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Editors

AnnaPelkonen
MikaMäkelä

Diagnosis and Treatment of Childhood Asthma

Essentials

  • Asthma should be detected early and correctly.
  • Good therapeutic control of asthma allows the child to lead a normal life.
  • When inhaled glucocorticoids are in use, the dose should be the lowest that still keeps the symptoms under control. Keep the safety limits in mind!
  • Asthma medication should be taken regularly and correctly.
  • In self-management of asthma exacerbations, routine increases in inhaled glucocorticoid dose are not used anymore.
  • An arrangement should be made whereby one physician is principally responsible for the care of the child's asthma.
  • The level and need of anti-asthmatic drug therapy should be periodically reviewed.

Epidemiology

  • Asthma is the most common chronic illness in children.
  • The prognosis for asthma in young children is good.
  • According to population surveys, 3-6% of children have medically treated asthma and a similar proportion have asthma-like symptoms at some time.
  • 20-30% of small children suffer from expiratory wheezing at least once in the first life years, 10% have recurrent wheezing and 2% are therefore hospitalized.

Symptoms

  • Recurrent expiratory difficulty and/or expiratory wheezing
  • Reduced exercise tolerance or avoidance of physical exertion because of cough and/or breathing difficulty
  • Patient woken up at night by cough and/or dyspnoea
  • Fatigue, reluctance or withdrawal from activity for no other reason
  • Continuous excessive production of mucus, rales
  • A prolonged cough as the sole symptom is rarely caused by asthma, but dyspnoea in association with prolonged coughing (over 8 weeks) suggests asthma.

Diagnosis

History

  • From patient, family and health/medical records
  • Current symptoms: onset, frequency, recurrence, severity, aggravating and alleviating factors, especially seasonal variations and symptoms related to certain locations.
  • Family history, especially parents and siblings with asthma
  • Environmental factors: smoking, exposure to animals, other exposures
  • Number of antimicrobial treatments (including e.g. those for bronchitis contrary to recommendations)
  • Has a bronchodilating drug been tried - effect?
  • Associated illnesses, e.g. atopic dermatitis, allergic rhinitis, food allergies

Physical examination

  • Careful inspection of the chest: posture, appearance of the thorax? How does the child's breathing look like? Does the child use accessory respiratory muscles? What is the respiratory rate?
  • Auscultation, also during forced expiration
  • Measurement of peak expiratory flow (PEF). Mastery of expiration technique is important; measurement may be attempted from 8-10 years of age.
  • Mouth, throat, nose, ears
  • Skin (presence of rash compatible with atopic dermatitis)
  • Inspection of the growth curve

Investigations

  • Allergy tests and blood eosinophil count
    • History is the most important; the tests are for the assessment of a possible sensitisation suggesting allergy, and its extent.
    • IgE mediated allergy to pollen and animal epithelia may be investigated either by skin prick tests or by measuring specific IgE antibodies in the serum.In children under 3 years of age, sensitization to food allergens is also determined.
    • Increased blood eosinophil count indicates an increased risk of asthma.
  • Efforts are made to detect bronchoconstriction that is correctable with medical treatment or increased sensitivity to bronchoconstriction triggered by different stimuli, such as exercise. The demonstration of asthma inflammation supports the diagnosis.
  • Bronchodilation test at surgery, as necessary (e.g. salbutamol 400 µg): auscultate and in older children measure PEF before and after bronchodilator administration (for calculations see Pulmonary Function Tests)
  • Therapeutic trial with a bronchodilator (teach correct inhalation technique), and assess the response
  • Spirometry and bronchodilator test are included in the initial investigations in school-age children.
  • Running-exercise test is often the most sensitive diagnostic tool.
    • Preferably outdoors, six minutes of hard running is sufficient (heart rate monitoring)
    • Auscultation of breath sounds, spirometric measurement of forced expiratory volume in 1 second (FEV1) from the age of 6 years onwards, oscillometric resistance (Rrs5) measurement from the age of 3 years onwards: before running, immediately after running and 4 and 10 (and 15) minutes after running
    • Exercise-induced asthmatic symptoms typically emerge 5-10 minutes after the end of exercise, and they subside without medication in about one hour. The response may be quicker in a child of preschool age.
    • Be prepared to administer a bronchodilator as required.
    • The test is diagnostic if the symptoms are compatible with asthma and the FEV1 values are reduced by at least 15% in spirometry or the oscillometric Rrs5 is increased by at least 40% from the baseline, and the change is restored with bronchodilatory medication.
    • Reductions of 10 to 14% in FEV1 values during spirometry are suggestive of asthma, and further investigations may be indicated.
  • PEF monitoring at home in diagnostics from the age of 12 years
    • Teach correct technique.
    • At every measurement occasion, three comparable recordings (difference no more than 20 l/min) are marked on the PEF chart to assess the reliability of the measurements.
    • PEF is measured every morning and evening during 2 weeks both before and 15 to 20 min after the administration of a bronchodilating drug (salbutamol 400 µg).
    • PEF should also be measured when there are symptoms and whenever a bronchodilator is used.
    • Repeated 20% fluctuations within 24 hours or 15% improvements with a bronchodilator are diagnostic of asthma (note: fluctuations may also be caused by a faulty expiration technique). For calculations see Pulmonary Function Tests.
    • PEF monitoring is not as reliable in children as it is in adults; therefore, the child has to reach the age of 12 years before it can be used for diagnosing asthma similarly to adults. For follow-up of treatment, PEF measurements can be used in even younger children.
  • In unclear cases, a metacholine challenge test (from the age of 12 years) and, as necessary, eucapnic voluntary hyperventilation test (from the age of 10 years) may be performed as additional investigations.
  • Additional investigations, if required, include x-ray studies (at least one normal chest x-ray should be obtained before the asthma diagnosis is confirmed; consider the possibility of chronic sinusitis and take sinus x-ray if needed; single projection sinus radiograph is of no great diagnostic value in children), blood tests and the measurement of exhaled nitric oxide concentration that reflects the degree of inflammation.

Diagnostic criteria in school-aged children

  1. Symptoms or signs compatible with asthma
    • Recurrent episodes of breathing difficulty where particularly the expiration is more difficult and which are relieved by bronchodilating drugs
  2. At least one of the following:
    • Significant improvement in FEV1 or FVC (at least 12% and 200 ml) in a bronchodilation test
    • Significant reduction in FEV1 (at least 15%) in an exercise test
    • In a child over 12 years of age: significant (at least 20% and 60 l/min and at least 3 times per 2 weeks) diurnal fluctuation in PEF values
    • In a child over 12 years of age: an increase (of at least 15% and and 60 l/min and at least 3 times per 2 weeks) in PEF values during monitoring
    • In a child over 12 years of age: in metacholine challenge test a cumulative dose of 0.6 mg or less reduces FEV1 by at least 20%
    • In a child over 12 years of age: FEV1 is increased in a glucocorticoid treatment trial by at least 15% and 200 ml, or the average PEF values are improved over a monitoring period of several days by at least 20% and 60 l/min on the average.
  • The most important diseases to be considered in differential diagnostics include infections and their sequelae (caused by e.g. RS virus, pertussis or mycoplasma), sinusitis, bronchitis and bronchiolitis. Hyperventilation and functional breathing problems as well as oesophageal reflux may in this age group cause symptoms suggesting asthma.

Diagnostic criteria in preschool-aged children

  • In preschool-aged children with symptoms of asthma, the abnormal pulmonary function may be demonstrated by impulse oscillometry.
  • If the resistance (Rrs5) measured by oscillometry decreases by at least 40% in the bronchodilation test and/or increases by at least 40% in the running-exercise test, the change is significant. A change of 35-40% in both tests is suggestive of asthma.

Drugs , , Nedocromil Sodium for Preventing Exercise-Induced Bronchoconstriction, Anticholinergic Therapy for Chronic Asthma in Children over Two Years of Age, Ketotifen for Asthma in Children, Nedocromil Sodium for Chronic Asthma in Children, Intermittent Inhaled Corticosteroid Versus Placebo for Persistent Asthma

Asthma in a child below 3 years of age

  • In small children, a therapeutic trial with antiasthmatic drugs can be started on clinical grounds.
  • The treatment is started with a bronchodilating drug taken as needed, but regular use of a bronchodilating drug alone is not recommended.
  • Chronic asthma in childhood is closely associated with genetic predisposition and atopy; therefore, a clinical risk index is used for grading of regular antiasthmatic medication in small children (table T1).

Clinical index for the assessment of asthma risk (at least one primary criterion or two secondary criteria in a child with recurrent wheezing)

Primary criteriaSecondary criteria
  • Physician-diagnosed asthma in the father or the mother
  • Physician-diagnosed atopic eczema
  • Sensitization to a respiratory allergen
  • IgE-mediated sensitization to a food allergen
  • Wheezing even at the absence of a respiratory infection
  • Eosinophilia > 4 % or > 0.4 × 109 /l

Starting a 3-month therapeutic trial with an inhaled glucocorticoid in a child below 3 years of age

  • Verified treatment response with bronchodilators in respiratory symptoms suggestive of asthma
  • Intermittent symptoms (in association with common colds)
    • 3 episodes of expiratory wheezing verified by a doctor (duration > 24 hours, symptoms present also during sleep) during the past year in a child with the risk factors of asthma presented in table T1
    • If there are no risk factors and the symptoms are mild, the situation is followed up.
  • Persistent symptoms
    • If the symptoms are frequent (at least 2 episodes within 6 weeks) or they are severe (repeated hospitalizations)
    • If the child has persistent symptoms already after the first wheezing episode and requires bronchodilating medication in more than 2 days per week for over a month
  • The diagnosis of asthma is confirmed at the latest when the need for anti-inflammatory medication has lasted for more than 6 months. The type of asthma is also then registered: either allergic, i.e. an IgE-mediated sensitization has been demonstrated, or non-allergic asthma. The risk of severe exacerbations and of becoming chronic are clearly higher in allergic asthma.

Basic principles of therapy Psychotherapeutic Interventions for Children with Asthma, Family Therapy for Chronic Asthma in Children, Commercial Versus Home-Made Spacers in Delivering Bronchodilator Therapy for Acute Therapy in Children, Allergen Reduction Interventions for Preventing Asthma in Children at High Risk., Dietary Marine Fatty Acids (Fish Oil) for Asthma in Adults and Children, Exhaled Nitric Oxide Levels to Guide Treatment for Children with Asthma

  • Drug therapy is usually implemented with inhaled drugs (bronchodilators and glucocorticoids): in children over 6 years of age with a dry powder inhaler and in younger children with a metered dose inhaler attached to a spacer. When the child has reached the age of 3 years, the mask is left out of the spacer. For children under 2 years of age, a spacer with an as small as possible dead space should be used (e.g. OptiChamber Diamond® or Aerochamber® ).
  • The goal is the minimal dosage needed to control symptoms. Make sure that physical exertion does not cause symptoms either.
  • Symptoms rare and mild: symptomatic bronchodilatory medication as needed
  • Symptoms weekly: low dose of inhaled glucocorticoid (e.g. budesonide 200-400 µg/day, fluticasone propionate 100-200 µg/day), or in mild symptoms a leukotriene antagonist may be considered
  • Symptoms frequent and severe: inhaled glucocorticoid combined, if needed, with montelukast and/or a long-acting bronchodilator drug and tiotropium bromide in children ≥ 6 years of age
  • Flexible combination therapy (budesonide-formoterol on a regular basis and additional dose(s) as necessary) is an effective treatment form in children over 12 years of age. Evidence on the efficacy of flexible combination therapy in 6-11-year-olds is currently limited.
  • If, despite the aforementioned medications, the child has at least two exacerbations or one hospitalization because of asthma, biological therapy should be considered in a specialized care unit with expertise in it.
  • The key to asthma drug therapy is to start treatment effectively and to increase and decrease treatment according to disease control. The goal is always good control of asthma. Asthma symptoms are investigated by using a structured questionnaire, such as an asthma test or similar.
  • The risk of systemic adverse effects in long-term use is low if the daily dose in a child does not exceed 400 µg of beclomethasone or of an equivalent drug.
  • Compliance is promoted by sufficient guidance at the start of therapy! Good compliance, the right drug administration technique and the most age-appropriate inhaler as well as a familiar and safe follow-up unit ensure the best disease management.
  • Written instructions on drugs, doses and the procedures to be followed when symptoms worsen. The most important thing is to take enough bronchodilator medicine 2-4(-6) times a day. The dose of a regular glucocorticoid can be increased if it is suspected that the dose is too small for permanent treatment. Routine doubling or quadrupling of the dose in association with a respiratory infection is not recommended in children with mild or moderate asthma.
  • Care must be taken so that the total dose of inhaled glucocorticoids does not become too large particularly in small children with asthma and with frequent infectious diseases. The number of days when the child takes an increased dose of the drug must be lower than the number of days on maintenance dose. The symptoms should be interpreted together with the doctor who is responsible for the treatment of the child.
  • Diagnosed irritants (e.g. animals) should be avoided individually.
  • Parents who smoke should be motivated to stop smoking.
  • Patient education Educational Interventions for Asthma in Children
    • Basics of diagnosis
    • Nature of asthma (= an inflammatory disease that is associated with bronchial hyperreactivity and often with genetic factors)
    • Basic principles of drug therapy, especially the purposes and differences of maintenance treatment and bronchodilator treatment
    • Technique of drug administration
    • Monitoring (symptoms, PEF)
    • Primary site of care, physician responsible for the care, specialised care
    • Avoidance of triggering factors: avoidance of smoking in all patients, of allergens on an individual basis
  • Once asthma medication has been started, there is rarely a reason to stop it after a shorted period than a year. After 6-12 months of asymptomatic asthma and when lung function is normal, medication can be stopped and from then on taken as necessary. Check the control of asthma and consider an outdoor running test 3-6 months after the discontinuation of medication.
  • Find out about locally relevant social benefits available for children with asthma and make appropriate medical certificates.

Referral to specialised medical care for diagnosis

  • A physician who is not familiar with the diagnosis and management of paediatric asthma should refer all paediatric patients with asthmatic symptoms.
  • Patients who are below school age
  • Patients whose symptoms are not brought under control by drug therapy
  • Patients in whom low-dose glucocorticoid treatment is insufficient or whose growth is retarded
  • Patients in whom the actual daily dose of inhaled glucocorticoid starts to exceed 400 µg of budesonide/beclomethasone or 200 µg of fluticasone
  • According to local agreements

Follow-up and shared care

  • A paediatrician should follow up all children below school age and all those in whom the need for an additional long-term drug is considered.
  • It is important to withdraw unnecessary maintenance therapy (trial after an asymptomatic period of, for example, six months; however, not at the start of the pollen season in patients with pollen allergy).
  • Patients followed up within primary health care:
    • School-aged children using normal doses of glucocorticoids in accordance with local care pathways
    • All patients whose symptoms are limited to the pollen season
    • Children in whom regular anti-asthmatic medication has been discontinued and drugs are only used periodically

Task list for follow-up visits Effect of Oral and Inhaled Corticosteroids on Growth in Children with Asthma, , Interventions for Educating Children Who are at Risk of Asthma-Related Emergency Department Attendance, Exhaled Nitric Oxide Levels to Guide Treatment for Children with Asthma

  • Detailed interview on the patient's condition: exercise tolerance, nocturnal symptoms, need for bronchodilator; preferably use a structured assessment tool
  • Symptom diary; possibly PEF monitoring at home (not necessary for children with mild asthma at every check-up)
  • Respiratory infections (awareness of the possibility to step up asthma medication)
  • Medication: name of drug, dosage, actual use (compliance)
  • Growth curve (physician's responsibility)
  • Any food allergies or special diets
  • Physical examination: skin, general status, posture, chest, examination of ears, nose and throat, PEF, auscultation
  • Future medication (written instructions = medication card): Is the drug still needed?
  • Further follow-up: where and when?
  • Need for spirometric tests
  • Always review drug administration technique; need for other guidance
  • Bringing certificates etc. up to date
  • Transfer of information to other health care professionals treating the child.

    References

    • Asthma. A Current Care Guideline. Working group appointed by Finnish Medical Society Duodecim, Finnish Respiratory Society, Finnish Paediatric Society and Finnish Society of Clinical Physiology. Helsinki: Finnish Medical Society Duodecim, 2022. Available in Finnish at: .