Guide to Asthma Management in Children
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This guide is based on the Paediatric Society of New Zealand Guidelines for the Management of Asthma in Children, 2005,1 The British Guideline on the Management of Asthma, 2008,2 and the National Asthma Council of Australia, Asthma Management Handbook, 2006.3
Diagnosis of asthma in children
The initial assessment in children who are suspected of having asthma should focus on the presence of key features and clinical findings from the history or examination, and careful consideration of alternative diagnoses.
The key features of asthma are:
- Recurrent wheeze and breathlessness with or without cough
- Variation in the intensity and duration of symptoms
- Symptom free periods
In very young children be especially aware of non-asthma causes of wheeze. The diagnosis of the cause of recurrent wheezing in infants is often difficult.
For more information please refer to Pattemore P. Wheeze in infants and young children. Diagnosis and management options. New Zealand Family Physician 2008; August 35(4):264-69.
Asthma should be suspected in any child with recurrent or persistent wheeze whether audible or detected on auscultation. However, alternative causes of wheeze should be considered especially in young children (Table 1). Wheeze due to asthma is often accompanied by cough, shortness of breath or both.
Asthma can occur in infants aged less than one year, but it is more difficult to diagnose because of the number of different causes of wheeze at this age. Instigation of inhaled corticosteroid treatment in infants should only be done with caution if the likelihood for asthma is high and preferably in consultation with a paediatrician.
|Table 1. Some non-asthma causes of wheeze in young children|
|Associated Signs/Symptoms||Possible causes|
|Fever, cough||Respiratory tract infections, e.g. bronchiolitis|
|Persistent wet cough||Cystic fibrosis, recurrent aspiration, bronchiectasis|
|Excessive vomiting or spilling||Reflux (with or without aspiration)|
|Dysphagia||Swallowing problems (with or without aspiration)|
|Transient infant wheezing (onset in infancy, no associated atopy)||Maternal smoking or other irritants|
|Abnormal voice or cry||Laryngeal problems|
|Focal signs in the chest||Developmental delay, post-viral pneumonia, bronchiectasis, tuberculosis|
|Inspiratory stridor as well as wheeze||Central airway or laryngeal disorder
Inhaled foreign body
|Recurrent wheeze and failure to thrive||Cystic fibrosis, gastroesophageal reflux|
|Clubbing||Cystic fibrosis, bronchiectasis|
|(adapted from 1,3)|
Cough is a common symptom of asthma, it can be the main symptom in children but it is very rare for it to be the only symptom. Cough due to asthma is usually associated with wheeze and episodes of breathlessness. A diagnosis of asthma is unlikely if cough is present without associated clinical findings consistent with asthma, especially wheeze.
|When cough is the predominant symptom of suspected asthma, careful assessment is required to avoid making an incorrect diagnosis of asthma.3 Chronic or recurrent cough in the absence of wheeze is unlikely to be due to asthma.9|
Recurrent non-specific cough, without accompanying wheeze, is very common particularly in pre-school age children, and can lead to a misdiagnosis of asthma. It is not usually associated with atopy or a family history of asthma and often occurs after a respiratory tract infection. Recurrent non-specific cough is typically dry, worse in the early morning and during exercise, and occurs in short paroxysms sometimes followed by vomiting. In between episodes the child is well with no wheeze.
Most children with acute cough are likely to have an uncomplicated viral acute respiratory tract infection, but the possibility of a more serious problem such as foreign body aspiration, should always be considered.
Clinical Features in the diagnosis of asthma
In addition to the key features of asthma, the presence or absence of other factors and clinical findings assist in determining the probability of a diagnosis of asthma.
Factors that increase the probability of asthma
- More than one of the following symptoms – wheeze, cough, breathlessness, chest tightness – particularly if these are frequent and recurrent; are worse at night and in the early morning; occur in response to or worsen after exercise or other triggers, such as emotional upsets; or occur apart from colds
- Audible wheeze or widespread wheeze heard on auscultation
- Clinical findings; increased respiratory rate, prolonged expiratory phase, chest shape (over-inflation, Harrison’s sulcus), use of accessory muscles
- Personal history of atopic disorder
- Family history of atopy or asthma, especially maternal
- Improvement in symptoms or lung function in response to reversibility testing or adequate treatment
Factors that lower the probability of asthma
- Isolated cough in absence of wheeze or difficulty breathing
- History of moist cough
- Prominent dizziness, light-headedness, peripheral tingling
- Repeatedly normal physical examination of chest when symptomatic
- Normal peak expiratory flow (PER) or spirometry when symptomatic
- No response to a trial of asthma treatment
- Clinical features suggesting alternative diagnosis
- Asymmetrical findings on chest examination
|The diagnosis of asthma is a clinical one. It is based on recognising a characteristic pattern of episodic symptoms in the absence of an alternative explanation.2|
This can help with the diagnosis of asthma and can be viewed as a trial of treatment.
If the child presents with a history of symptoms and has clinical findings at the time of examination, one suggested method is:
- One puff of salbutamol MDI via a spacer, followed by six breaths through the spacer
- Repeat above
- Review and assess the response after 20 minutes
- Base confirmation of clinical asthma on easing of signs and symptoms following treatment
- Practices vary and some practitioners consider that up to six puffs (given separately) are required for reliable testing
If the child presents with a history of symptoms but no clinical findings consistent with asthma at the time of examination, instruct caregiver to administer salbutamol as above recording response to treatment in an asthma symptoms diary.
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