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Asthma is a common and undiagnosed problem in children and adults. By some estimates, about 5% of people have asthma.
While asthma is sometimes easy to diagnose when your child has classic wheezing and trouble breathing, many other children have more subtle symptoms which are harder for parents and pediatricians to recognize.
The following questions, adapted from the Global Initiative for Asthma and National Institute of Health's Global Strategy for Asthma Management and Prevention, should be considered when trying to diagnosis a child with asthma:
- Has your child had an attack or recurrent attacks of wheezing?
- Does your child have a troublesome cough at night?
- Does your child have a wheeze or cough after exercise?
- Does your child have wheeze, chest tightness, or cough after exposure to airborne allergens or pollutants?
- Do your child’s colds 'go to the chest' or take more than 10 days to clear up?
- Are symptoms improved by appropriate anti-asthma treatment?
If you answered “yes” to any of these questions, a diagnosis of asthma may be likely and you should talk to your Pediatrician. If you answered yes to any of these questions and you think your child has asthma, but your Pediatrician doesn't agree, consider getting a second opinion from a Pediatric Pulmonologist.
It can also be helpful to 'remind' your Pediatrician about your child's previous symptoms. Saying something like, 'didn't he have wheezing the last time he had a cold?' or 'could his nighttime cough be asthma?' might help get your child diagnosed correctly.
Concerning childhood asthma, the Global Strategy for Asthma Management and Prevention also states that:
Diagnosis of asthma in children can present a particularly difficult problem, largely because episodic wheezing and cough are among the most common symptoms encountered in childhood illnesses, particularly in children under 3 years old. Although health care professionals are increasingly encouraged to make a positive diagnosis of asthma whenever recurrent wheezing, breathlessness, and cough occur (particularly if these symptoms occur at night and in the early morning), the disorder’s underlying process may be different in infants than in older children and adults. The use of the label “asthma” to describe such children has important clinical consequences. It implies a syndrome in which there is airway inflammation and for which there is a specific protocol of management.
The younger the child, the greater the likelihood that an alternative diagnosis may explain recurrent wheeze. Alternative causes of recurrent wheezing in infancy include cystic fibrosis, recurrent milk inhalation, primary ciliary dyskinesia syndrome, primary immune deficiency, congenital heart disease, congenital malformation causing narrowing of the intrathoracic airways, and foreign body aspiration.
Features such as a neonatal onset of symptoms, associated failure to thrive, vomitingassociated symptoms, and focal lung or cardiovascular signs all suggest an alternative diagnosis and indicate the need for further investigations, such as a sweat test to exclude cystic fibrosis, measurements of immune function, and reflux studies. Chest radiography is an important diagnostic test to exclude such alternative causes of wheezing.
Among those children in whom an alternative diagnosis has been excluded, there is the possibility that recurrent wheezing does not have a uniform underlying pathogenesis. Nonetheless, there are two general patterns of wheezing in infancy. Some infants who have recurrent episodes of wheeze associated with acute viral respiratory infections, often with a first episode in association with respiratory syncytial virus bronchiolitis, come from nonatopic families and have no evidence of atopy themselves. These infants usually outgrow their symptoms in the preschool years and have no evidence of subsequent asthma, though they may have minor defects of lung function and airway hyperresponsiveness. This syndrome may have more to do with airway geometry than airway inflammation, and thus may differ mechanistically from the more established chronic inflammatory condition that underlies asthma in older children and adults.
Other infants with asthma have an atopic background often associated with eczema and develop symptoms later in infancy that persist through childhood and into adult life. In these children, characteristic features of airway inflammation can be found even in infancy. However, there are no practical, clinical tests that can be done to establish the presence of airway inflammation. Also, there are no clear markers to predict the prognosis for an individual child. However, in young children with frequent wheezing, a parental history of asthma along with the presence of other atopic manifestations in the child are significantly associated with the presence of asthma at age 6. The onset of wheeze at an early age (under 2 years) is a poor predictor of whether asthma will persist in later childhood.
It is likely that the relationship between wheezing associated with recurrent viral infections and the later development of persistent asthma requires further study. Not only are the etiological mechanisms of asthma in childhood unclear, but there is also considerable reluctance on the part of doctors to establish a diagnosis and, therefore, to initiate appropriate therapy. Because lower respiratory tract symptoms similar to symptoms of asthma are so common in childhood (and frequently occur in association with upper respiratory tract symptoms), often either a correct diagnosis is not made or an inappropriate diagnosis is given, thereby depriving the child of antiasthma medication. Although in these young children there is the possibility of overtreatment, the episodes of wheezing may be foreshortened and reduced in intensity by the effective use of anti-inflammatory medications and bronchodilators rather than antibiotics. It is for this reason that health care professionals are encouraged to use the word “asthma” rather than other terminology to describe recurrent viral-associated wheezing in early childhood.
Asthma in all age groups may present only as repeated coughing, especially at night, with exercise, and with viral illness, but these are particularly common patterns of presentation of the disease in childhood. The presence of recurrent nocturnal cough in an otherwise healthy child should raise asthma as a probable diagnosis.
In children under the age of 5, the diagnosis of asthma has to be based largely on clinical judgment and an assessment of symptoms and physical findings. Because the measurement of airflow limitation and airway hyperresponsiveness in infants and small children requires complex equipment and is difficult, these measurements can only be recommended as a research tool.
A trial of treatment is probably the most confident way to make a diagnosis of asthma in children (and in many adults as well). Prognostic features include a family history of asthma or eczema and the presence of eczema in a young child with respiratory symptoms. Children 4 to 5 years old can be taught to use a PEF meter and obtain reliable readings. However, unless there is careful parental supervision of when and how the measurements are made, PEF recording in childhood can be unreliable. The use of diary cards to record symptoms, PEF, and treatment has proved an invaluable part of asthma management strategies.
Some children with asthma present only with exercise-induced symptoms. In this group, or when there is doubt over the presence of mild asthma in a child, exercise testing is helpful. A 6-minute running protocol is easily performed in clinical practice. When used in conjunction with measurements of airflow limitation (FEV1 or PEF), this can be most helpful in establishing a firm diagnosis of asthma, especially if the cough produced by the exercise is similar to that occurring spontaneously at night.
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