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Children aged 5-12

- History
- Examination
- Tests
- Red Flags

History

Taking a thorough history is an integral part of diagnosing asthma; 90% of the diagnosis is based on the patient history.

Asthma is a syndrome with a collection of symptoms. The history should record the nature, duration, frequency and severity of symptoms. It should also seek to identify triggers (i.e. aggravating and precipitating factors), associated diseases and family history.

Assessment should ascertain whether:

  • There is a family history of atopy: eczema, hay fever or asthma
  • The child has been diagnosed with asthma previously
  • Symptom triggers
  • The child has asthma symptoms - (coughing, wheezing, chest tightness, breathlessness) and establish the severity and frequency of asthma symptoms.
Completion of the short Childhood asthma diagnosis questionnaire (approximately 1 minute completion time) will indicate the likelihood of asthma diagnosis based on a patient’s reported symptoms. Further clinical investigation is suggested for those patients whose questionnaire responses are highly suggestive of asthma. (Not all tests may be available within the scope of general practice)

Examination

A physical examination should aim to ascertain the presence or absence of:
  • Expiratory wheeze on auscultation.
  • Increased expiratory time.

Tests

Overview

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 emotions or laughter
      • Occur apart from when the child has a cold
    • Personal history of atopy
    • Family history of atopy including asthma
    • Widespread wheeze heard on auscultation
    • History of improvement in symptoms or lung function in response to appropriate 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
  • Normal peak expiratory flow (PEF) or spirometry 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

Lung function tests

Children may be able to demonstrate a degree of peak flow reversibility and co-operate with formal bronchodilator investigations from approximately 8 years old.

A less threatening method of performing these investigations is to ask the child to take approximately 2 puffs of salbutamol inhaler using a spacer device and to record peak flow immediately before and a few minutes after the inhalations.

Diagnostic tool Findings that support diagnosis
Reversibility testing with spirometry or PEFR Demonstration of reversible airflow limitation:
  • FEV1 improves at least 12% either spontaneously, after inhaled bronchodilator, or after trial of corticosteroid therapy; OR
  • PEFR improves at least 15% after inhaled bronchodilator or after trial of corticosteroid therapy.
Exercise challenge with spirometry or PEFR Demonstration of airway hyper-responsiveness:
  • FEV1 decreases at least 15% from baseline after 6 minutes of exercise; OR
  • PEFR decreases at least 20% from baseline after 6 minutes of exercise.
Home PEFR diary (if needed) Demonstration of variable airflow limitation:
  • PEFR varies more than 20% from morning measurement upon arising to measurement 12 hours later in patients taking a bronchodilator (more than 10% in patients not taking a bronchodilator).

Adapted from Global Initiative for Asthma (GINA). Pocket Guide for Asthma Management and Prevention in Children. 2004.

Available from http://www.ginasthma.org

6-minute running test

A useful diagnostic aid in children aged 5-10, is the 6-minute running test (where facilities permit). The child's peak flow should be measured and they should then be asked to run around for 6 minutes. At the end of this period of running, their peak flow should be recorded again to measure whether there has been a drop in the child's peak flow as a result of the exertion. If their peak flow has dropped, the child should be given salbutamol to assess whether this improves their flow rate.

Allergy skin testing

Skin-prick testing is used to confirm reaction to an allergen and can be used for children aged over 5 years. A drop of liquid containing the allergen is placed on the skin (usually 15-30 concurrent tests for the most common allergens), then the skin is pierced with a lancet. If the individual is hypersensitive a hive will form within 2 minutes.

IgE testing (radioallergosorbent test/IgE specific immunoassay –RAST testing)

Specific IgE testing is helpful where skin-prick testing cannot be performed, e.g. presence of eczema. The blood test measures the amount of IgE antibody in the blood for the suspected allergen(s) and is very specific.

Chest X-Ray (CXR)

Chest x-rays are not normally required in the assessment of suspected asthma in children and should only be considered if clinical signs indicate another condition eg inhaled foreign body, pneumothorax etc.

Therapeutic trial

When clinical judgement indicates a high probability of asthma, but reversibility is not demonstrated on spirometry, a therapeutic trial with inhaled corticosteroid therapy (200-400mcg beclomethasone equivalent, daily) may be useful to confirm a diagnosis. The patient's symptoms should be monitored for improvement for 6-8 weeks. If symptoms recur on stopping therapy a diagnosis of asthma can be established.

Red Flags and differential diagnoses

Acute situation

The table below details of the clinical clues (not normally features of children with asthma) to alternative diagnoses in wheezy children. The list is not exhaustive.

Clinical clues to alternative diagnoses in wheezy children
Perinatal and family history Possible diagnosis
Symptoms present from birth or perinatal lung problem Cystic fibrosis; chronic lung disease of prematurity; ciliary dyskinesia, developmental anomaly tracheo-oesophageal fistula
Family history of unusual chest disease Cystic fibrosis; neuromuscular disorder
Severe upper respiratory tract disease Defect of host defence; ciliary dyskinesia
Perinatal and family history
Persistent moist cough Cystic fibrosis; bronchiectasis; protracted bronchitis; recurrent aspiration; host defence disorder; ciliary dyskinesia
Excessive vomiting Gastro-oesophageal reflux (± aspiration)
Dysphagia Swallowing problems (± aspiration)
Breathlessness with light-headedness and peripheral tingling Hyperventilation / panic attacks (more common in patients in their teenaged years or above)
Inspiratory stridor Tracheal or laryngeal disorder
Abnormal voice or cry Laryngeal problem
Focal signs in chest Developmental anomaly; post-infective syndrome; bronchiectasis, tuberculosis
Finger Clubbing Cystic fibrosis; bronchiectasis
Failure to thrive Cystic fibrosis; host defence disorder, gastro-oesophageal reflux

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

Chronic situation

If a patient continues to have symptoms, despite a thorough history having been taken and both inhaler technique and good compliance have been confirmed, then referral to secondary care should be considered. Approximately 5-10% of asthma patients will require the assistance of secondary care facilities in their diagnosis.

Indications for specialist referral in children
Diagnosis unclear or in doubt
Symptoms present from birth or perinatal lung problem
Excessive vomiting
Severe upper respiratory tract infection
Persistent wet or productive cough
Family history of unusual chest disease
Failure to thrive
Nasal polyps
Unexpected clinical findings, e.g. focal signs, abnormal voice or cry, dysphagia, inspiratory stridor
Failure to respond to conventional treatment (particularly inhaled corticosteroids above 400 mcg/day or frequent use of steroid tablets)
Parental anxiety or need for reassurance

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