Although 50% to 80% of people with asthma develop symptoms before age 5, many children are misdiagnosed with reactive airway disease, allergic bronchitis, wheezy bronchitis, asthmatic bronchitis, recurrent pneumonia, or recurrent bronchiolitis. Asthma is diagnosed after a young child has had multiple admissions for the same condition and when other respiratory illnesses, such as cystic fibrosis, bronchopulmonary dysplasia, tracheoesophageal fistula, gastroesophageal reflux, and vocal cord dysfunction, have been ruled out. Caregivers who do not understand that asthma can be controlled may react strongly to the diagnosis. The pharmacist, along with other members of the health care team, can provide reassurance through extensive education.
The diagnosis of childhood asthma relies heavily on the child’s medical history (e.g., family history of asthma, frequency and severity of symptoms, and medications used to relieve these symptoms), physical examination, and the gold standard test, spirometry, which is usually not feasible in children younger than 5. Children in this age-group are typically diagnosed based on the frequency and presence of at least one of the classic symptoms: coughing, wheezing, dyspnea, increased work of breathing, tachypnea, and anxiety. Coughing, which can waken children at night, may be the only symptom. Other symptoms frequently accompanying an asthma exacerbation include posttussive emesis, fatigue, chest tightness, decreased appetite, avoidance of favorite activities, nasal flaring, and abdominal pain from supraclavicular and substernal retractions. A child with a severe asthma exacerbation may present with loss of consciousness, inability to speak, markedly diminished or absent breath sounds, or cyanosis indicating respiratory failure and possibly requiring intubation.
While wheezing prevails in 40% of children with asthma, “all that wheezes is not asthma.” In fact, it can be difficult to diagnose asthma in an infant because it is not possible to accurately use spirometry. Furthermore, other pulmonary diseases common in this age-group, such as bronchiolitis or pneumonia, present with respiratory distress, coughing, and wheezing. Nevertheless, having a history of allergy (eczema, allergic rhinitis, positive skin tests), family members with asthma or allergy, perinatal exposure to cigarette smoke, viral respiratory infections, bronchiolitis, male gender, and low birth weight strengthens the diagnosis of asthma. Of note, 70% to 90% of children over age 5 with asthma have some type of allergy and test positive to skin allergy tests.
While many children seem to outgrow their asthma, others have persistent asthma throughout childhood and even adulthood. Still others may have a remission of symptoms during childhood, followed by sudden exacerbations in their adolescent or adult years. Unfortunately, there are no markers for predicting an individual child’s prognosis, but certain factors, including allergy, a family history of asthma and/or allergy, and perinatal exposure to passive smoke and aeroallergens, have been associated with persistent asthma. In addition, a child’s triggers seem to worsen symptoms. Maintaining a diary of symptoms can be helpful in assessing the severity and persistence of the child’s chronic asthma.