05-10-2020

DIAGNOSIS OF ASTHMA IN CHILDREN

Dr. Sushant Mane
MD (Ped) Associate Professor in Paediatrics
In-charge – Pediatric Asthma & Pediatric Tuberculosis Clinics
Grant Govt. Medical College, Sir J. J. Group of Hospitals,
Mumbai

DIAGNOSIS OF ASTHMA IN CHILDREN

In Children Under 5 years In older children

• Challenging • Less challenging

• Diagnosis is mainly clinical • Objective diagnostic tools
like Spirometry and PEFR
can be used

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Asthma diagnosis in children 5 years and

younger can often be based on 3 factors:
Recurrent, Persistent, Non productive, Worse at night, Accompanied by some wheezing,
Accompanied by breathing difficulties, Occurs during exercise/crying/exposure to
COUGH
tobacco smoke, In absence of an apparent respiratory infection
Symptom patterns

Recurrent, Including during sleep, Or with triggers such as activity, laughing, crying or
WHEEZING exposure to tobacco smoke or air pollution

Difficult
/heavy/ Occurring with exercise, laughing or crying , Recurrent
short breath
Not running, playing or laughing at the same intensity as other children; tires early
Reduced
during walks (wants to be carried)
activity

Past/Family
factors

History/ Other allergic disease (atopic dermatitis or allergic rhinitis)

Risk

non-genetic Asthma in I° relatives/ Intrauterine & early life exposures to risk factors
factors
Clinical improvement during 2-3 months of controller treatment and worsening when
Therapeutic trial treatment is stopped

When should we suspect a child to

have asthma?
When a child comes to our clinic with recurrent (>3 times a
year) symptoms of:-
• Cough
• Breathlessness
• Wheeze

However, there are certain typical characteristics of these symptoms

in a child with Asthma which should lead us to have a high suspicion
of Asthma

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Cough in Asthma
Breathlessness
• Remember, Cough is and Wheeze
the most common
presenting feature of
Asthma in children Cough
• Cough is the most
predominant presenting
feature of Asthma in
children along with
breathlessness and
wheeze

Not
Asthma
Asthma
Recurrent, Persistent, Dry Productive

If always
COUGH Worse at night/ early mornings
associated
with
infection/
fever
Occurs during exercise/ crying/
laughing/exposure to environmental triggers No diurnal
like tobacco, moulds, smoke etc. variation

May or may not be accompanied by some Not

worsened
wheezing or breathing difficulty
by exercise
or exposure
to triggers
Present even in the absence of a respiratory
infection No response to
bronchodilator

Responds to bronchodilators, no cough syrup

helps

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Asthma
Present even in the absence of a
WHEEZE respiratory infection
Recurrent (More than 03 episodes in
• Remember, all asthmatics do a year)
not wheeze!
Including during sleep
• All that wheezes is not Asthma.
Triggered by activity, laughing,
• Wheeze needs to be crying, exposure to tobacco smoke,
confirmed by you either by exposure to air pollution
inspection or by means of an
audio/video recording from Associated with breathlessness
parents.
No cough syrup helps, Responds to
bronchodilators

Asthma

Occurring with exercise,

Shortness laughing or crying
of breath Recurrent (More than 03
episodes in a year)

No cyanosis if not very

severe

Accompanied by
wheeze/ rhonchi

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Additionally: Reduced activity

Not running, playing or laughing at the same intensity as
other children

Gets tired early during walks/ climbing stairs/ running as

compared to other children

Additional questions which will favor the diagnosis

of Asthma:-
Child’s History:-
• History of eczema/ skin atopy in early childhood. H/O use of
emollients in early childhood
• History of Allergic Rhinitis in the child
• Antenatal exposure to tobacco smoke (maternal smoking, smoker
at home) Paracetamol, antibiotics
• Birth by caesarean delivery, low birth weight, small for age baby,
top feeds before six months of age.
• Early life exposure to tobacco smoke, aeroallergens, air pollution,
molds, dust.

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Additional questions which will favor the diagnosis of Asthma:-

Grandfather Grandmother Grandfather Grandmother

Father’s Fathers Mother’s Mothers

Father Mother
brothers Sisters Brothers sisters
PRESENCE OF ANY OF THE ATOPIC DISORDERS IN
GENETICALLY
Patient’s
Brothers
RELATED
Patient RELATIVES
Patient’s
Sisters

Patient’s Patient’s Patient’s Patient’s

cousins cousins cousins cousins

Asthma Allergic Rhinitis Eczema Migraine

Additional questions which will favor the diagnosis of Asthma:-

Grandfather Grandmother Grandfather Grandmother

Father’s Fathers Mother’s Mothers

Father Mother
brothers Sisters Brothers sisters

Patient’s Patient’s
Patient
Brothers Sisters

Patient’s Patient’s Patient’s Patient’s

cousins cousins cousins cousins

Asthma Allergic Rhinitis Eczema Migraine

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The GINA 2020 guides us to make a probability

based diagnosis for under fives:
• Explain your reasons for labelling the child as Asthma.

• At the first instance, a probability of Asthma is much more

acceptable than a confirmed diagnosis of Asthma for the
parents

• Particularly helpful in counselling parents of a small baby

• It also gives us the scope of revising our diagnosis without

causing any harm to the child, provided we have ruled out
all other possibilities for the recurrent respiratory symptoms.

GINA 2020: Probability of Asthma Diagnosis in Children 5 years and

Younger
SYMPTOM PATTERN
(may change over time)

Symptoms (cough, Symptoms (cough,

Symptoms (cough,
wheeze, heavy breathing)
wheeze, heavy breathing)
for > 10 days during upper
for < 10 days during upper
respiratory tract infections
respiratory tract infections
2-3 episodes per year >3 episodes per year, or
severe episodes and/or
night worsening
No symptoms between
episodes Between episodes child
may have occasional
cough, wheeze or heavy
breathing
Few have asthma Some have asthma
wheeze, heavy breathing)
for > 10 days during upper
respiratory tract infections
>3 episodes per year, or
severe episodes and/or
night worsening
Between episodes child
has cough, wheeze or
heavy breathing during
play or when laughing
Allergic, sensitization,
atopic dermatitis, food
allergy, or family history of
asthma
Most have asthma

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GINA 2020: Probability of Asthma Diagnosis in Children 5 years and

Younger
SYMPTOM PATTERN
(may change over time)

Symptoms (cough, Symptoms (cough,

Symptoms (cough,
wheeze, heavy breathing) wheeze, heavy breathing)
wheeze, heavy breathing)
for > 10 days during upper for > 10 days during upper
for < 10 days during upper
respiratory tract infections respiratory tract infections
respiratory tract infections
>3 episodes per year, or
2-3 episodes per year >3 episodes per year, or severe episodes and/or
severe episodes and/or night worsening
night worsening Between episodes child
No symptoms between has cough, wheeze or
episodes Between episodes child heavy breathing during
may have occasional play or when laughing
cough, wheeze or heavy
breathing Allergic, sensitization,
atopic dermatitis, food
allergy, or family history of
asthma
Give Inhaled
Few have asthma
Bronchodilators sos Give Trialhave
Some of ICS Therapy
asthma Most
Give Trialhave asthma
of ICS Therapy

TRIAL OF ICS THERAPY

Drug: Low dose Inhaled corticosteroid (ICS) twice a day
Device: pMDI+ Spacer ± Mask Duration: 3 months

Review after 6
weeks Check:-
Technique
Adherance
If symptoms co-morbids
persistent
environmental triggers
If symptoms
controlled-
continue ICS for 3
months If all
are
good
Stop ICS after
03 months.

Review
If symptoms recur then restart diagnosis
ICS. If child responds-
diagnose as Asthma and treat
accordingly

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Children above 5 years

Presenting symptoms
• Cough
• Breathlessness
• Wheeze
• Chest tightness

As per GINA 2020

2 main Diagnostic Features of Asthma for adults and children
6-11 yrs.

1. History of variable respiratory symptoms

2. Confirmed Variable expiratory airflow limitation

NOTE

If possible: Document the evidence supporting the diagnosis of Asthma in the first visit, before starting the
treatment because the patient may improve spontaneously or with treatment. Hence it becomes more
difficult to confirm diagnosis of asthma once the patient is started on ICS.

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Thank you!

CASE 1
• 1 year 9 months old Aditya suffering from cough,
wheezing and breathlessness for 4 days, associated
with cold brought to the consultation room.

• History of similar episode 3 months back which

lasted for 7 days. Otherwise child is free from any
symptom in between

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GINA 2020: Probability of Asthma Diagnosis in Children 5 years and

Younger
SYMPTOM PATTERN
(may change over time)

Symptoms (cough, Symptoms (cough,

Symptoms (cough,
wheeze, heavy breathing) wheeze, heavy breathing)
wheeze, heavy breathing)
for > 10 days during upper for > 10 days during upper
for < 10 days during upper
respiratory tract infections respiratory tract infections
respiratory tract infections
>3 episodes per year, or
2-3 episodes per year >3 episodes per year, or severe episodes and/or
severe episodes and/or night worsening
night worsening Between episodes child
No symptoms between has cough, wheeze or
episodes Between episodes child heavy breathing during
may have occasional play or when laughing
cough, wheeze or heavy
breathing Allergic, sensitization,
atopic dermatitis, food
allergy, or family history of
asthma
Give Inhaled
Few have asthma
Bronchodilators sos Some have asthma Most have asthma

CASE 2
• 2 years old Preeti brought with cough, wheezing
and heavy breathing for the last 10 days
associated with URTI.

• History of similar 3 episodes in the past 1 year.

Child is having disturbed sleep.

• Child is having occasional cough in between the

episodes.

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GINA 2020: Probability of Asthma Diagnosis in Children 5 years and

Younger
SYMPTOM PATTERN
(may change over time)

Symptoms (cough, Symptoms (cough,

Symptoms (cough,
wheeze, heavy breathing) wheeze, heavy breathing)
wheeze, heavy breathing)
for > 10 days during upper for > 10 days during upper
for < 10 days during upper
respiratory tract infections respiratory tract infections
respiratory tract infections
>3 episodes per year, or
2-3 episodes per year >3 episodes per year, or severe episodes and/or
severe episodes and/or night worsening
night worsening Between episodes child
No symptoms between has cough, wheeze or
episodes Between episodes child heavy breathing during
may have occasional play or when laughing
cough, wheeze or heavy
breathing Allergic, sensitization,
atopic dermatitis, food
allergy, or family history of
asthma
Few have asthma Give Trialhave
Some of ICS Therapy
asthma Most have asthma

CASE 3
• 3 years old Naveen has been brought to the hospital
for the 4th time with cough, wheezing and
breathlessness.
• Each episodes are with URTI and lasting for 7-14 days.
• Child is coughing while playing and crying.
• Family history asthma present.
• Child has itchy skin during infancy necessitating usage
of creams and lotions.

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 05-10-2020

GINA 2020: Probability of Asthma Diagnosis in Children 5 years and

Younger
SYMPTOM PATTERN
(may change over time)

Symptoms (cough, Symptoms (cough,

Symptoms (cough,
wheeze, heavy breathing)
wheeze, heavy breathing)
for > 10 days during upper
for < 10 days during upper
respiratory tract infections
respiratory tract infections
2-3 episodes per year >3 episodes per year, or
severe episodes and/or
night worsening
No symptoms between
episodes Between episodes child
may have occasional
cough, wheeze or heavy
breathing
Few have asthma Some have asthma
wheeze, heavy breathing)
for > 10 days during upper
respiratory tract infections
>3 episodes per year, or
severe episodes and/or
night worsening
Between episodes child
has cough, wheeze or
heavy breathing during
play or when laughing
Allergic, sensitization,
atopic dermatitis, food
allergy, or family history of
asthma
Most
Give Trialhave asthma
of ICS Therapy

Case 4:

• Abhay Nair
• 10 years
• Recurrent episodes of chesty cough and occasional
breathlessness (nearly 5-6 episodes every year) since the
age of 3 years
• Settles with medication, especially Nebulizations
• Has been on and off on controllers but parents
discontinued and resort to reliever medication.

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• Referred by primary care pediatrician

• On talking to the parents it seemed that they were in
denial about asthma and not convinced about need of
controller therapy.
• Abhay’s paternal grandfather had Asthma.
• Spirometry was done on Abhay.
• A bronchodilator reversibility with Salbutamol was also
done.

Graph image

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Situation post Spirometry:-

• A) We as the treating physician had an objective diagnosis of

Obstructive Airways Disease which was reversible.
• B) Parents were shown the graphs and the values
• C) Explained the need of controller therapy

• Acceptance of diagnosis and treatment plan by the parents

• Taught the correct technique

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• Have been coming for regular follow up

• Adherence has been good
• Symptomatically, very well controlled
• PEFR has been increasing to show them objective
improvement after treatment.

Thank you!

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