wheeze heard on auscultation by a healthcare professional increases the possibility of asthma.1 It can be useful to ask the parent to record the wheeze on their smartphone.
If a child has a high probability of asthma they should be treated and monitored for a response. If the diagnosis is asthma and the treatment is right, symptoms usually get better. However, with children we often do a trial of treatment, in agreement with the parents, to ensure that the diagnosis is robust and that symptoms have not just resolved spontaneously.
Diagnostic tests may support a diagnosis of asthma in a child with intermediate probability. Remember that asthma varies between active and inactive disease so tests performed at a single point in time may not be reliable.
There is no diagnostic test available for children younger than five years of age, so making a diagnosis in this age group is more difficult than in older children. Healthcare professionals have to rely on the child’s medical history, signs and symptoms, and physical examination to make a diagnosis. Bear in mind that there may be no findings on physical examination.
Most paediatricians and respiratory specialists are wary of making a diagnosis of asthma in children younger than five years.4 In this case it would be appropriate to document suspected asthma until a clearer picture is available.
Over the age of five years it is possible for a child to have a spirometry test, although this can be challenging, even for adults. Results can reveal if the child's airflow could be improved with medication. Reversibility of airway obstruction is a key feature of asthma. If administration of a bronchodilator significantly reverses airway narrowing, the diagnosis is probably asthma.
If diagnostic doubt still exists and there has been a failure to respond adequately to a low-to-medium dose of inhaled corticosteroids (ICS), referral should be made to a specialist team.2
If the probability of asthma is low, consider other differential diagnoses.
ICS are the cornerstone of asthma therapy in school-aged children. The starting dose of ICS should be a low paediatric dose. All children should also have a short-acting beta2-agonist as rescue therapy prescribed on an ‘as needed’ basis.
Important! ICS are the cornerstone of asthma therapy in school-aged children.
Long-acting beta2-agonists (LABA) are not recommended in children aged five years and younger, because of an absence of trials and safety data. The Global Initiative for Asthma guideline does advocate increasing the dose of ICS or adding a LABA and/or montelukast if the asthma is not-well controlled on a low-to-moderate dose of ICS,3 although the evidence for these steps is somewhat limited. One study suggests starting with the addition of a LABA, because this appeared to be effective in most children.5 But, many children benefit from a doubling of the ICS dosage and addition of montelukast.5 This suggests that therapy should be individualised to patients.
In problematic cases of childhood asthma, try to avoid immediately escalating treatment. Instead, adopt a systematic approach, including a review of the diagnosis, adherence, and the child’s environment.2 Non-adherence to treatment, overuse of bronchodilators and underuse of ICS are common problems.2
Remember that parental ideas and concerns are important. Concerns may include side effects of treatment and long term problems. Administration or supervision of medication by parents is important for children of all ages. There is evidence that by the time children with asthma are 10 years old, fewer than 50% of parents supervise their medication.
There are many common triggers that can aggravate asthma and these may be hard to eradicate. Nonetheless, it is important to identify triggers and develop avoidance or control strategies.
Allergic triggers include pet dander, pollen and dust mites. Non-allergic triggers include exercise, viral infections, smoke or other irritants.
Perhaps the easiest trigger to identify is smoking (in the child, or parent). Ask about this in children who have an asthma diagnosis and support smoking cessation.6
Parents often ask about allergen avoidance for asthma prevention.Routine house dust mite aeroallergen avoidance is not recommended for asthma prevention.1 Furthermore, physical and chemical methods of reducing house dust mite levels (including acaricides, mattress covers, vacuum cleaning, heating, ventilation, freezing, washing, air filtration and ionisers) are ineffective.1
Obese and overweight children should be offered weight-loss programmes to reduce respiratory symptoms.1
Exercise is important for everyone and having asthma should not stop children from exercising. Remind patients that many top athletes have asthma and if treatment is taken correctly there should be no barrier to attainment.
BTS/SIGN guidance states that breathing exercise programmes (including physiotherapist-taught methods) could be offered to people with asthma as an adjuvant to pharmacological treatment to improve quality of life and reduce symptoms.1
Action plans for children with asthma should be developed with the individual child and their family in mind. For example, parental smoking should be actively discouraged, and if a child is sensitive to pet dander then it makes sense not to have a pet.
Regular reviews should be undertaken by a clinician - at three monthly intervals for children - especially if there has been an emergency contact or admission.
Important! Reviews should be undertaken at three monthly intervals.
In children with asthma, consider comorbidities such as rhinitis and bronchiectasis, as well as anxiety, deconditioning and obesity.
Asthma can become a particular burden in adolescence. Patients may have school or college absences, night-time disturbances and restricted participation in everyday activities. A delay in puberty can occur, making the adolescent smaller and less sexually mature than peers who do not have asthma.7
Negotiating the move from paediatric to adult services can be difficult for young people with long-standing asthma.8
Adherence to treatment can be especially problematic in adolescence. Patients may forget to take their medication, deny their diagnosis, have difficulty using inhalers or find them inconvenient, worry about side-effects or simply be embarrassed about having asthma.9 Indeed, adherence is better in younger children who are given medication by their parents than in adolescents who are responsible for their own medication.10 Perhaps it is not surprising that adolescents are disproportionately represented in mortality statistics.10
- Jane Scullion, Respiratory nurse consultant.
- Dr Steve Holmes, GP with an interest in respiratory care.
- British Thoracic Society / Scottish Intercollegiate Guidelines Network. 2016 British Guideline on the management of asthma. Available at: https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016/ (accessed 19 April 2017)
- Bush A. Diagnosis and management of asthma in children. BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h996
- Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org (accessed 19 April 2017)
- Brand PL, Baraldi E, Bisgaard H et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J 2008; 32: 1096-110
- Van Aalderen WM. Childhood asthma: diagnosis and treatment. Scientifica 2012; Article ID 674204. Available at: http://dx.doi.org/10.6064/2012/674204 (accessed 19 April 2017)
- Polosa R, Thomson NC. Smoking and asthma: dangerous liaisons. Eur Respir J 2013; 41(3): 716-26
- Price JF. Issues in adolescent asthma: what are the needs? Thorax 1996; 51(suppl 1):S13-S17
- MacDonald P. Managing asthma in adolescence. Nursing Times 2001; 97: 38 pp40
- Buston KM, Wood SF. Non-compliance amongst adolescents with asthma: listening to what they tell us about self-management. Fam Pract 2000; 17(2): 134-8.
- Raherison C Tunon-de-Lara JM, Vernejoux JM et al. Practical evaluation of asthma exacerbation self-management in children and adolescents. Respir Med 2000; 94(11): 1047-52