Children under the age of 5

- History
- Examination
- Tests
- Red Flags

History

There are very few asthma assessment tools available for use with children under the age of 5 years so taking a comprehensive history is fundamental to reaching a diagnosis.

Key points to consider:

Assess the pattern, nature, duration and severity of symptoms.
In early years, the absence of a personal history or strong family history of eczema or allergy substantially lessens the likelihood of asthma.
Symptom triggers (e.g. if each attack is associated with a viral infection, the most likely diagnosis is viral associated wheeze, rather than asthma).
Clarify what the parent means by wheezing and identify whether the wheezing is from the upper airways (ENT) or lower airways.

Clinical features that increase the probability of asthma
More than one of the following symptoms: wheeze, cough, difficulty breathing, chest tightness, particularly if these symptoms: Are frequent and recurrent Are worse at night and in the early morning Occur in response to, or are worse after, exercise or other triggers, such as exposure to pets, cold or damp air, or are related to strong emotion or laughter Occur apart from when the child has a cold Personal history of atopic disorder Family history of atopic disorder and/or asthma Widespread wheeze heard on auscultation History of improvement in symptoms or lung function in response to adequate therapy
Clinical features that lower the probability of asthma
Symptoms with colds only, with no interval symptoms Isolated cough in the absence of wheeze or difficulty breathing History of moist cough Repeatedly normal physical examination of chest when symptomatic No response to a trial of asthma therapy Clinical features pointing to alternative diagnosis

Adapted from British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network (SIGN) 101. British Guideline on the Management of Asthma: a national clinical guideline. 2009.

Available from http://www.sign.ac.uk/guidelines/fulltext/101/index.html

Examination

The presence of wheeze does not mean a diagnosis of asthma. Similarly, the absence of wheeze does not preclude a diagnosis. A global assessment of the child's well being is important.

Tests

Effective clinical investigation for asthma diagnosis in under 5’s is difficult in primary care. Specially designed equipment may be used for assessment in secondary care. Thorough and comprehensive history taking from the child’s carer is therefore fundamental to reaching a diagnosis for the very young child.

As the child gets older, additional diagnostic investigations (see Children: 5-12 years old) can be performed to confirm or exclude the asthma diagnosis.

Aids for making a diagnosis

Therapeutic trial

In children with a high probability of asthma, a therapeutic trial of inhaled corticosteroids (ICS) should be undertaken. The child should be reviewed regularly. It is important to cease treatment once symptoms have been eliminated; a rapid return of symptoms after treatment cessation helps confirm the diagnosis.

If the patient does NOT improve after a trial of asthma therapy, referral to a specialist for further investigation of other diagnoses is recommended.

Frequent reassessment

When managing young children with a presumptive diagnosis of asthma, healthcare professionals should always be prepared to reconsider the diagnosis if management proves ineffective or if the clinical situation changes.

Red Flags and differential diagnoses

If the patient's history and your clinical judgement support the diagnosis of asthma, proceed to AsthmaTrak Management. However, if your diagnostic investigations and clinical judgement suggest that asthma is unlikely, consider other diagnoses or specialist referral.

The diagnosis of asthma in children under age 5 is primarily one of exclusion. Asthma is not the most common cause of wheezing in young children; the younger the child, the more likely that an alternative cause is responsible for the child's wheezing. The differential diagnosis of asthma in this age group is substantially different from that in older children and is summarised in the table below.

Age	Common	Uncommon	Rare
6 months - 2 years	Bronchiolitis Gastro-esophageal reflux	Aspiration pneumonia** Bronchopulmonary dysplasia Congestive heart failure Cystic fibrosisa	Asthma Foreign body aspiration
6 months - 2 years	Bronchiolitis Foreign body aspiration	Aspiration pneumonia** Asthma Bronchopulmonary dysplasia Cystic fibrosis Gastro-esophageal reflux	Congestive heart failure
2-5 years	Asthma Foreign body aspiration	Cystic fibrosis Gastro-esophageal reflux Viral pneumonia	Aspiration pneumonia** Bronchiolitis Congestive heart failure Gastro-esophageal reflux

Adapted from Anbar RD, Iannuzzi DM. The wheezing child. SUNY Upstate Medical University, Department of Pediatrics Pulmonary Disease Manual.

*The compete procedures for diagnosis of these alternative causes of wheezing are beyond the scope of this website. Further information about the signs and symptoms characteristic of some of these conditions may be found in the British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network (SIGN) 101. British Guideline on the Management of Asthma: a national clinical guideline. 2009. Available at http://www.sign.ac.uk/guidelines/fulltext/101/index.html