VERSION 2.0 DIAGNOSIS

VERSION 2.0

DIAGNOSIS Children

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ABBREVIATIONS

CFC chlorofluorocarbon

COPD chronic obstructive pulmonary disease

COX cyclo-oxygenase

DXA dual-energy X-ray absorptiometry

ED emergency department

EIB exercise-induced bronchoconstriction

FEV1 forced expiratory volume over one second FEV6 forced expiratory volume over six seconds FSANZ Food Standards Australia and New Zealand FVC forced vital capacity

GORD gastro-oesophageal reflux disease

HFA formulated with hydrofluroalkane propellant

ICS inhaled corticosteroid

ICU intensive care unit

IgE Immunoglobulin E IL interleukin

IU international units

IV intravenous

LABA long-acting beta2-adrenergic receptor agonist

LAMA long-acting muscarinic antagonist

LTRA leukotriene receptor antagonist

MBS Medical Benefits Scheme

NHMRC National Health and Medical Research Council

NIPPV non-invasive positive pressure ventilation

NSAIDs nonsteroidal anti-inflammatory drugs

OCS oral corticosteroids

OSA obstructive sleep apnoea

PaCO carbon dioxide partial pressure on blood gas

analysis

PaO oxygen partial pressure on blood gas analysis

PBS Pharmaceutical Benefits Scheme

PEF peak expiratory flow

pMDI pressurised metered-dose inhaler or 'puffer'

PPE personal protective equipment

SABA short-acting beta2 -adrenergic receptor agonist

SAMA short-acting muscarinic antagonist

SaO2 oxygen saturation

SpO2 peripheral capillary oxygen saturation measured

by pulse oximetry

TGA Therapeutic Goods Administration

RECOMMENDED CITATION

National Asthma Council Australia. Australian Asthma Handbook, Version 2.0. National Asthma Council Australia, Melbourne, 2019.

Available from: http://www.asthmahandbook.org.au

ISSN 2203-4722

© National Asthma Council Australia Ltd, 2019

SPONSORS

National Asthma Council Australia would like to acknowledge the support of the sponsors of Version 2.0 of the Australian Asthma Handbook:

• Boehringer Ingelheim Australia

• Novartis Australia

NATIONAL ASTHMA COUNCIL AUSTRALIA

ABN 61 058 044 634

Suite 104, Level 1 153-161 Park Street South Melbourne VIC 3205 Australia

Tel: 03 9929 4333

Fax: 03 9929 4300

Email: [email protected]

Website: nationalasthma.org.au

DISCLAIMER

The Australian Asthma Handbook has been compiled by the National Asthma Council Australia for use by general practitioners, pharmacists, asthma educators, nurses and other health professionals and healthcare students. The information and treatment protocols contained in the Australian Asthma Handbook are based on current evidence and medical knowledge and practice as at the date of publication and to the best of our knowledge. Although reasonable care has been taken in the preparation of the Australian Asthma Handbook, the National Asthma Council Australia makes no representation or warranty as to the accuracy, completeness, currency or reliability of its contents.

The information and treatment protocols contained in the Australian Asthma Handbook are intended as a general guide only and are not intended to avoid the necessity for the individual examination and assessment of appropriate courses of treatment on a case-by-case basis. To the maximum extent permitted by law, acknowledging that provisions of the Australia Consumer Law may have application and cannot be excluded, the National Asthma Council Australia, and its employees, directors, officers, agents and affiliates exclude liability (including but not limited to liability for any loss, damage or personal injury resulting from negligence) which may arise from use of the Australian Asthma Handbook or from treating asthma according to the guidelines therein.

http://www.asthmahandbook.org.au/

mailto:[email protected]

HOME > DIAGNOSIS > CHILDREN

Overview

A clinical definition of asthma in children

Asthma is defined clinically as the combination of variable respiratory symptoms (e.g. wheeze, shortness of breath, cough and chesttightness) and excessive variation in lung function, i.e. variation in expiratory airflow that is greater than that seen in healthy children(‘variable airflow limitation’).

See: A working definition of asthma

There is no single reliable test (‘gold standard’) and there are no standardised diagnostic criteria for asthma.

The diagnosis of asthma is based on:

historyphysical examinationconsidering other diagnosesclinical response to a treatment trial with an inhaled short-acting beta2 agonist reliever or preventer

Figure: Steps in the diagnosis of asthma in children aged 1-5 years

Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/17

Figure. Steps in the diagnosis of asthma in children aged 6 years and over

Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/121

Infants (age 0–12 months)

Asthma should not be diagnosed in infants aged less than 12 months old. Wheezing in this age group is most commonly due to acute viralbronchiolitis or to small and/or floppy airways. Infants with clinically significant wheezing should be referred to a paediatric respiratoryphysician or paediatrician.

Preschool wheeze (age 1–5 years)

Although many individuals later diagnosed with asthma first show respiratory symptoms by the age of 5 years, it is difficult to make thediagnosis of asthma with a high degree of certainty in children aged 1–5 years, because:

episodic respiratory symptoms such as wheezing and cough are very common in children, particularly in children under 3 yearsobjective lung function testing by spirometry is usually not feasible in this age groupa high proportion of children who respond to bronchodilator treatment do not go on to have asthma in later childhood (e.g. by primaryschool age).

Children aged 6–11 years

In school-aged children able to perform spirometry, the diagnosis is supported by documentation of variable expiratory airflow limitation.

Adolescents

In older adolescents, the guidance on the diagnosis of asthma in adults generally applies.

See: Diagnosing asthma in adults

A diagnosis of asthma should not be made if cough is the only or predominant respiratory symptom and there are no signs of airflowlimitation (e.g. wheeze or breathlessness).

In this section

Diagnosis: ages 1–5

Investigating wheeze and other asthma symptoms in preschool children, including history and physical examination, differentialdiagnosis, further investigations and treatment trials

http://www.asthmahandbook.org.au/diagnosis/children/1-5-years

Diagnosis: age 6 and over

Investigating asthma symptoms in school-aged children, including history and physical examination, spirometry, differential diagnosis,further investigations and treatment trials

http://www.asthmahandbook.org.au/diagnosis/children/6-years-and-over

Figure: Steps in the diagnosis of asthma in children aged 1-5 years

asthmahandbook.org.auAustralian Asthma Handbook v2.0 asset ID: 17

YES

Episodic wheezing with increased work of breathing

HISTORY AND PHYSICAL EXAMINATION

Table. Findings that increase or decrease the probability of asthma in children

Supports asthma diagnosis?

ALTERNATIVE DIAGNOSIS

PROVISIONAL DIAGNOSIS OF ASTHMA

Manage according to frequency and severity of symptoms.

Monitor and review response regularly.

INVESTIGATIONS FOR SPECIFIC ALTERNATIVE DIAGNOSIS

Alternative diagnosis confirmed?

Table: Findings that require investigation in children

Table: Conditions that can be confused with asthma in children

Consider referral

NO

NO*

YES

YES

treatment trial

Trial reliever and/or preventer as indicated

Table. Classification of preschool wheeze and indications for initiating preventer treatment in children aged 1–5 years

See: Treatment trial for preschool wheeze

Clear response to treatment?

NO

Figure. Steps in the diagnosis of asthma in children aged 6 years and over

asthmahandbook.org.auAustralian Asthma Handbook v2.0 asset ID: 121

NO

YES

NO

asthmaStart asthma treatment and review response

episodic respiratory Symptoms that suggest asthma

HISTORY AND PHYSICAL EXAMINATIONTable. Findings that increase or decrease the probability of asthma in children


Child able to perform spirometry?

CONFIRMEDALTERNATIVE DIAGNOSIS

ASTHMA NOT CONFIRMED

Monitor signs and symptoms and consider referral

consider alternative diagnoses and referral

INVESTIGATIONS FOR SPECIFIC ALTERNATIVE DIAGNOSIS

Table: Findings that require investigation in children

Table: Conditions that can be confused with asthma in children

Alternative diagnosis confirmed?

FURTHER INVESTIGATIONSConsider bronchial provocation test, cardiopulmonary exercise test and other tests as indicated


NO

NO*NO*

YES

YESNO

YES

SPIROMETRYFEV1 before and 10-15 mins after bronchodilator

Reversible airflow limitation? (FEV1 increase ≥12% from baseline)

treatment trialTrial reliever and/or preventer as indicated

Table: Classification of asthma and indications for initiating preventer treatment in chidlren aged 6 years and over.See: Provisional diagnosis and treatment trial for asthma in a child aged 6 years or over

Clear response to treatment?

YES YES

NO

HOME > DIAGNOSIS > CHILDREN > DIAGNOSIS: AGES 1–5

In this section

History and physical examination

Taking a history and performing physical examination for a wheezing child aged 1–5 years

http://www.asthmahandbook.org.au/diagnosis/children/1-5-years/history-and-physical-examination

Differential diagnosis

Considering alternative or comorbid conditions in wheezing in children aged 1–5 years

http://www.asthmahandbook.org.au/diagnosis/children/1-5-years/alternative-diagnoses

Further investigations

The role of further investigations for wheezing in children aged 1–5 years

http://www.asthmahandbook.org.au/diagnosis/children/1-5-years/further-investigations

Treatment trial

Conducting a treatment trial and reviewing effects in a wheezing child aged 1–5 years

http://www.asthmahandbook.org.au/diagnosis/children/1-5-years/treatment-trial-for-preschool-wheeze

HOME > DIAGNOSIS > CHILDREN > DIAGNOSIS: AGES 1–5 > HISTORY AND PHYSICAL EXAMINATION

Recommendations

Confirm that the breathing sounds described by parents/carers as ‘wheezing’ are actually wheeze:

If possible, see the child during a bout of ‘wheezing’.Ask parents/carers to make an audio or video recording of noisy breathing (e.g. on phone).Show parents/carers a video of true wheezing and ask them whether signs match their child.

Ask about:

current symptomspattern of symptoms, including frequency and timing of wheezing episodes (whether they occur only when child has a viral cold, orare unrelated to colds, and whether child coughs or wheezes at other times, e.g. when playing or laughing) appearance of child’s chest during episodes of noisy breathing to identify chest recession (e.g. ask whether chest appears to besucked inwards as child breathes in)whether child is generally alert, active, socially responsive, joins in play with other childrenhome environment (e.g. exposure to smoke, pets)allergies, including atopic dermatitis (eczema) and allergic rhinitis (‘hay fever’)family history of asthma and allergies.

Conduct a general physical examination, including:

height and weight compared with normal range for ageinspection of chest for deformityinspection of upper airway for signs of allergic rhinitis (e.g. swollen turbinates, transverse nasal crease, mouth breathing, darknessand swelling under eyes caused by sinus congestion) or polypsauscultation of chestinspection of fingers for clubbing (requires investigation)skin inspection for atopic dermatitis (eczema).

Go to: Royal Children’s Hospital Melbourne’s What is asthma video (see section on ‘What to look for’ from 2:52 to 3:52)

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to thefollowing source(s):

Brand et al. 20081

Global Initiative for Asthma (GINA), 20092

Weinberger and Abu-Hasan, 20073

Last reviewed version 2.0


Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).


Table. Findings that require investigations in children

Finding Notes

Persistent cough that is not associated with

wheeze/breathlessness or systemic disease

Unlikely to be due to asthma

Onset of signs from birth or very early in life Suggests cystic fibrosis, chronic lung disease of

prematurity, primary ciliary dyskinesia,

bronchopulmonary dysplasia, congenital abnormality

Family history of unusual chest disease Should be enquired about before attributing all the signs

and symptoms to asthma

Severe upper respiratory tract disease (e.g. severe rhinitis,

enlarged tonsils and adenoids or nasal polyps)

Specialist assessment should be considered

Crepitations on chest auscultation that do not clear on

coughing

Suggest a serious lower respiratory tract condition such

as pneumonia, atelectasis, bronchiectasis

Unilateral wheeze Suggests inhaled foreign body

Systemic symptoms (e.g. fever, weight loss, failure to thrive) Suggest an alternative systemic disorder

Feeding difficulties, including choking or vomiting Suggests aspiration – specialist assessment should be

considered

Inspiratory upper airway noises (e.g. stridor, snoring) Acute stridor suggests tracheobronchitis (croup)

Persistent voice abnormality Suggests upper airway disorder

Finger clubbing Suggests cystic fibrosis, bronchiectasis

Chronic (>4 weeks) wet or productive cough Suggests cystic fibrosis, bronchiectasis, chronic

bronchitis, recurrent aspiration, immune abnormality,

ciliary dyskinesia

Focal (localised) lung signs Suggests pneumonia

Nasal polyps in child under 5 years old Suggests cystic fibrosis

Severe chest deformity Harrison’s Sulcus and Pectus Carinatum can be due to

uncontrolled asthma, but severe deformity suggests an

alternative diagnosis

Obvious breathing difficulty, especially at rest or at night Specialist assessment should be considered

Recurrent pneumonia Specialist assessment should be considered

Asset ID: 59

Identify any signs and symptoms that suggest an alternative diagnosis and which require investigation.


Finding Notes













coughing






considered






ciliary dyskinesia



Consensus



Finding Notes







Asset ID: 59

More information

Definition of wheeze

Wheeze is defined as a high-pitched sound coming from the chest during inspiration or expiration.1 It is a non-specific sign caused byturbulent air flow due to narrowing of intrathoracic airways and indicates expiratory airflow limitation, irrespective of the underlying

mechanism1 (e.g. bronchoconstriction or secretions in the airway lumen).

Inspiratory sounds (e.g. rattling or stridor) should not be described as ‘wheeze’.3

Various forms of noisy breathing, including wheezing, are common among babies and preschoolers.1 Noisy breathing is particularly

common among infants under 6 months old, but only a small proportion have wheeze.1

Parents and doctors sometimes use the word ‘wheeze’ to mean different things,1, 3 including cough, gasp, a change in breathing rate orstyle of breathing. If based on parental report alone, children may be labelled as having wheeze when they do not have narrowed

airways and expiratory flow limitation.1

There are no validated questionnaire-based instruments to identify wheeze in preschoolers,1 so wheezing is best confirmed by listeningwith a stethoscope during an episode.

Reported noisy breathing that responds to bronchodilator therapy is likely to be genuine wheeze and to be caused, at least in part, by

constriction of airway smooth muscle.1



Consensus



Gibson et al. 2010 4

'Wheeze-detecting' devices

Some hand-held devices and smart phone applications are marketed for detecting and measuring wheeze by audio recording andanalysis.

There is not enough evidence to recommend these devices and apps for use in monitoring asthma symptoms or asthma control in adultsor children, or in distinguishing wheeze from other airway sounds in children.

Reliance on these devices could result in over- or under-treatment.


Significance of wheeze in children 1–5 years

Approximately one in three children has at least one episode of wheezing before their third birthday,1 and almost half of all children

have at least one episode of wheezing by age 6 years.1

Wheezing is the most common symptom associated with asthma in children aged 5 years and under. Among people with a diagnosis ofasthma at any time in their life, approximately 80% will have shown signs of respiratory disease, such as wheezing, in the first years of

life.5

However, the presence of wheeze does not mean a child has asthma or will develop asthma:

wheezing in infants up to 12 months old is most commonly due to acute viral bronchiolitis or to small and/or floppy airwayswheezing in children aged 1–5 years is usually associated with viral upper respiratory tract infections, which recur frequently in this

age group.1, 2 Many children wheeze when they have viral respiratory infections, even if they do not have asthma2

among preschoolers with recurrent wheezing, only approximately one in three will have asthma at age 6 years5

wheezing can also be due to many conditions other than asthma, including anatomical abnormalities of the airways, cystic fibrosis,

bronchomalacia.1


Relationship of allergies to asthma

Asthma can be atopic or non-atopic. Atopic asthma, characterised by eosinophilic airway inflammation associated with sensitisation to

aeroallergens (positive skin prick test or specific immunoglobulin E on serology) is the more common form in children.6

The links between asthma and atopy are unclear.7 Many children with asthma are also atopic and have eczema, hay fever, or food

allergies, but not all children with atopy develop asthma.7

Eczema and allergic rhinitis are risk factors for developing asthma.8, 9, 10, 11, 12, 13 Parental atopy has been identified as a risk factor for

asthma in several studies, but the strength of the association differs between populations.14

A family history of atopy or asthma, or a personal history of atopy are generally considered to increase the probability that wheezing inchildren is due to asthma.

The association between allergic rhinitis and asthma may reflect the common allergic causes of both conditions, rather than a causal

link.13 However, few studies have examined interactions between genes and environment for asthma and for atopy in the same

population, and there is not consistent evidence that similar gene–environment interactions are common to asthma and atopy.7


Wheezing phenotypes in preschool children

Longitudinal population-based cohort studies15, 16 of preschool children with wheezing have identified various long-term patterns

(wheezing phenotypes).1

Table. Systems for retrospectively classifying the duration of childhood wheeze

Classification

system/source

Phenotypes

identified

Description

See: Allergies and asthma

Classification

system/source

Phenotypes

identified

Description

Tucson Children’s

Respiratory Study † ‡

Transient wheeze Wheezing commences before the age of 3 years and disappear by age

6 years

Persistent wheeze Wheezing continues until up to or after age 6 years

Late-onset wheeze Wheezing starts after age 3 years.

Avon Longitudinal

Study of Parents and

Children §

Transient early

wheeze

Wheezing mainly occurs before 18 months, then mainly disappears by

age 3.5 years

Not associated with hypersensitivity to airborne allergens

Prolonged early

wheeze

Wheezing occurs mainly between age 6 months and 4.5 years, then

mainly disappears before child’s 6th birthday


Associated with a higher risk of airway hyperresponsiveness and

reduced lung function at age 8–9 years, compared with

never/infrequent wheeze phenotype

Intermediate-onset

wheeze

Wheezing begins sometime after age 18 months and before 3.5 years.

Strongly associated with atopy (especially house mite, cat allergen),

higher risk of airway hyperresponsiveness and reduced lung function

at age 8–9 years, compared with never/infrequent wheeze phenotype

Late-onset wheeze Wheezing mainly begins after age 3.5 years

Strongly associated with atopy (especially house mite, cat allergen,

grass pollen)

Persistent wheeze Wheezing mainly begins after 6 months and continues through to

primary school

Strongly associated with atopy

Notes

Terms can only be identified after the child has stopped wheezing for several years and cannot be applied to a preschool child.

Transient wheeze, persistent wheeze and late-onset wheeze can be episodic or multiple-trigger wheeze.#

Sources

† Martinez FD, Wright AL, Taussig LM et al. Asthma and wheezing in the first six years of life. The Group Health Medical Associates.N Engl J Med 1995; 332: 133-8. Available from: http://www.nejm.org/doi/full/10.1056/NEJM199501193320301#t=article

‡ Morgan WJ, Stern DA, Sherrill DL et al. Outcome of asthma and wheezing in the first 6 years of life: follow-up through adolescence.Am J Respir Crit Care Med 2005; 172: 1253-8. Available from: http://ajrccm.atsjournals.org/content/172/10/1253.long

§ Henderson J, Granell R, Heron J et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung function andairway responsiveness in mid-childhood. Thorax 2008; 63: 974-80. Available from: http://thorax.bmj.com/content/63/11/974.long

# Brand PL, Baraldi E, Bisgaard H et al. Definition, assessment and treatment of wheezing disorders in preschool children: anevidence-based approach [European Respiratory Society Task Force]. Eur Respir J 2008; 32: 1096-110. Available from:

http://erj.ersjournals.com/content/32/4/1096.full

Asset ID: 10

Early childhood wheezing phenotypes cannot be recognised or applied clinically, because they are recognised retrospectively.1 In an

individual child with episodic wheeze, it is not possible to accurately predict epidemiological phenotype from clinical phenotype.1

Currently available tools for predicting whether a wheezing preschool child will have asthma at school age (e.g. the Asthma Predictive

Index5) have limited clinical value.17


References

Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: anevidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from: http://erj.ersjournals.com/content/32/4/1096.full

1.

Global Initiative for Asthma (GINA). Global strategy for the diagnosis and management of asthma in children 5 years and younger. GINA,2009. Available from: http://www.ginasthma.org/

2.

Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics. 2007; 120: 855-864.Available from: http://pediatrics.aappublications.org/content/120/4/855.full

3.

Gibson PG, Chang AB, Glasgow NJ, et al. CICADA: cough in children and adults: diagnosis and assessment. Australian coughguidelines summary statement. Med J Aust. 2010; 192: 265-271. Available from: https://www.mja.com.au/journal/2010/192/5/cicada-cough-children-and-adults-diagnosis-and-assessment-australian-cough

4.

Castro-Rodriguez JA. The Asthma Predictive Index: a very useful tool for predicting asthma in young children. J Allergy ClinImmunol. 2010; 126: 212-216. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20624655

5.

Comberiati P, Di Cicco ME, D'Elios S, Peroni DG. How much asthma is atopic in children? Front Pediatr. 2017; 5: 122. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5445121/

6.

Turner S. Gene-environment interactions-what can these tell us about the relationship between asthma and allergy? Front Pediatr.2017; 5: 118. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28589116

7.

van der Hulst AE, Klip H, Brand PL. Risk of developing asthma in young children with atopic eczema: a systematic review. J AllergyClin Immunol. 2007; 120: 565-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17655920

8.

Pallasaho P, Juusela M, Lindqvist A et al. Allergic rhinoconjunctivitis doubles the risk for incident asthma – results from a populationstudy in Helsinki, Finland. Respir Med. 2011; 105: 1449-56. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21600752

9.

Rochat MK, Illi S, Ege MJ et al. Allergic rhinitis as a predictor for wheezing onset in school-aged children. J Allergy Clin Immunology.2010; 126: 1170-5.e2. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21051078

10.

van den Nieuwenhof L, Schermer T, Bosch Y et al. Is physician-diagnosed allergic rhinitis a risk factor for the development ofasthma? Allergy. 2010; 65: 1049-55. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20132162

11.

Morais-Almeida M, Gaspar A, Pires G et al. Risk factors for asthma symptoms at school age: an 8-year prospective study. AllergyAsthma Proc. 2007; 28: 183-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17479602

12.

Shaaban R, Zureik M, Soussan D et al. Rhinitis and onset of asthma: a longitudinal population-based study. Lancet. 2008; 372:1047-57. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18805333

13.

Bjerg A, Hedman L, Perzanowski MS et al. Family history of asthma and atopy: in-depth analyses of the impact on asthma andwheeze in 7- to 8-year-old children. Pediatrics. 2007; 120: 741-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17908760

14.

Martinez FD, Wright AL, Taussig LM, et al. Asthma and wheezing in the first six years of life. N Engl J Med. 1995; 332: 133-138.Available from: http://www.nejm.org/doi/full/10.1056/NEJM199501193320301#t=article

15.

Henderson J, Granell R, Heron J, et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung function andairway responsiveness in mid-childhood. Thorax. 2008; 63: 974-980. Available from: http://thorax.bmj.com/content/63/11/974.long

16.

Savenije OE, Kerkhof M, Koppelman GH, Postma DS. Predicting who will have asthma at school age among preschool children. JAllergy Clin Immunol. 2012; 130: 325-331. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22704537

17.

HOME > DIAGNOSIS > CHILDREN > DIAGNOSIS: AGES 1–5 > DIFFERENTIAL DIAGNOSIS

Recommendations

Consider features that increase or reduce the probability of asthma.


Asthma more likely Asthma less likely

More than one of:

wheeze

difficulty breathing

feeling of tightness in the chest

cough

Any of:

symptoms only occur when child has a cold, but not

between colds

isolated cough in the absence of wheeze or difficulty

breathing

history of moist cough

dizziness, light-headedness or peripheral tingling

repeatedly normal physical examination of chest

when symptomatic

normal spirometry when symptomatic (children old

enough to perform spirometry)

no response to a trial of asthma treatment

clinical features that suggest an alternative diagnosis

AND

Any of:

symptoms recur frequently

symptoms worse at night and in the early morning

symptoms triggered by exercise, exposure to pets,

cold air, damp air, emotions, laughing

symptoms occur when child doesn’t have a cold

history of allergies (e.g. allergic rhinitis, atopic

dermatitis)

family history of allergies

family history of asthma

widespread wheeze heard on auscultation

symptoms respond to treatment trial of reliever, with

or without a preventer

lung function measured by spirometry increases in

response to rapid-acting bronchodilator


response to a treatment trial with inhaled

corticosteroid (where indicated)

Sources

British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the management of Asthma. A

national clinical guideline. BTS/SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-

standards/asthma-guideline

Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic GuidelinesLimited, Melbourne, 2009.

Asset ID: 12

If cough is a prominent symptom, investigate according to the current Australian Cough Guidelines.

Consider alternative diagnoses and comorbidities, including:

congenital conditions, e.g. structural airway problems (e.g. tracheomalacia, bronchopulmonary dysplasia, malformation causingnarrowing of intrathoracic airways, vascular ring anomaly compressing bronchus, trachea-oesophageal fistula), cystic fibrosis,immune deficiency, primary ciliary dyskinesia, congenital heart diseaseinfective conditions, e.g. bronchiolitis (infants < 12 months), laryngotracheobronchitis (croup), chronic rhinosinusitis, recurrentrespiratory tract infections, chronic suppurative lung disease (consider protracted bacterial bronchitis or bronchiectasis as acause)acquired conditions, e.g. inhaled foreign body, gastro-oesophageal reflux, recurrent aspiration, tumour or pulmonary oedema.

Table. Conditions that can be confused with asthma in children

Conditions characterised by cough

Pertussis (whooping cough)

Post-viral cough

Cystic fibrosis

Airway abnormalities (e.g. tracheobronchomalacia)

Protracted bacterial bronchitis in young children

Habit-cough syndrome

Conditions characterised by wheezing

Upper airway dysfunction

Inhaled foreign body causing partial airway obstruction

Tracheobronchomalacia


Consensus


British Thoracic Society, Scottish Intercollegiate Guidelines Network, 2012 1

Respiratory Expert Group Therapeutic Guidelines Limited, 2009 2

Go to: Australian Cough Guidelines


Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):



Conditions characterised by difficulty breathing

Hyperventilation

Anxiety

Breathlessness on exertion due to poor cardiopulmonary fitness


Source

Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics 2007; 120: 855-64.Available from: http://pediatrics.aappublications.org/content/120/4/855.full


Asset ID: 11


Finding Notes













coughing






considered




Finding Notes



ciliary dyskinesia








Asset ID: 59

More information

Cough and asthma in children

Relationship of cough to asthma in childrenMisdiagnosis of nonspecific cough as asthma can result in overtreatment in children.

Cough can indicate the possibility of a serious underlying illness and warrant further assessment and investigations.3

Table. Red flags for cough in children

Wet or productive cough lasting more than 4 weeks

Obvious difficulty breathing, especially at rest or at night

Systemic symptoms: fever, failure to thrive or poor growth velocity

Feeding difficulties (including choking or vomiting)

Recurrent pneumonia

Inspiratory stridor (other than during acute tracheobronchitis)

Abnormalities on respiratory examination

Abnormal findings on chest X-ray

‘Clubbing’ of fingers


Consensus



Source

Gibson PG, Chang AB, Glasgow NJ et al., CICADA: Cough in Children and Adults: Diagnosis and Assessment. Australian coughguidelines summary statement. Med J Aust, 2010; 192: 265-71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20201760

Asset ID: 13

Chronic cough (cough lasting more than 4 weeks) without other features of asthma is unlikely to be due to asthma.3

Cough is a frequent symptom in children with asthma, but may have a different mechanism from other symptoms of asthma (e.g.

wheeze, chest tightness or breathlessness). Children who have recurrent cough, but do not wheeze, are unlikely to have asthma.4 A verysmall minority of children with recurrent nocturnal cough, but no other asthma symptoms, may be considered to have a diagnosis of

atypical asthma.4 This diagnosis should be only made in consultation with a paediatric respiratory physician.

In children with no abnormalities detected on physical examination, chest X-ray or spirometry, and no wheezing or breathlessness,

chronic cough is most likely:3

due to protracted bacterial bronchitis (resolves with 2–6 weeks’ treatment with antibiotics)3

post-viral (resolves with time)

due to exposure to tobacco smoke and other pollutants.3

Frequency of cough reported by parents correlates poorly with frequency measured using diary cards or by audio recording monitors.5

0-5 years

Most cases of coughing in preschool children are not due to asthma:

Recurrent cough in preschool children, in the absence of other signs, is most likely due to recurrent viral bronchitis. Cough due toviral infection is unresponsive to bronchodilators and preventers such as montelukast, cromones or inhaled corticosteroids.

Children attending day care or preschool can have a succession of viral infections that merge into each other,5 giving the falseappearance of chronic cough (cough lasting more than 4 weeks).

In preschool-aged children, cough may be due to asthma when it occurs during episodes of wheezing and breathlessness or when thechild does not have a cold.

6 years and over

Chronic cough may be due to asthma if the cough is episodic and associated with other features of asthma such as expiratory wheeze,

exercise-related breathlessness, or airflow limitation objectively demonstrated by spirometry (particularly if responsive to a

bronchodilator).3

Alternative diagnoses in children

Other conditions characterised by wheezing, breathlessness or cough can be confused with asthma. These include:

protracted bacterial bronchitis3, 6

habit-cough syndrome3

upper airway dysfunction.7




Post-viral cough

Cystic fibrosis











Hyperventilation

Anxiety



Source



Asset ID: 11



More than one of:

wheeze



cough

Any of:


between colds


breathing



repeatedly normal physical examination of chest when

symptomatic





AND

Any of:



symptoms triggered by exercise, exposure to pets, cold

air, damp air, emotions, laughing



dermatitis)












Sources





Asset ID: 12

References

British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. Anational clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/

1.

Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic GuidelinesLimited, West Melbourne, 2009.

2.


3.

van Asperen PP. Cough and asthma. Paediatr Resp Rev. 2006; 7: 26-30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16473813

4.

Bush A. Diagnosis of asthma in children under five. Prim Care Respir J. 2007; 16: 7-15. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17297521

5.

Craven V, Everard ML. Protracted bacterial bronchitis: reinventing an old disease. Arch Dis Child. 2013; 98: 72-76. Available from:http://www.ncbi.nlm.nih.gov/pubmed/23175647

6.


7.


HOME > DIAGNOSIS > CHILDREN > DIAGNOSIS: AGES 1–5 > FURTHER INVESTIGATIONS

Recommendations

Consider allergy tests (skin prick test or specific IgE assay) for common aeroallergens for children with recurrent wheezing when theresults might guide you in (either of):

assessing the prognosis (the presence of allergies in preschool children increases the probability that the child will have asthma atprimary school age)managing symptoms (e.g. advising parents/carers about management if avoidable allergic triggers are identified).

Notes: Allergy tests are not essential in the diagnostic investigation of asthma in children. The finding of allergic sensitisation on skin-prick testing orspecific IgE does not necessarily mean that it is clinically important.

Arrange chest X-ray if the child has unusual respiratory symptoms or if wheezing is localised. Routine chest X-ray is not otherwiserecommended in the investigation of asthma symptoms in children.

Measurement of exhaled nitric oxide is not recommended as a diagnostic test for asthma in routine clinical practice.

Routine microbiological investigations are not recommended in the investigation of symptoms that suggest asthma.


Consensus




Consensus



Consensus


Brand et al. 2008 1

Dweik et al. 2011 2


Consensus


Brand et al. 2008 1


Offer referral to a specialist for further assessment and investigation if the diagnosis is unclear or if a serious condition cannot beruled out.

More information













Allergy tests in children

Skin-prick testingAllergy tests have a very limited role in the clinical investigation of asthma. They may be useful to guide management if the child issensitised to aeroallergens that are avoidable (e.g. advise parents against getting a cat if skin-prick testing has shown that the child issensitised to cat allergens, or advise parents that there is no need to remove a family pet if the child is not sensitised).

Skin-prick testing is the recommended test for allergies in children.

Risk factors for anaphylaxis during skin prick testing are thought to include asthma (particularly uncontrolled or unstable asthma), age

less than 6 months, and widespread atopic dermatitis in children.12 As a precaution, the Australasian Society of Clinical Immunologyand Allergy (ASCIA) advises that skin prick testing should be performed only in specialist practices for children under 2 years and

children with severe or unstable asthma.12 ASCIA’s manual on skin prick testing lists other risk factors.12

Total serum IgE testing

In children aged 0–5 years, total serum immunoglobulin E measurement is a poor predictor of allergies or asthma.1

Specific serum IgE testing

Among children aged 1–4 years attending primary care, those with raised specific IgE for inhaled allergens (e.g. house dust mite, cat

dander) are two-to-three times more likely to have asthma at age 6 than non-sensitised children.1 Sensitisation to hen’s egg at the age of

1 year (specific IgE) is a strong predictor of allergic sensitisation to inhaled allergens at age 3 years.1

Further investigations in children aged 1–5 years

In preschool children, further investigations (other than allergy tests) are not necessary and are generally not helpful.1


Consensus



Go to: Australasian Society of Clinical Immunology and Allergy Skin Prick Testing Working Party's Skin prick testing for the diagnosis ofallergic disease. A manual for practitioners


Investigations in a preschool child may be justified in any of the following circumstances:1

symptoms are present from birthairway obstruction is abnormally severerecovery is very slow or incomplete (resulting in prolonged or repeated hospital admission in the first few years of life)episodes continue in the absence of a viral infectionwhen parents are very anxious.


References


1.

Dweik RA, Boggs PB, Erzurum SC, et al. An Official ATS Clinical Practice Guideline: Interpretation of Exhaled Nitric Oxide Levels(FeNO) for Clinical Applications. Am J Respir Crit Care Med. 2011; 184: 602-615. Available from: http://ajrccm.atsjournals.org/content/184/5/602.long

2.


3.


4.


5.


6.


7.


8.


9.


10.


11.

Australasian Society of Clinical Immunology and Allergy (ASCIA), Skin Prick Testing Working Party. Skin prick testing for the diagnosisof allergic disease: A manual for practitioners. ASCIA, Sydney, 2013. Available from: http://www.allergy.org.au/health-professionals/papers/skin-prick-testing

12.

HOME > DIAGNOSIS > CHILDREN > DIAGNOSIS: AGES 1–5 > TREATMENT TRIAL

Recommendations

For children over 12 months old with wheezing episodes that are associated with increased work of breathing (e.g. intercostalretraction), consider a trial of treatment with an inhaled short-acting beta2 agonist given as needed.

If the child is wheezing during the consultation, administer 2–4 puffs (200–400 microg) of salbutamol via spacer and mask. Note anyresponse to treatment (improvement in work of breathing, respiratory rate, breath sounds or wheeze).

If there is a positive response:

show parents/carers how to give salbutamol via a pressurised metered-dose inhaler plus spacer (older preschool children) orpressurised metered-dose inhaler plus spacer and mask (infants and children unable to use spacer alone)tell parents/carers to give 2–4 puffs (200–400 microg) when child wheezes, and repeat if wheezing recursask parents/carers to watch closely for whether child’s breathing improves (e.g. child stops showing signs of increased work ofbreathing) and report effects.

If the child is not wheezing during the consultation, show parents/carers how to administer salbutamol, and ask them to trial thistreatment over 1–2 days, starting the next time wheezing occurs and to monitor the response.

If child needs salbutamol again within 4 hours, or increased work of breathing does not respond to salbutamol, parents/carersshould seek urgent medical attention (go to emergency department or call 000).

Notes:If increased work of breathing resolves in response to inhaled bronchodilator (either during a treatment trial at home or observed in the clinic orhospital), consider whether preventer is indicated.

Table. Classification of preschool wheeze and indications for preventer treatment in children aged 1–5

Severity of flare-ups Frequency of symptoms

Symptoms every

6 months or less

Symptoms every

3–4 months

Symptoms every

4–6 weeks

Symptoms at least

once per week

Mild flare-ups

(managed with

salbutamol in community)

Not indicated Not indicated Consider Indicated

Moderate–severe flare-

ups

(require ED care/oral

corticosteroids)

Indicated Indicated Indicated Indicated


Symptoms every

6 months or less

Symptoms every

3–4 months

Symptoms every

4–6 weeks

Symptoms at least

once per week

Life-threatening flare-ups

(require hospitalisation or

PICU)


PICU: paediatric intensive care unit; ED: emergency department

Indicated: Prescribe preventer and monitor as a treatment trial. Discontinue if ineffective.

Not indicated: Preventer is unlikely to be beneficial

Consider prescribing preventer according to overall risk for severe flare-ups

Symptoms: wheeze, cough or breathlessness. May be triggered by viral infection, exercise or inhaled allergens

Flare-up: increase in symptoms from usual day-to-day symptoms (ranging from worsening asthma over a few days to an acuteasthma episode)

Preventer options: an inhaled corticosteroid (low dose) or montelukast

[!] Advise parents/carers about potential adverse behavioural and/or neuropsychiatric effects of montelukast

Notes:Preventer medication is unlikely to be beneficial in a child whose symptoms do not generally respond to salbutamol

In children taking preventer, symptoms should be managed with a short-acting inhaled beta2 agonist reliever (e.g. when child showsdifficulty breathing).


Asset ID: 20

The trial can be repeated if it is inconclusive.

For children aged 12 months and over with a provisional diagnosis of asthma, consider a trial of preventer treatment, if indicated.



Symptoms every

6 months or less

Symptoms every

3–4 months

Symptoms every

4–6 weeks

Symptoms at least

once per week

Mild flare-ups

(managed with




Consensus




Symptoms every

6 months or less

Symptoms every

3–4 months

Symptoms every

4–6 weeks

Symptoms at least

once per week


ups


corticosteroids)




PICU)











In children taking preventer, symptoms should be managed with a short-acting inhaled beta2 agonist reliever (e.g. when child showsdifficulty breathing).


Asset ID: 20

If wheezing accompanied by increased work of breathing is markedly reduced during a treatment trial with a preventer, then recurswhen treatment is stopped, this supports a provisional diagnosis of asthma in a preschool child.

Note: If the diagnosis is in doubt, performing spirometry later, when the child is able, may be useful to confirm the diagnosis


Consensus




Consensus



More information

Short-acting beta-2 agonist relievers for children: 1–5 years

Infants under 12 months

In infants under 12 months, bronchiolitis is the most likely cause of acute respiratory distress. Bronchodilators are not recommended in

children under 12 months old, consistent with current guidelines for the management of acute bronchiolitis.1


Inhaled short-acting beta2 agonists are effective bronchodilators in children aged 1–5 years.2

Short-acting beta2 agonists may be less effective for wheezing in children under 2 years old than in older children.3 However, many

clinical trials in infants have included those with bronchiolitis, so there is limited evidence for the effects of short-acting beta2 agonists

specifically in asthma.3 Studies conducted in emergency departments have shown that short-acting beta2 agonists are more effective

than placebo in controlling acute wheeze in children under 2 years, but may not achieve clinically significant improvements.3

Inhaled short-acting beta2 agonists are generally well tolerated in children aged 1–5 years.2 Adverse effects can include muscle tremor,

headache, palpitations and agitation. Muscle tremor and agitation are common with initial use of standard doses, but often settle over

time. Serious adverse effects such as hypokalaemia have been reported at very high doses.2

Oral short-acting beta2 agonists are associated with adverse effects2 and should not be used for the treatment of asthma in any age

group.


Administration of inhaled medicines in children: 1-5 years

To use inhaler devices correctly, parents and children need training in inhaler technique and in the care and cleaning of inhalers andspacers.

Children need careful supervision when taking their inhaled medicines (e.g. at preschool), especially when using a reliever for acuteasthma symptoms.

Types of inhalers suitable for preschool children

Preschool children cannot use pressurised metered-dose inhalers properly unless a spacer is attached (with mask when necessary),

because it is difficult for them to coordinate inspiratory effort with actuating the device.2 Note that breath-actuated pressurisedmetered-dose inhalers cannot be used with a spacer.

Dry-powder inhalers are usually ineffective for preschool children because they cannot generate sufficient inspiratory air flow.2

Drug delivery is very variable in young children with any type of inhaler, including pressurised metered dose inhalers and spacers.4

Filter studies have shown high day-to-day variability in delivered doses in preschool children.2 This variation might explain fluctuationsin effectiveness, even if the child’s parents have been trained to use the device correctly.

Table. Types of inhaler devices for delivering asthma and COPD medicines

Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/75

Pressurised metered-dose inhalers plus spacers for relievers

During acute wheezing episodes, delivery of short-acting beta2 agonist to airways is more effective with a pressurised metered-dose

inhaler plus spacer than with a nebuliser.2 In older children, salbutamol has also been associated with a greater increase in heart rate

when delivered by nebuliser than when delivered by pressurised metered-dose inhaler plus spacer.5

When administering salbutamol to relieve asthma symptoms in a preschool child, the standard recommendation is to shake the

inhaler, actuate one puff at a time into the spacer and have the child take 4–6 breaths in and out of the spacer (tidal breathing).6 Fewerbreaths may suffice; in children with asthma aged 2–7 years (not tested during an acute asthma episode), the number of tidal breathsneeded to inhale salbutamol adequately from a spacer has been estimated at 2 breaths for small-volume spacers, 2 breaths for a spacer

made from a 500-mL modified soft drink bottle, and 3 breaths for a large (Volumatic) spacer.7

Face masks for infants

When using a spacer with face mask (e.g. for an infant too young or uncooperative to be able to use a mouthpiece), effective delivery ofmedicine to the airways depends on a tight seal around the face.

When masks are used for inhaled corticosteroids, there is a risk of exposure to eyes and skin if the seal over the mouth and nose is notadequate. Parents should be advised to wash the child's face after administering inhaled corticosteroids by mask.

Babies are unlikely to inhale enough medicine while crying.5 The use of a spacer and face mask for a crying infant may require patienceand skill: the child can be comforted (e.g. held by a parent, in own pram, or sitting on the floor) while the mask is kept on, and theactuation carefully timed just before the next intake of breath. Most infants will tolerate the spacer and mask eventually. The child maybe more likely to accept the spacer and mask if allowed to handle them first (and at other times), if the devices are personalised (e.g. withstickers), or if the mask has a scent associated with the mother (e.g. lip gloss). The use of a spacer with a coloured valve allows parents tosee the valve move as the child breathes in and out.


Preparation of new spacers before first use

Spacers are made of plastic, antistatic polymer/polycarbonate polyurethane, or cardboard.

Plastic spacers (e.g. Breath-A-Tech, Volumatic)

Electrostatic surface charge on new spacers made of plastic (e.g. Breath-A-Tech, Volumatic) reduces the proportion of medicine availablefor delivery to the airway. This charge can be reduced by washing the plastic spacer in dishwashing liquid and allowing it to air dry or

drip-dry without rinsing or wiping.2

Alternatively, priming the spacer by actuating the device several times into the spacer also overcomes the charge, but this wastesmedicine. The optimal number of actuations for priming is not known and the findings of in vitro studies vary widely. One study (usingolder, CFC-based formulations of asthma medicines) reported that up to 40 actuations fired into a new plastic spacer overcame the

effect of the electrostatic charge.8 Others have concluded that the electrostatic charge on plastic spacers does not reduce in vivo

efficacy of bronchodilator therapy in children with asthma.9 The number of actuations necessary may be known when the results ofrecent studies become available.

When a new plastic spacer must be used immediately (e.g. for a person with asthma symptoms), patients, parents and carers shouldfollow the manufacturer's priming instructions. In hospitals and emergency departments, a new spacer that has not been pre-treated bywashing can be primed using multiple (at least 10) puffs of salbutamol. (This is an arbitrary number of actuations in the absence ofevidence that would enable a precise guideline.)

Non-plastic spacers

Disposable cardboard spacers (e.g. DispozABLE, LiteAire) and polyurethane/antistatic polymer spacers (e.g. Able A2A, AeroChamber Plus,La Petite E-Chamber, La Grande E-Chamber) do not require preparation before first use.2

Note: The term 'priming' is also used for the preparation process that is necessary for new pressurised metered-dose inhalers that havenot been used for more than a week. This involves first actuating the inhaler into the air (away from the patient). Users should follow themanufacturer’s instructions for the particular brand of inhaler, which specify the number of actuations required.


Wheezing phenotypes in preschool children

Longitudinal population-based cohort studies10, 11 of preschool children with wheezing have identified various long-term patterns

(wheezing phenotypes).2

Table. Systems for retrospectively classifying the duration of childhood wheeze

Classification

system/source

Phenotypes

identified

Description

Tucson Children’s

Respiratory Study † ‡

Transient wheeze Wheezing commences before the age of 3 years and disappear by age

6 years

Persistent wheeze Wheezing continues until up to or after age 6 years

Late-onset wheeze Wheezing starts after age 3 years.

Go to: National Asthma Council Australia's information paper for health professionals on Inhaler technique for people with asthma orCOPD

Classification

system/source

Phenotypes

identified

Description

Avon Longitudinal

Study of Parents and

Children §

Transient early

wheeze

Wheezing mainly occurs before 18 months, then mainly disappears by

age 3.5 years


Prolonged early

wheeze

Wheezing occurs mainly between age 6 months and 4.5 years, then

mainly disappears before child’s 6th birthday


Associated with a higher risk of airway hyperresponsiveness and

reduced lung function at age 8–9 years, compared with

never/infrequent wheeze phenotype

Intermediate-onset

wheeze

Wheezing begins sometime after age 18 months and before 3.5 years.

Strongly associated with atopy (especially house mite, cat allergen),

higher risk of airway hyperresponsiveness and reduced lung function

at age 8–9 years, compared with never/infrequent wheeze phenotype

Late-onset wheeze Wheezing mainly begins after age 3.5 years

Strongly associated with atopy (especially house mite, cat allergen,

grass pollen)

Persistent wheeze Wheezing mainly begins after 6 months and continues through to

primary school

Strongly associated with atopy

Notes

Terms can only be identified after the child has stopped wheezing for several years and cannot be applied to a preschool child.

Transient wheeze, persistent wheeze and late-onset wheeze can be episodic or multiple-trigger wheeze.#

Sources

† Martinez FD, Wright AL, Taussig LM et al. Asthma and wheezing in the first six years of life. The Group Health Medical Associates.N Engl J Med 1995; 332: 133-8. Available from: http://www.nejm.org/doi/full/10.1056/NEJM199501193320301#t=article

‡ Morgan WJ, Stern DA, Sherrill DL et al. Outcome of asthma and wheezing in the first 6 years of life: follow-up through adolescence.Am J Respir Crit Care Med 2005; 172: 1253-8. Available from: http://ajrccm.atsjournals.org/content/172/10/1253.long

§ Henderson J, Granell R, Heron J et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung function andairway responsiveness in mid-childhood. Thorax 2008; 63: 974-80. Available from: http://thorax.bmj.com/content/63/11/974.long

# Brand PL, Baraldi E, Bisgaard H et al. Definition, assessment and treatment of wheezing disorders in preschool children: anevidence-based approach [European Respiratory Society Task Force]. Eur Respir J 2008; 32: 1096-110. Available from:http://erj.ersjournals.com/content/32/4/1096.full

Asset ID: 10

Early childhood wheezing phenotypes cannot be recognised or applied clinically, because they are recognised retrospectively.2 In an

individual child with episodic wheeze, it is not possible to accurately predict epidemiological phenotype from clinical phenotype.2

Currently available tools for predicting whether a wheezing preschool child will have asthma at school age (e.g. the Asthma Predictive

Index12) have limited clinical value.13


References

Paediatric Research in Emergency Departments International Collaborative. Australasian bronchiolitis guideline. PREDICT; 2016.Available from: http://www.predict.org.au/publications/2016-pubs/

1.


2.

Chavasse RJ, Bara A, McKean MC. Short acting beta2-agonists for recurrent wheeze in children under two years of age. CochraneDatabase Syst Rev. 2002; Issue 2: CD002873. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002873/full

3.

Schultz A, Sly PD, Zhang G, et al. Incentive device improves spacer technique but not clinical outcome in preschool children withasthma. J Paediatr Child Health. 2012; 48: 52-6. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1754.2011.02190.x/full

4.

Schuh, S., Johnson, D. W., Stephens, D., et al. Comparison of albuterol delivered by a metered dose inhaler with spacer versus anebulizer in children with mild acute asthma. The Journal of pediatrics. 1999; 135: 22-7. Available from:https://www.ncbi.nlm.nih.gov/pubmed/10393599

5.

National Asthma Council Australia. Kids' First Aid for Asthma. National Asthma Council Australia, Melbourne, 2011. Available from:http://www.nationalasthma.org.au/first-aid

6.

Schultz A, Le Souëf TJ, Venter A, et al. Aerosol inhalation from spacers and valved holding chambers requires few tidal breaths forchildren. Pediatrics. 2010; 126: e1493-8. Available from: http://pediatrics.aappublications.org/content/126/6/e1493.long

7.

Berg E. In vitro properties of pressurized metered dose inhalers with and without spacer devices. J Aerosol Med. 1995; 8 Suppl 3:S3-10; discussion S11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10157897

8.

Dompeling E, Oudesluys-Murphy AM, Janssens HM, et al. Randomised controlled study of clinical efficacy of spacer therapy inasthma with regard to electrostatic charge. Arch Dis Child. 2001; 84: 178-182. Available from: http://adc.bmj.com/content/84/2/178.full

9.

Martinez FD, Wright AL, Taussig LM, et al. Asthma and wheezing in the first six years of life. N Engl J Med. 1995; 332: 133-138.Available from: http://www.nejm.org/doi/full/10.1056/NEJM199501193320301#t=article

10.

Henderson J, Granell R, Heron J, et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung function andairway responsiveness in mid-childhood. Thorax. 2008; 63: 974-980. Available from: http://thorax.bmj.com/content/63/11/974.long

11.


12.

Savenije OE, Kerkhof M, Koppelman GH, Postma DS. Predicting who will have asthma at school age among preschool children. JAllergy Clin Immunol. 2012; 130: 325-331. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22704537

13.

HOME > DIAGNOSIS > CHILDREN > DIAGNOSIS: AGE 6 AND OVER

In this section

History and physical examination

Taking a history and performing physical examination for a wheezing child aged 6 years or over

http://www.asthmahandbook.org.au/diagnosis/children/6-years-and-over/history-and-physical-examination

Lung function

Assessing lung function in children 6 years and over

http://www.asthmahandbook.org.au/diagnosis/children/6-years-and-over/lung-function

Differential diagnosis

Considering alternative or comorbid conditions in children with asthma-like symptoms aged 6 years and over

http://www.asthmahandbook.org.au/diagnosis/children/6-years-and-over/differential-diagnosis-for-asthma-like-symptoms

Further investigations

The role of further investigations for asthma-like symptoms in children aged 6 years and over

http://www.asthmahandbook.org.au/diagnosis/children/6-years-and-over/further-investigations

Treatment trial

Making a provisional diagnosis of asthma and conducting a treatment trial for children aged 6 years and over

http://www.asthmahandbook.org.au/diagnosis/children/6-years-and-over/provisional-diagnosis

HOME > DIAGNOSIS > CHILDREN > DIAGNOSIS: AGE 6 AND OVER > HISTORY AND PHYSICAL EXAMINATION

Recommendations

Ask about:

current symptomspattern of symptoms, including frequency and timing of wheezing episodes (whether they occur only when child has a viral cold, orare unrelated to colds, and whether child coughs or wheezes at other times, e.g. when playing or laughing) appearance of child’s chest during episodes of noisy breathing to identify chest recession (e.g. ask whether chest appears to besucked inwards as child breathes in)whether child is generally alert, active, socially responsive, joins in play with other childrenhome environment (e.g. exposure to smoke, pets)allergies, including atopic dermatitis (eczema) and allergic rhinitis (‘hay fever’)family history of asthma and allergies.

Conduct a general physical examination, including:

height and weight compared with normal range for ageinspection of chest for deformityinspection of upper airway for signs of allergic rhinitis (e.g. swollen turbinates, transverse nasal crease, mouth breathing, darknessand swelling under eyes caused by sinus congestion) or polypsauscultation of chestinspection of fingers for clubbing (requires investigation)skin inspection for atopic dermatitis (eczema).


Finding Notes










Consensus



Finding Notes





coughing






considered






ciliary dyskinesia








Asset ID: 59

Identify any signs and symptoms that suggest an alternative diagnosis and which require investigation.



Consensus



Finding Notes

Asset ID: 59

More information

Definition of wheeze

Wheeze is defined as a high-pitched sound coming from the chest during inspiration or expiration.3 It is a non-specific sign caused byturbulent air flow due to narrowing of intrathoracic airways and indicates expiratory airflow limitation, irrespective of the underlying

mechanism3 (e.g. bronchoconstriction or secretions in the airway lumen).

Inspiratory sounds (e.g. rattling or stridor) should not be described as ‘wheeze’.1

Various forms of noisy breathing, including wheezing, are common among babies and preschoolers.3 Noisy breathing is particularly

common among infants under 6 months old, but only a small proportion have wheeze.3

Parents and doctors sometimes use the word ‘wheeze’ to mean different things,3, 1 including cough, gasp, a change in breathing rate orstyle of breathing. If based on parental report alone, children may be labelled as having wheeze when they do not have narrowed

airways and expiratory flow limitation.3

There are no validated questionnaire-based instruments to identify wheeze in preschoolers,3 so wheezing is best confirmed by listeningwith a stethoscope during an episode.

Reported noisy breathing that responds to bronchodilator therapy is likely to be genuine wheeze and to be caused, at least in part, by

constriction of airway smooth muscle.3














Diagnostic difficulties when investigating asthma-like symptoms in adolescents

Asthma is commonly misdiagnosed in young people presenting with exercise-related symptoms or cough.13 Conditions associated with


Consensus





dyspnoea include hyperventilation, anxiety, and poor cardiopulmonary fitness.1

Both denial and overplay of symptoms has been observed among adolescents.13 Adolescents with new or re-emerging asthma

symptoms may deny their symptoms.13 US data suggest that risk factors for undiagnosed asthma among adolescents include femalesex, smoking (current smoking and exposure to others’ smoke), low socioeconomic status, family problems, low physical activity and

high body mass.14

Confidentiality issues for adolescents

Adolescents’ concerns about confidentiality prevent them using health care services, especially if substance use is likely to be raised.Adolescents are more likely to disclose information about health risk behaviours, and are more likely to return for review, if they know

that confidential information will not be revealed to their parents or others.15

When adolescents are accompanied by parents or carers, health care providers should consider seeing the adolescent alone for part of

each consultation.15

Health professionals should discuss confidentiality and its limits with adolescents.15 Adolescents are more willing to communicate

honestly with healthcare professionals who discuss confidentiality with them.16

Health professionals need to clearly explain which personal health information can be confidential and which must be shared withparents, and keep parents informed.

Health care providers should advise adolescents that they can obtain their own Medicare card once they turn 15.15


Exercise-related symptoms in adolescents

In adolescents, exercise-related wheezing and breathlessness are poor predictors of exercise-induced bronchoconstriction. Only aminority of adolescents referred for assessment of exercise-induced respiratory symptoms show objective evidence of exercise-

induced bronchoconstriction.17

For adolescents with exercise-related symptoms, common conditions that should be considered in the differential diagnosis

include poor cardiopulmonary fitness, exercise-induced upper airway dysfunction and exercise-induced hyperventilation.13, 18

In addition to spirometry, other objective tests (e.g. cardiopulmonary fitness testing, bronchial provocation tests) may be helpful toclarify the diagnosis and inform management.


References


1.


2.


3.


4.


5.


6.


7.


8.

Go to: Royal Australasian College of Physicians’ Working with young people online resource (see Privacy and confidentiality inadolescent health care in Topic 2: Ethical and legal issues)Go to: Australian Government Department of Human Services' Financial and health support for young people webpage

See: Investigation and management of exercise-induced bronchoconstriction


9.


10.


11.


12.

Towns SJ, van Asperen PP. Diagnosis and management of asthma in adolescents. Clin Respir J. 2009; 3: 69-76. Available from:http://www.ncbi.nlm.nih.gov/pubmed/20298380

13.

Yeatts K, Davis KJ, Sotir M, et al. Who gets diagnosed with asthma? Frequent wheeze among adolescents with and without adiagnosis of asthma. Pediatrics. 2003; 111: 1046-54. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12728087

14.

The Royal Australasian College of Physicians Joint Adolescent Health Committee. Confidential Health Care for Adolescents and YoungPeople (12–24 years). The Royal Australasian College of Physicians, 2010. Available from: http://www.racp.edu.au/

15.

The Royal Australasian College of Physicians. Routine adolescent psychosocial health assessment. Position statement. The RoyalAustralasian College of Physicians, Sydney, 2008. Available from: http://www.racp.edu.au/fellows/resources/paediatric-resources

16.

Schuh, S, Willan, AR, Stephens, D, et al. Can montelukast shorten prednisolone therapy in children with mild to moderate acuteasthma? A randomized controlled trial. J Pediatr. 2009; 155: 795-800. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19656525

17.

Tilles SA. Exercise-induced respiratory symptoms: an epidemic among adolescents. Ann Allergy Asthma Immunol. 2010; 104: 361-7;368-70, 412. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20486325

18.

HOME > DIAGNOSIS > CHILDREN > DIAGNOSIS: AGE 6 AND OVER > LUNG FUNCTION

Recommendations

In children able to perform spirometry, measure bronchodilator reversibility by performing spirometry before and after giving inhaledrapid-onset beta2 agonist bronchodilator (e.g. 4 puffs of salbutamol 100 microg/actuation) by metered-dose inhaler and spacer.

Notes

If reliable equipment and appropriately trained staff are available, spirometry can be performed in primary care. If not, refer to an appropriateprovider such as an accredited respiratory function laboratory.

Most children aged 6 and older can perform spirometry reliably.

Airflow limitation is defined as reversible (i.e. bronchodilator response is clinically important) if FEV1 increases by ≥12%.

Operators who perform spirometry should receive comprehensive training to ensure good quality.

More information

Role of spirometry in the diagnosis of asthma in children

Generally, spirometry cannot be performed to acceptable standards in children younger than 4–5 years.1

Some older children cannot perform spirometry either. However, children who are unable to perform spirometry satisfactorily on their

first visit are often able to perform the test correctly at the next visit.1

Normal spirometry in a child, especially when asymptomatic, does not exclude the diagnosis of asthma. FEV1 is often normal in children

with persistent asthma.

Reduced FEV1 alone does not indicate that a child has asthma, because it may be seen with other lung diseases (or be due to poor

spirometric technique). However, reduced ratio of FEV1 to FVC for age indicates expiratory airflow limitation.

A significant increase in FEV1 (>12% from baseline) after administering a bronchodilator (e.g. 2–4 puffs of salbutamol 100

microg/actuation) indicates that airflow limitation is reversible and supports the diagnosis of asthma. However, an absent response tobronchodilators does not exclude asthma.

In children with asthma, bronchodilator reversibility is also predictive of a good lung function response to inhaled corticosteroids.2

Go to: National Asthma Council Australia’s Spirometry Resources


Bronchial provocation (challenge) tests in children


Consensus

Based on clinical experience and expert opinion (informed by evidence, where available)



Consensus


Clinical assessment is more sensitive for confirming the diagnosis of asthma than tests for airway hyperresponsiveness.

The main roles of bronchial provocation (challenge) tests of airway hyperresponsiveness (airway hyperreactivity) are to confirm orexclude asthma as the cause of current symptoms, including exercise-associated respiratory symptoms such as dyspnoea or noisy

breathing. 3, 4

Challenge tests are performed in accredited lung function testing laboratories. These tests are usually difficult to perform in childrenunder 8 years of age because they involve repeated spirometry tests.

If challenge testing is needed, consider referring to a paediatric respiratory physician for investigation, or discussing with a paediatricrespiratory physician before selecting which test to order.

Do not test during a respiratory infection, or initiate inhaled corticosteroid treatment a few weeks before challenge testing, becausethese could invalidate the result.

Bronchial provocation tests of airway hyperresponsiveness include:

exercise challenge test5

mannitol challenge test6, 7

methacholine challenge test.8, 9

Roles of other lung function tests in diagnosing asthma in children

Peak expiratory flow meters in asthma diagnosisUsing a peak flow meter to measure peak expiratory flow in children does not reliably rule the diagnosis of asthma in or out.

Newer tests under investigation

Impulse oscillometry, tests of specific airways resistance, and measurements of residual volume are being investigated for use in asthma

diagnosis and management,10, 11 but their availability is mainly restricted to specialist and research centres.


References

Johns DP, Pierce R. Pocket guide to spirometry. 3rd edn. McGraw Hill, North Ryde, 2011.1. Szefler, SJ, Phillips, BR, Martinez, FD, et al. Characterization of within-subject responses to fluticasone and montelukast inchildhood asthma. J Allergy Clin Immunol. 2005; 115: 233-242. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15696076

2.

Anderson SD. Bronchial challenge tests: usefulness, availability and challenges. Breathe. 2011; 8: 53-60. Available from:http://www.ers-education.org

3.

Cockcroft DW. Direct challenge tests: airway hyperresponsiveness in asthma: its measurement and clinical significance. Chest.2010; 138(2 Suppl): 18S-24S. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1086632

4.

Anderson SD, Pearlman DS, Rundell KW, et al. Reproducibility of the airway response to an exercise protocol standardized forintensity, duration, and inspired air conditions, in subjects with symptoms suggestive of asthma. Respir Res. 2010; Sept 1: 120.Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939602/

5.

Barben J, Roberts M, Chew N, et al. Repeatability of bronchial responsiveness to mannitol dry powder in children with asthma.Pediatr Pulmonol. 2003; 36: 490-4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14618640

6.

Kersten ET, Driessen JM, van der Berg JD, Thio BJ. Mannitol and exercise challenge tests in asthmatic children. Pediatr Pulmonol.2009; 44: 655-661. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19499571

7.

Liem JJ, Kozyrskyj AL, Cockroft DW, Becker AB. Diagnosing asthma in children: what is the role for methacholinebronchoprovocation testing?. Pediatr Pulmonol. 2008; 43: 481-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18383334

8.

Carlsten C, Dimich-Ward H, Ferguson A, et al. Airway hyperresponsiveness to methacholine in 7-year-old children: sensitivity andspecificity for pediatric allergist-diagnosed asthma. Pediatr Pulmonol. 2011; 46: 175-178. Available from:http://www.ncbi.nlm.nih.gov/pubmed/20963839

9.

Child F. The measurement of airways resistance using the interrupter technique (Rint). Paediatr Respir Rev. 2005; 6: 273-7.Available from: http://www.ncbi.nlm.nih.gov/pubmed/16298310

10.

Oostveen E, MacLeod D, Lorino H, et al. The forced oscillation technique in clinical practice: methodology, recommendations andfuture developments. Eur Respir J Supplement. 2003; 22: 1026-41. Available from: http://erj.ersjournals.com/content/22/6/1026.long

11.

HOME > DIAGNOSIS > CHILDREN > DIAGNOSIS: AGE 6 AND OVER > DIFFERENTIAL DIAGNOSIS

Recommendations

Consider features that increase or reduce the probability of asthma.



More than one of:

wheeze



cough

Any of:


between colds


breathing




when symptomatic





AND

Any of:







dermatitis)











Sources





Asset ID: 12

Do not assume that cough is due to asthma in the absence of wheezing or breathlessness. Misdiagnosis of asthma in a child withnonspecific cough can result in overtreatment in children.

If cough is a prominent symptom, investigate according to the current Australian Cough Guidelines.

Consider alternative diagnoses and comorbidities, including:

congenital conditions, e.g. structural airway problems (e.g. tracheomalacia, bronchopulmonary dysplasia, malformation causingnarrowing of intrathoracic airways, vascular ring anomaly compressing bronchus, trachea-oesophageal fistula), cystic fibrosis,immune deficiency, primary ciliary dyskinesia, congenital heart diseaseinfective conditions, e.g. laryngotracheobronchitis (croup), chronic rhinosinusitis, recurrent respiratory tract infections, chronicsuppurative lung disease (consider protracted bacterial bronchitis or bronchiectasis as a cause)acquired conditions, e.g. inhaled foreign body, gastro-oesophageal reflux, recurrent aspiration, tumour or pulmonary oedema.




Post-viral cough

Cystic fibrosis


Consensus


British Thoracic Society, Scottish Intercollegiate Guidelines Network, 2012 1

Respiratory Expert Group Therapeutic Guidelines Limited, 2009 2



















Hyperventilation

Anxiety



Source



Asset ID: 11


Finding Notes













coughing




Finding Notes



considered






ciliary dyskinesia








Asset ID: 59

More information







Consensus






Recurrent pneumonia





Source


Asset ID: 13











0-5 years





6 years and over



bronchodilator).3

Alternative diagnoses in children

Other conditions characterised by wheezing, breathlessness or cough can be confused with asthma. These include:

protracted bacterial bronchitis3, 6

habit-cough syndrome3

upper airway dysfunction.7





Post-viral cough

Cystic fibrosis









Hyperventilation

Anxiety



Source



Asset ID: 11



More than one of:

wheeze



cough

Any of:


between colds


breathing


dizziness, light-headedness or peripheral tinglingAND


repeatedly normal physical examination of chest when

symptomatic





Any of:



symptoms triggered by exercise, exposure to pets, cold

air, damp air, emotions, laughing



dermatitis)











Sources





Asset ID: 12

Diagnostic difficulties when investigating asthma-like symptoms in adolescents

Asthma is commonly misdiagnosed in young people presenting with exercise-related symptoms or cough.8 Conditions associated with

dyspnoea include hyperventilation, anxiety, and poor cardiopulmonary fitness.7

Both denial and overplay of symptoms has been observed among adolescents.8 Adolescents with new or re-emerging asthma symptoms

may deny their symptoms.8 US data suggest that risk factors for undiagnosed asthma among adolescents include female sex, smoking

(current smoking and exposure to others’ smoke), low socioeconomic status, family problems, low physical activity and high body mass.9

Exercise-related symptoms in adolescents

In adolescents, exercise-related wheezing and breathlessness are poor predictors of exercise-induced bronchoconstriction. Only aminority of adolescents referred for assessment of exercise-induced respiratory symptoms show objective evidence of exercise-

induced bronchoconstriction.10

For adolescents with exercise-related symptoms, common conditions that should be considered in the differential diagnosis

include poor cardiopulmonary fitness, exercise-induced upper airway dysfunction and exercise-induced hyperventilation.8, 11

In addition to spirometry, other objective tests (e.g. cardiopulmonary fitness testing, bronchial provocation tests) may be helpful to


clarify the diagnosis and inform management.


References

British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. Anational clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/

1.

Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic GuidelinesLimited, West Melbourne, 2009.

2.


3.


4.


5.

Craven V, Everard ML. Protracted bacterial bronchitis: reinventing an old disease. Arch Dis Child. 2013; 98: 72-76. Available from:http://www.ncbi.nlm.nih.gov/pubmed/23175647

6.


7.

Towns SJ, van Asperen PP. Diagnosis and management of asthma in adolescents. Clin Respir J. 2009; 3: 69-76. Available from:http://www.ncbi.nlm.nih.gov/pubmed/20298380

8.

Yeatts K, Davis KJ, Sotir M, et al. Who gets diagnosed with asthma? Frequent wheeze among adolescents with and without adiagnosis of asthma. Pediatrics. 2003; 111: 1046-54. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12728087

9.


10.

Tilles SA. Exercise-induced respiratory symptoms: an epidemic among adolescents. Ann Allergy Asthma Immunol. 2010; 104: 361-7;368-70, 412. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20486325

11.


HOME > DIAGNOSIS > CHILDREN > DIAGNOSIS: AGE 6 AND OVER > FURTHER INVESTIGATIONS

Recommendations

Consider skin prick testing for common aeroallergens for children with recurrent wheezing when the results might guide you inmanaging symptoms (e.g. advising parents/carers about management if avoidable allergic triggers are identified).

Notes:

Allergy tests are not essential in the diagnostic investigation of asthma in children. The finding of allergic sensitisation on skin-prick testing orspecific IgE does not necessarily mean that it is clinically important.

Blood test (immunoassay for allergen-specific immunoglobulin E) can be used if skin prick testing is unavailable, impractical or inappropriate.

If the diagnosis is uncertain, consider arranging bronchial provocation (challenge) testing.

Arrange chest X-ray if the child has unusual respiratory symptoms or if wheezing is localised. Routine chest X-ray is not otherwiserecommended in the investigation of asthma symptoms in children.

Measurement of exhaled nitric oxide is not recommended as a diagnostic test for asthma in routine clinical practice.

Routine microbiological investigations are not recommended in the investigation of symptoms that suggest asthma.


Consensus




Consensus




Consensus



Consensus


Brand et al. 2008 1

Dweik et al. 2011 2


Consensus

Offer referral to a specialist for further assessment and investigation if the diagnosis is unclear or if a serious condition cannot beruled out.

More information













Allergy tests in children

Skin-prick testingAllergy tests have a very limited role in the clinical investigation of asthma. They may be useful to guide management if the child issensitised to aeroallergens that are avoidable (e.g. advise parents against getting a cat if skin-prick testing has shown that the child issensitised to cat allergens, or advise parents that there is no need to remove a family pet if the child is not sensitised).

Skin-prick testing is the recommended test for allergies in children.

Risk factors for anaphylaxis during skin prick testing are thought to include asthma (particularly uncontrolled or unstable asthma), age

less than 6 months, and widespread atopic dermatitis in children.12 As a precaution, the Australasian Society of Clinical Immunologyand Allergy (ASCIA) advises that skin prick testing should be performed only in specialist practices for children under 2 years and

children with severe or unstable asthma.12 ASCIA’s manual on skin prick testing lists other risk factors.12

Total serum IgE testing

In children aged 0–5 years, total serum immunoglobulin E measurement is a poor predictor of allergies or asthma.1

Specific serum IgE testing

Among children aged 1–4 years attending primary care, those with raised specific IgE for inhaled allergens (e.g. house dust mite, cat

dander) are two-to-three times more likely to have asthma at age 6 than non-sensitised children.1 Sensitisation to hen’s egg at the age of

1 year (specific IgE) is a strong predictor of allergic sensitisation to inhaled allergens at age 3 years.1


Brand et al. 2008 1



Consensus



Go to: Australasian Society of Clinical Immunology and Allergy Skin Prick Testing Working Party's Skin prick testing for the diagnosis ofallergic disease. A manual for practitioners

Bronchial provocation (challenge) tests in children

Clinical assessment is more sensitive for confirming the diagnosis of asthma than tests for airway hyperresponsiveness.

The main roles of bronchial provocation (challenge) tests of airway hyperresponsiveness (airway hyperreactivity) are to confirm orexclude asthma as the cause of current symptoms, including exercise-associated respiratory symptoms such as dyspnoea or noisy

breathing. 13, 14

Challenge tests are performed in accredited lung function testing laboratories. These tests are usually difficult to perform in childrenunder 8 years of age because they involve repeated spirometry tests.

If challenge testing is needed, consider referring to a paediatric respiratory physician for investigation, or discussing with a paediatricrespiratory physician before selecting which test to order.

Do not test during a respiratory infection, or initiate inhaled corticosteroid treatment a few weeks before challenge testing, becausethese could invalidate the result.

Bronchial provocation tests of airway hyperresponsiveness include:

exercise challenge test15

mannitol challenge test16, 17

methacholine challenge test.18, 19

Roles of other lung function tests in diagnosing asthma in children

Peak expiratory flow meters in asthma diagnosisUsing a peak flow meter to measure peak expiratory flow in children does not reliably rule the diagnosis of asthma in or out.

Newer tests under investigation

Impulse oscillometry, tests of specific airways resistance, and measurements of residual volume are being investigated for use in asthma

diagnosis and management,20, 21 but their availability is mainly restricted to specialist and research centres.


Cardiopulmonary exercise challenge test

Cardiopulmonary exercise (stress) testing may be appropriate to assess cardiopulmonary fitness and identify respiratory or cardiaclimitation of exercise in children presenting with exercise associated respiratory symptoms such as dyspnoea or noisy breathing.

Further investigations in children

Microbiological investigationMicrobiological investigations are not routinely recommended in children because the result does not alter management decisions,

even though respiratory viruses can be identified.1

However, it may be useful to identify the virus in atypical cases (e.g. children with severe viral infections or Mycoplasma infections).

Chest X-ray and other imaging technologies

Chest X-ray should be ordered when a child’s symptoms and signs suggest an alternative diagnosis that can be identified or ruled out byX-ray.

A chest X-ray will neither establish nor rule out a diagnosis of asthma.1

Exhaled nitric oxide testing

The exhaled nitric oxide test is not currently available as a standard clinical test for the diagnosis of asthma and is mainly a research tool

at present. Standardised reference values are available for children aged 4 years and older.1

Induced sputum

The sputum test for airway inflammation is not used in the diagnosis of asthma clinical practice.

White cell count

Blood eosinophil level is a component of the Asthma Predictive Index.22 However, this test is not routinely


recommended because the Asthma Predictive Index has limited clinical value in predicting whether a wheezingpreschool child will have asthma at school age.1, 23

Invasive tests

Airway wall biopsy and bronchoalveolar lavage are invasive investigations. These should only be used in unusualcases, and must be performed in specialised centres.1


References


1.

Dweik RA, Boggs PB, Erzurum SC, et al. An Official ATS Clinical Practice Guideline: Interpretation of Exhaled Nitric Oxide Levels(FeNO) for Clinical Applications. Am J Respir Crit Care Med. 2011; 184: 602-615. Available from: http://ajrccm.atsjournals.org/content/184/5/602.long

2.


3.


4.


5.


6.


7.


8.


9.


10.


11.

Australasian Society of Clinical Immunology and Allergy (ASCIA), Skin Prick Testing Working Party. Skin prick testing for the diagnosisof allergic disease: A manual for practitioners. ASCIA, Sydney, 2013. Available from: http://www.allergy.org.au/health-professionals/papers/skin-prick-testing

12.

Anderson SD. Bronchial challenge tests: usefulness, availability and challenges. Breathe. 2011; 8: 53-60. Available from:http://www.ers-education.org

13.

Cockcroft DW. Direct challenge tests: airway hyperresponsiveness in asthma: its measurement and clinical significance. Chest.2010; 138(2 Suppl): 18S-24S. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1086632

14.

Anderson SD, Pearlman DS, Rundell KW, et al. Reproducibility of the airway response to an exercise protocol standardized forintensity, duration, and inspired air conditions, in subjects with symptoms suggestive of asthma. Respir Res. 2010; Sept 1: 120.Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939602/

15.

Barben J, Roberts M, Chew N, et al. Repeatability of bronchial responsiveness to mannitol dry powder in children with asthma.Pediatr Pulmonol. 2003; 36: 490-4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14618640

16.

Kersten ET, Driessen JM, van der Berg JD, Thio BJ. Mannitol and exercise challenge tests in asthmatic children. Pediatr Pulmonol.2009; 44: 655-661. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19499571

17.

Liem JJ, Kozyrskyj AL, Cockroft DW, Becker AB. Diagnosing asthma in children: what is the role for methacholinebronchoprovocation testing?. Pediatr Pulmonol. 2008; 43: 481-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18383334

18.

Carlsten C, Dimich-Ward H, Ferguson A, et al. Airway hyperresponsiveness to methacholine in 7-year-old children: sensitivity andspecificity for pediatric allergist-diagnosed asthma. Pediatr Pulmonol. 2011; 46: 175-178. Available from:http://www.ncbi.nlm.nih.gov/pubmed/20963839

19.

Child F. The measurement of airways resistance using the interrupter technique (Rint). Paediatr Respir Rev. 2005; 6: 273-7.Available from: http://www.ncbi.nlm.nih.gov/pubmed/16298310

20.

Oostveen E, MacLeod D, Lorino H, et al. The forced oscillation technique in clinical practice: methodology, recommendations andfuture developments. Eur Respir J Supplement. 2003; 22: 1026-41. Available from: http://erj.ersjournals.com/content/22/6/1026.long

21.


22.

Savenije OE, Kerkhof M, Koppelman GH, Postma DS. Predicting who will have asthma at school age among preschool children. J23. Allergy Clin Immunol. 2012; 130: 325-331. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22704537

HOME > DIAGNOSIS > CHILDREN > DIAGNOSIS: AGE 6 AND OVER > TREATMENT TRIAL

Recommendations

A provisional diagnosis of asthma can be made if the child has (all of):

wheezing accompanied by breathing difficulty or coughother features that increase the probability of asthma such as a history of allergic rhinitis, atopic dermatitis or a strong familyhistory of asthma and allergiesno signs or symptoms that suggest a serious alternative diagnosisclinically important response to bronchodilator demonstrated on spirometry performed before and after short-acting beta2

agonist (if child is able to perform spirometry).

Notes

If reliable equipment and appropriately trained staff are available, spirometry can be performed in primary care. If not, refer to an appropriateprovider such as an accredited respiratory function laboratory.

Most children aged 6 and older can perform spirometry reliably.

Airflow limitation is defined as reversible (i.e. bronchodilator response is clinically important) if FEV1 increases by ≥12%.

If spirometry does not demonstrate a clinically important response to bronchodilator, the test can be repeated when the child has symptoms.



More than one of:

wheeze



cough

Any of:


between colds


breathing




when symptomatic





AND

Any of:







dermatitis)












Sources





Asset ID: 12




Post-viral cough

Cystic fibrosis









Hyperventilation

Anxiety



Source



Asset ID: 11


Finding Notes













coughing






considered






ciliary dyskinesia






Finding Notes



Asset ID: 59

Assess and record frequency and severity of symptoms, including flare-ups.

Trial treatment with short-acting beta2 agonist reliever as needed, or with regular preventer (and reliever as needed), as indicated.

Table. Classification of asthma and indications for initiating preventer treatment in children aged 6–11

Severity of flare-ups

Average frequency of flare-ups and symptoms between flare-ups

Infrequent intermittent

Flare-ups every 6 weeks or

less and no symptoms

between flare-ups

Frequent intermittent

Flare-ups more than once

every 6 weeks and no

symptoms between flare-

ups

Persistent

Between flare-ups (any of):

Daytime

symptoms‡ more than

once per week

Night-time


twice per month

Symptoms restrict

activity or sleep

Mild flare-ups

(almost always managed with Not indicated Consider Indicated


Consensus



Consensus




Moderate–severe flare-ups

(>2 in past year requiring ED

or oral corticosteroids)

Consider Indicated Indicated



PICU)

Indicated Indicated Indicated

Preventer should be started as a treatment trial. Assess response after 4–6 weeks and review before prescribing long term.

ED: emergency department

Indicated: Prescribe preventer and monitor as a treatment trial. At follow-up, discontinue if ineffective



‡ Symptoms between flare-ups. A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g. symptoms that arejust outside the normal range of variation for the child, documented when well) to severe (e.g. events that require urgent action byparents/carers and health professionals to prevent a serious outcome such as hospitalisation or death from asthma).


Asset ID: 16

Table. Definitions of ICS dose levels in children

Inhaled corticosteroid Daily dose (microg)

Low High

Beclometasone dipropionate † 100–200 >200 (maximum 400)

Budesonide 200–400 >400 (maximum 800)

Ciclesonide ‡ 80–160 >160 (maximum 320)

Fluticasone propionate 100–200 >200 (maximum 500)

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate)

‡ Ciclesonide is registered by the TGA for use in children aged 6 and over

Source

van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The ThoracicSociety of Australia and New Zealand, 2010. Available from: http://www.thoracic.org.au/clinical-documents/area?command=record&id=14


Asset ID: 21

Assess response after 4–6 weeks and review before prescribing long term. At this follow-up, discontinue if ineffective.

See: Reviewing initial treatment in children aged 6 years and over

If cough does not respond to a treatment trial with a preventer, cease treatment instead of increasing the dose.

Repeat the treatment trial if the effect on symptoms is unclear.

More information

Classification of symptom patterns in children

The pattern and severity of symptoms in a child with asthma or preschool wheeze is a guide to initial treatment.



Symptoms every

6 months or less

Symptoms every

3–4 months

Symptoms every

4–6 weeks

Symptoms at least

once per week

Mild flare-ups

(managed with

salbutamol in

community)



ups


corticosteroids)



Consensus




Consensus



Consensus



Symptoms every

6 months or less

Symptoms every

3–4 months

Symptoms every

4–6 weeks

Symptoms at least

once per week



PICU)











In children taking preventer, symptoms should be managed with a short-acting inhaled beta2 agonist reliever (e.g. when child shows

difficulty breathing).


Asset ID: 20

Table. Definitions of asthma patterns in children aged 6 years and over not taking regular preventer

Category Pattern and intensity of symptoms (when not taking regular

treatment)

Infrequent intermittent asthma † Symptom-free for at least 6 weeks at a time (flare-ups up to once

every 6 weeks on average but no symptoms between flare-ups)

Frequent intermittent asthma Flare-ups more than once every 6 weeks on average but no symptoms

between flare-ups

Persistent asthma Mild FEV1 ≥80% predicted and at least one of:

Daytime symptoms‡ more than once per week but not every day

Night-time symptoms‡ more than twice per month but not every

week

Moderate Any of:

FEV1 <80% predicted‡

Daytime symptoms‡ daily

Night-time symptoms‡ more than once per week

Category Pattern and intensity of symptoms (when not taking regular

treatment)

Symptoms sometimes restrict activity or sleep

Severe Any of:

FEV1 ≤60% predicted‡

Daytime symptoms‡ continual

Night-time symptoms‡ frequent

Flare-ups frequent

Symptoms frequently restrict activity or sleep

† It may not be appropriate to make the diagnosis of asthma in children aged 6 or older who wheeze only during upper respiratory

tract infections. These children can be considered to have episodic (viral) wheeze.

‡ Symptoms between flare-ups. A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g. symptoms that arejust outside the normal range of variation for the child, documented when well) to severe (e.g. events that require urgent action byparents and health professionals to prevent a serious outcome such as hospitalisation or death from asthma).

Asset ID: 15

Table. Classification of asthma and indications for initiating preventer treatment in children aged 6–11

Severity of flare-ups

Average frequency of flare-ups and symptoms between flare-ups

Infrequent intermittent

Flare-ups every 6 weeks

or less and no symptoms

between flare-ups

Frequent intermittent

Flare-ups more than once

every 6 weeks and no

symptoms between flare-

ups

Persistent

Between flare-ups (any

of):

Daytime


once per week

Night-time


twice per month

Symptoms restrict

activity or sleep

Mild flare-ups

(almost always managed

with salbutamol in

Not indicated Consider Indicated

community)

Moderate–severe flare-ups

(>2 in past year requiring ED

or oral corticosteroids)

Consider Indicated Indicated



PICU)

Indicated Indicated Indicated

Preventer should be started as a treatment trial. Assess response after 4–6 weeks and review before prescribing long term.

ED: emergency department

Indicated: Prescribe preventer and monitor as a treatment trial. At follow-up, discontinue if ineffective



‡ Symptoms between flare-ups. A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g. symptoms that arejust outside the normal range of variation for the child, documented when well) to severe (e.g. events that require urgent action byparents/carers and health professionals to prevent a serious outcome such as hospitalisation or death from asthma).


Asset ID: 16

For children already taking regular preventer treatment, adjustments to the treatment regimen are based on finding the lowest dose ofmedicines that will maintain good control of symptoms.










Recurrent pneumonia





Source


Asset ID: 13











0-5 years





6 years and over



bronchodilator).1

Short-acting beta-2 agonist relievers for children: 6 years and over

Inhaled short-acting beta2 agonists is the major class of bronchodilators used for relief of symptoms in asthma.4

Children with well-controlled asthma need little or no reliever (on no more than 2 days per week).

Increased use of short-acting beta2 agonists for relief of asthma symptoms, especially daily use, indicates deterioration of asthma

control.5, 6

Dispensing of 3 or more canisters in a year (average 1.6 puffs per day) is associated with increased risk of flare-ups.7 Dispensing 12 or

more canisters in a year (average 6.6 puffs per day) is associated with increased risk of asthma death.2

Table. Definition of levels of recent asthma symptom control in children (regardless of current treatmentregimen)

Good control Partial control Poor control

All of:

Daytime symptoms† ≤2 days per

week (lasting only a few minutes

Any of:

Daytime symptoms† >2 days per

week (lasting only a few minutes

Either of:

Daytime symptoms† >2 days per

week (lasting from minutes to


Good control Partial control Poor control

and rapidly relieved by rapid-

acting bronchodilator)

No limitation of activities‡

No symptoms§ during night or

when wakes up

Need for SABA reliever# ≤2 days

per week

and rapidly relieved by rapid-

acting bronchodilator)

Any limitation of activities*

Any symptoms during night or

when wakes up††

Need for SABA reliever# >2 days

per week

hours or recurring, and partially or

fully relieved by SABA reliever)

≥3 features of partial control

within the same week

SABA: short-acting beta2 agonist

† e.g. wheezing or breathing problems

‡ child is fully active; runs and plays without symptoms

§ including no coughing during sleep

# not including doses taken prophylactically before exercise. (Record this separately and take into account when assessingmanagement.)

* e.g. wheeze or breathlessness during exercise, vigorous play or laughing

†† e.g. waking with symptoms of wheezing or breathing problems

Notes:

Recent asthma control is based on symptoms over the previous 4 weeks. Each child’s risk factors for future asthma outcomes shouldalso be assessed and taken into account in management.

Validated questionnaires can be used for assessing recent symptom control:Test for Respiratory and Asthma Control in Kids (TRACK) for children < 5 yearsChildhood Asthma Control Test (C-ACT) for children aged 4–11 years


Asset ID: 23


Inhaled corticosteroids for children: efficacy

Role in treatment asthma in children

The effectiveness of ICS in children appears to depend on several factors including the child’s age, which triggers are causing symptoms,

wheezing phenotype, tobacco smoke exposure and genotype.8 Overall, inhaled corticosteroids seem to be more effective in older

children and those with more severe disease.9

Early introduction of inhaled corticosteroid for children with recurrent wheeze does not prevent airway remodelling, improve long-term lung function or prevent the onset of persistent asthma, according to current evidence from long-term randomised controlled

clinical trials in preschool children and school-aged children with intermittent or mild persistent asthma.9

Current evidence does not support planned seasonal use of inhaled corticosteroids in children not taking preventer at other times.10


Intermittent wheeze/asthma

In preschool children who only have wheezing episodes with viral respiratory infections, limited available evidence suggests that regulartreatment with inhaled corticosteroids does not reduce the risk of hospitalisation, flare-ups that require oral corticosteroid use, or

reduce the frequency and duration of acute episodes.8, 11 Inhaled corticosteroid treatment does not reduce these children’s risk of

developing persistent wheeze by age 6 years.12

Persistent wheeze/asthma

In preschool children who have episodes of wheezing from time to time, but also cough and wheezes at other times when they do not

have a viral cold (e.g. when cries, plays or laughs), regular inhaled corticosteroids are moderately effective in controlling symptoms,

though less effective than in older children.12 When wheeze improves markedly during a short treatment trial (e.g. 3 months), it is not

possible to tell whether improvement was due to the treatment or spontaneous resolution of symptoms.12 However, this can beclarified by stopping inhaled corticosteroid treatment, monitoring symptoms, and re-starting.

In infants and preschoolers with persistent wheezing or asthma of at least 6 months’ duration, regular treatment with inhaled

corticosteroids improves wheezing, asthma symptoms and lung function, and reduces flare-ups.9, 13

Children aged 6 years and over

Most clinical trials of regular inhaled corticosteroid treatment in children have been conducted among children with asthma symptoms

every week or more often (‘persistent asthma’).9

Beclometasone dipropionate, budesonide, ciclesonide and fluticasone propionate have all been shown to be effective in children. There

have been relatively fewer studies of ciclesonide in children,9 but, overall, randomised clinical trials show that it is equally effective as

budesonide or fluticasone propionate in improving asthma symptoms and reducing flare-ups.14 In some studies, ciclesonide was

associated with less adrenal suppression or height than comparator inhaled corticosteroids.14

In a study of school-aged children with more than 2 days per week with symptoms, night waking more than twice per month due toasthma symptoms, or needing regular preventer, regular low-dose daily inhaled corticosteroid treatment reduced the rate of flare-ups that require treatment with oral corticosteroids, compared with no regular preventer treatment and as-needed short-acting

beta2agonist for wheezing episodes.15

In a study of children aged 4–11 years with asthma diagnosed within the previous 2 years and symptoms more than weekly in theprevious 3 months, regular preventer was associated with a reduction in serious flare-ups, school absence due to asthma, an increase in

symptom-free days, and improved lung function, compared with placebo.16, 17

The Thoracic Society of Australia and New Zealand’s current position statement on the use of inhaled corticosteroids in children9

recommends regular treatment with inhaled corticosteroid:

as a first-choice preventer for children with asthma symptoms at least daily or night-time symptoms at least twice per week betweenflare-upsas an alternative to cromones (nedocromil or sodium cromoglycate) or montelukast in children with any daytime or night-timesymptoms between flare-ups, or those with flare-ups every 6 weeks or more.

Doses

In the majority of children, asthma control can be achieved with any of the following initial doses:9

budesonide up to 400 microg/daybeclometasone (Qvar) up to 200 microg/dayciclesonide up to 160 microg/dayfluticasone propionate up to 200 microg/day.

If these doses do not achieve control of symptoms, possible explanations include alternative diagnoses, adherence, incorrect inhaler

technique, psychosocial factors and exposure to tobacco smoke or other triggers such as allergens.9

Dose–response studies of inhaled corticosteroids show that the maximal efficacy is generally achieved at a dose equivalent to

approximately 200 microg/day fluticasone propionate,9 while the risk of adrenal suppression increases exponentially at doses above

500 microg/day.9 Therefore (based on theoretical equivalents between different agents), upper limits of daily doses for children are:

budesonide 800 microg/daybeclometasone dipropionate [Qvar] 400 microg/dayciclesonide 320 microg/dayfluticasone propionate 500 microg/day.

Higher doses are unlikely to be more effective, and are likely to cause systemic effects.9

Most studies of inhaled corticosteroids in children have used twice-daily dosing.9 Fluticasone propionate is only approved for twice-

daily dosing, but the other inhaled corticosteroids are approved for once daily dosing. Ciclesonide is effective when given once daily.9

Note: Do not use beclometasone dose recommendations from outdated or overseas guidelines based on older formulationscontaining CFC propellant – doses are different.

Table. Definitions of ICS dose levels in children

Inhaled corticosteroid Daily dose (microg)

Low High

Beclometasone dipropionate † 100–200 >200 (maximum 400)

Budesonide 200–400 >400 (maximum 800)

Ciclesonide ‡ 80–160 >160 (maximum 320)

Fluticasone propionate 100–200 >200 (maximum 500)

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate)

‡ Ciclesonide is registered by the TGA for use in children aged 6 and over

Source

van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The ThoracicSociety of Australia and New Zealand, 2010. Available from: http://www.thoracic.org.au/clinical-documents/area?command=record&id=14


Asset ID: 21


Montelukast for children: efficacy

Montelukast use has been associated with behavioural and/or neuropsychiatric adverse effects, including suicidality.

Overview

Montelukast is a leukotriene receptor antagonist preventer. It is registered by the TGA for the treatment of asthma in children aged 2

years and older, and for the symptomatic treatment of allergic rhinitis.18

Montelukast can be used as an alternative to inhaled corticosteroids or as an add-on treatment in a child already taking regular inhaledcorticosteroids.

However, it is not effective for all children. Overall, only approximately 20–30% of children will respond to montelukast treatment. The

effect is thought to depend mainly on the child’s genotype.19, 20, 21 Clinically, it is not possible to predict accurately which children willbenefit most from montelukast treatment.

Montelukast as first-line preventer in children aged 2–5 years

Viral-induced wheezing

Overall, regular maintenance montelukast treatment does not reduce the risk of wheezing episodes requiring oral corticosteroid

treatment among preschool children who only have wheezing episodes when they have viral upper respiratory tract infections.22

However, montelukast may be effective for some children. Some randomised controlled trials have reported a reduction the risk of

flare-ups in preschool children with intermittent asthma/wheeze,23, 24 while others have not.25

Persistent asthma or wheezing

A systematic review comparing montelukast with inhaled corticosteroids in preschoolers with asthma or recurrent wheezing requiring

daily preventer treatment26 reported that inhaled corticosteroids appeared to achieve better symptom control and reduce flare-ups(including severe flare-ups requiring treatment with systemic corticosteroids). However, results were inconsistent and meta-analysis

was not possible due to heterogeneity of outcomes measured in available clinical trials.26

Some preschool children with persistent asthma/wheeze respond to montelukast. A crossover study in preschool children withpersistent asthma/wheeze reported that some children showed their best response to montelukast, while most responded better to

regular inhaled corticosteroids.27 Predictors of a better response to inhaled corticosteroids than montelukast were aeroallergen

hypersensitivity and blood eosinophilia (eosinophil counts ≥ 300/μL).27 However, routine blood eosinophil count is not feasible orrecommended for this purpose.

Montelukast as first-line preventer children aged 6 years and over

Go to: TGA alert

In school-aged children with persistent asthma, inhaled corticosteroids are more effective overall than montelukast in improving lung

function and controlling asthma symptoms.28, 30

However, symptoms will respond to a treatment trial of montelukast in approximately one-quarter to one-third of children,28, 31,32 and

some may benefit more than from an inhaled corticosteroid.28 More severe asthma and markers of allergic inflammation may predict a

better response to inhaled corticosteroids.28

Montelukast as add-on treatment

A systematic review of studies in children over 6 years and adolescents with mild-to-moderate persistent asthma found that theaddition of montelukast to inhaled corticosteroids did reduce flare-ups requiring oral corticosteroids or hospital admissions for asthma,

compared with the same or an increased dose.30

In a study comparing step-up treatments in children with asthma symptoms uncontrolled by low-dose inhaled corticosteroids, theaddition of a long-acting beta2 agonist was effective in more children than either montelukast or increasing the dose of inhaled

corticosteroid for controlling asthma symptoms and preventing flare-ups requiring systemic corticosteroids.33 However, some studiesin school-aged children with persistent asthma already taking regular inhaled corticosteroids have reported that add-on montelukast

reduced the risk of flare-ups33, 34 and exercise-induced asthma symptoms.34 Not all children will respond.

In a small study in children with persistent asthma already taking regular inhaled corticosteroids who were homozygous for the Arg16genotype, montelukast was more effective as an add-on therapy than long-acting beta2 agonist in reducing symptoms, reliever use and

days absent from school due to asthma, depending on the child’s beta receptor genotype.21 However, children were given inhaledcorticosteroid and long-acting beta2 agonists in separate inhalers, which is which is known to be associated with increased risks.

However, genotyping it is not currently feasible in clinical practice. In practice, a treatment trial of 4–6 weeks can determine which

preventer is suitable for controlling a child’s asthma symptoms,28 but longer treatment may be required to evaluate effect on flare-ups,because flare-ups may be independent of symptom control.

Exercise-induced symptoms

In school-aged children who experience exercise-induced symptoms despite taking regular inhaled corticosteroids, the addition of

montelukast is effective in controlling symptoms, but not all children experience a response.35, 36


Short-term use in the management of flare-ups

Some, but not all studies suggest that a short course of montelukast, introduced at the first signs of an upper respiratory tract infection,may be effective in controlling flare-ups. An Australian study reported that this strategy could achieve a small reduction in symptoms,

school absence and medical consultations in preschool and school-aged children with episodic wheeze.37

However, the evidence is inconsistent, with some studies showing no benefit.25,38, 39, 40, 41 The findings of one study suggested that

whether or not intermittent montelukast is effective in wheezing children aged 5 years and under depends on genotype.20

Montelukast is not TGA-approved or PBS-subsidised for intermittent use.

Note: PBS status as at March 2019: Montelukast is not subsidised by the PBS for adolescents 15 years and over.


Administration of inhaled medicines in children: 6 years and over

Parents, carers and children need training to use inhaler devices correctly, including inhaler technique, and care and cleaning of inhalersand spacers.

School-aged children (depending on the child’s age, ability, and with individualised training) can learn to use a range of inhalertypes, including manually actuated pressurised metered-dose inhalers with spacers, breath-actuated pressurised metered-dose

inhalers (e.g. Autohaler), and dry-powder inhalers (e.g. Accuhaler, Turbuhaler).42, 43, 44, 45, 46

Table. Types of inhaler devices for delivering asthma and COPD medicines

Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/75

A pressurised metered-dose inhaler and spacer is an appropriate first choice for most children.44

School-aged children are unlikely to use their inhaler device correctly without careful training and repeated checking.47


Correct use of inhaler devices

Checking and correcting inhaler technique is essential to effective asthma management.

Most patients with asthma or COPD do not use their inhalers properly,48, 49,50, 50, 51 and most have not had their technique checked orcorrected by a health professional.

Incorrect inhaler technique when using maintenance treatments increases the risk of severe flare-ups and hospitalisation for people

with asthma or COPD.48, 49, 52, 53, 54, 55

Poor asthma symptom control is often due to incorrect inhaler technique.56, 57

Incorrect inhaler technique when using inhaled corticosteroids increases the risk of local side effects like dysphonia and oral thrush.

The steps for using an inhaler device correctly differ between brands. Checklists of correct steps for each inhaler type and how-tovideos are available from the National Asthma Council website.


References


1.


2.


3.

Walters EH, Walters JA, Gibson PG, Jones P. Inhaled short acting beta2-agonist use in chronic asthma: regular versus as neededtreatment. Cochrane Database Syst Rev. 2003; Issue 1: CD001285. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001285/full

4.

Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available from:http://www.ginasthma.org

5.

British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma.Quick Reference Guide. Revised May 2011. BTS, SIGN, Edinburgh, 2008.

6.

Stanford, R. H., Shah, M. B., D'Souza, A. O., et al. Short-acting beta-agonist use and its ability to predict future asthma-relatedoutcomes. Ann Allergy Asthma Immunol. 2012; 109: 403-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23176877

7.

Ducharme FM, Krajinovic M. Steroid responsiveness and wheezing phenotypes. Paediatr Respir Rev. 2011; 12: 170-176. Available8.

Go to: National Asthma Council Australia’s How to use a puffer and spacer for kids videoGo to: National Asthma Council Australia's information paper for health professionals on Inhaler technique for people with asthma orCOPD

Go to: National Asthma Council Australia's Using your inhaler webpage for information, patient resources and videos on inhalertechniqueGo to: National Asthma Council Australia's information paper for health professionals on Inhaler technique for people with asthma orCOPDGo to: NPS MedicineWise information on Inhaler devices for respiratory medicines

from: http://www.ncbi.nlm.nih.gov/pubmed/21722845van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The ThoracicSociety of Australia and New Zealand, 2010. Available from: https://www.thoracic.org.au/journal-publishing/command/download_file/id/25/filename/The_role_of_corticosteroids_in_the_management_of_childhood_asthma_-_2010.pdf

9.

Chong J, Haran C, Chauhan BF, Asher I. Intermittent inhaled corticosteroid therapy versus placebo for persistent asthma inchildren and adults. Cochrane Database Syst Rev. 2015; : Cd011032. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26197430

10.

McKean MC, Ducharme F. Inhaled steroids for episodic viral wheeze of childhood. Cochrane Database Syst Rev. 2000; 2: CD001107.Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001107/full

11.


12.

Castro-Rodriguez JA, Rodrigo GJ. Efficacy of inhaled corticosteroids in infants and preschoolers with recurrent wheezing andasthma: A systematic review with meta-analysis. Pediatrics. 2009; 123: e519-e525. Available from:http://pediatrics.aappublications.org/content/123/3/e519.full

13.

Kramer S, Rottier BL, Scholten RJ, Boluyt N. Ciclesonide versus other inhaled corticosteroids for chronic asthma in children.Cochrane Database Syst Rev. 2013; Issue 2: CD010352. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010352/full

14.

Martinez FD, Chinchilli VM, Morgan WJ, et al. Use of beclomethasone dipropionate as rescue treatment for children with mildpersistent asthma (TREXA): a randomised, double-blind, placebo-controlled trial. Lancet. 2011; 377: 650-7. Available from:http://www.ncbi.nlm.nih.gov/pubmed/21324520

15.

Weiss K, Buxton M, Andersson FL et al. Cost-effectiveness of early intervention with once-daily budesonide in children with mildpersistent asthma: results from the START study. Pediatr Allergy Immunol 2006; 17 Suppl 17: 21-7. Available from:https://www.ncbi.nlm.nih.gov/pubmed/16573705

16.

Chen YZ, Busse WW, Pedersen S et al. Early intervention of recent onset mild persistent asthma in children aged under 11 yrs: theSteroid Treatment As Regular Therapy in early asthma (START) trial. Pediatr Allergy Immunol 2006; 17 Suppl 17: 7-13. Availablefrom: https://www.ncbi.nlm.nih.gov/pubmed/16573703

17.

Merck, Sharp and Dohme Australia Pty Ltd. Product Information: Singulair (montelukast sodium) Tablets. Therapeutic GoodsAdministration, Canberra, 2013. Available from: https://www.ebs.tga.gov.au/

18.

Bush A. Montelukast in paediatric asthma: where we are now and what still needs to be done? Paediatr Respir Rev. 2015; 16:97-100. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25499571

19.

Nwokoro C, Pandya H, Turner S, et al. Intermittent montelukast in children aged 10 months to 5 years with wheeze (WAIT trial): amulticentre, randomised, placebo-controlled trial. Lancet Respir Med. 2014; 2: 796-803. Available from:https://www.ncbi.nlm.nih.gov/pubmed/25212745

20.

Lipworth BJ, Basu K, Donald HP, et al. Tailored second-line therapy in asthmatic children with the Arg(16) genotype. Clin Sci (Lond).2013; 124: 521-528. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23126384

21.

Brodlie M, Gupta A, Rodriguez-Martinez CE, et al. Leukotriene receptor antagonists as maintenance and intermittent therapy forepisodic viral wheeze in children. Cochrane Database Syst Rev. 2015; Issue 10: CD008202. Available from:https://www.ncbi.nlm.nih.gov/pubmed/26482324

22.

Bisgaard H, Zielen S, Garcia-Garcia ML, et al. Montelukast reduces asthma exacerbations in 2- to 5-year-old children withintermittent asthma. Am J Respir Crit Care Med. 2005; 171: 315-322. Available from: http://ajrccm.atsjournals.org/content/171/4/315.long

23.

Nagao M, Ikeda M, Fukuda N, et al. Early control treatment with montelukast in preschool children with asthma: a randomizedcontrolled trial. Allergol Int. 2018; 67: 72-78. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28526210

24.

Valovirta, E., Boza, M. L., Robertson, C. F., et al. Intermittent or daily montelukast versus placebo for episodic asthma in children.Ann Allergy Asthma Immunol. 2011; 106: 518-26. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21624752

25.

Castro-Rodriguez JA, Rodriguez-Martinez CE, Ducharme FM. Daily inhaled corticosteroids or montelukast for preschoolers withasthma or recurrent wheezing: A systematic review. Pediatr Pulmonol. 2018; Epub ahead of print 6 November. Available from:https://www.ncbi.nlm.nih.gov/pubmed/30394700

26.

Fitzpatrick AM, Jackson DJ, Mauger DT et al. Individualized therapy for persistent asthma in young children. J Allergy Clin Immunol.2016; 138: 1608-18.e12. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27777180

27.

Jartti T. Inhaled corticosteroids or montelukast as the preferred primary long-term treatment for pediatric asthma? Eur J Pediatr.2008; 167: 731-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18214538

28.

Benard, B., Bastien, V., Vinet, B., et al. Neuropsychiatric adverse drug reactions in children initiated on montelukast in real-lifepractice. Eur Respir J. 2017; 50: . Available from: https://www.ncbi.nlm.nih.gov/pubmed/28818882

29.

Chauhan BF, Ben Salah R, Ducharme FM. Addition of anti-leukotriene agents to inhaled corticosteroids in children with persistentasthma. Cochrane Database Syst Rev. 2013; Issue 10: CD009585. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24089325

30.

Maspero, J, Guerra, F, Cuevas, F, et al. Efficacy and tolerability of salmeterol/fluticasone propionate versus montelukast inchildhood asthma: a prospective, randomized, double-blind, double-dummy, parallel-group study. Clin Ther. 2008; 30: 1492-1504.

31.

Pedersen S, Maspero J, Gul N, Sharma R. Components of asthma control and treatment response of individual control criteria inchildren: analysis of the PEACE study. Pediatr Pulmonol. 2011; 46: 1182-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21751432

32.

Malka J, Mauger DT, Covar R, et al. Eczema and race as combined determinants for differential response to step-up asthma therapy.J Allergy Clin Immunol. 2014; 134: 483-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24835502

33.

Stelmach I, Ozarek-Hanc A, Zaczeniuk M et al. Do children with stable asthma benefit from addition of montelukast to inhaled34.

corticosteroids: randomized, placebo controlled trial. Pulm Pharmacol Ther. 2015; 31: 42-8. Available from:https://www.ncbi.nlm.nih.gov/pubmed/25640020Grzelewski, T, Stelmach, I. Exercise-induced bronchoconstriction in asthmatic children: a comparative systematic review of theavailable treatment options. Drugs. 2009; 69: 1533-1553. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19678711

35.

Fogel RB, Rosario N, Aristizabal G, et al. Effect of montelukast or salmeterol added to inhaled fluticasone on exercise-inducedbronchoconstriction in children. Ann Allergy Asthma Immunol. 2010; 104: 511-517. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20568384

36.

Robertson CF, Price D, Henry R, et al. Short-course montelukast for intermittent asthma in children: a randomized controlled trial.Am J Respir Crit Care Med. 2007; 175: 323-329. Available from: http://ajrccm.atsjournals.org/content/175/4/323.long

37.

Watts, K, Chavasse, R J P G. Leukotriene receptor antagonists in addition to usual care for acute asthma in adults and children.Cochrane Database Syst Rev. 2012; Issue 5: . Available from: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD006100.pub2/full

38.

Capsomidis, A., Tighe, M.. Archimedes. Question 2. Is oral montelukast beneficial in treating acute asthma exacerbations inchildren?. Arch Dis Child. 2010; 95: 948-50. Available from: http://adc.bmj.com/content/95/11/948.long

39.


40.

Bacharier LB, Phillips BR, Zeiger RS, et al. Episodic use of an inhaled corticosteroid or leukotriene receptor antagonist in preschoolchildren with moderate-to-severe intermittent wheezing. J Allergy Clin Immunol. 2008; 122: 1127-1135. Available from:https://www.ncbi.nlm.nih.gov/pubmed/18973936

41.

Gillette, C., Rockich-Winston, N., Kuhn, J. A., et al. Inhaler technique in children with asthma: a systematic review. Acad Pediatr.2016; 16: 605-15. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27130811

42.

Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their effect ondisease control among children with asthma using metered dose or dry powder inhalers. J Asthma. 2015; 52: 838-45. Availablefrom: http://www.ncbi.nlm.nih.gov/pubmed/26037396

43.

Ram, F S F, Brocklebank, D D M, White, J, et al. Pressurised metered dose inhalers versus all other hand-held inhaler devices todeliver beta-2 agonist bronchodilators for non-acute asthma. Cochrane Database Syst Rev. 2002; Issue 2: .

44.

Nikander, K, Turpeinen, M, Pelkonen, A S, et al. True adherence with the Turbuhaler in young children with asthma. Arch Dis Child.2011; 96: 168-173.

45.

Pedersen, S., Mortensen, S.. Use of different inhalation devices in children. Lung. 1990; 168 Suppl: 653-7. Available from:https://www.ncbi.nlm.nih.gov/pubmed/2117175

46.

Sleath, B, Ayala, G X, Gillette, C, et al. Provider demonstration and assessment of child device technique during pediatric asthmavisits. Pediatrics. 2011; 127: 642-648.

47.

The Inhaler Error Steering Committee,, Price, D., Bosnic-Anticevich, S., et al. Inhaler competence in asthma: common errors,barriers to use and recommended solutions. Respir Med. 2013; 107: 37-46. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23098685

48.

Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease.Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25195762

49.

Basheti, I A, Armour, C L, Bosnic-Anticevich, S Z, Reddel, H K. Evaluation of a novel educational strategy, including inhaler-basedreminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from:http://www.ncbi.nlm.nih.gov/pubmed/18314294

50.

Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational interventionsdelivered in community pharmacy over time. The Journal of asthma : official journal of the Association for the Care of Asthma. 2010; 47:251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511

51.

Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced diseasecontrol. Respir Med. 2011; 105: 930-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21367593

52.

Levy ML, Dekhuijzen PN, Barnes PJ, et al. Inhaler technique: facts and fantasies. A view from the Aerosol Drug ManagementImprovement Team (ADMIT). NPJ Prim Care Respir Med. 2016; 26: 16017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27098045

53.

Haughney, J., Price, D., Barnes, N. C., et al. Choosing inhaler devices for people with asthma: current knowledge and outstandingresearch needs. Respiratory medicine. 2010; 104: 1237-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20472415

54.

Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. The Europeanrespiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004

55.

Harnett, C. M., Hunt, E. B., Bowen, B. R., et al. A study to assess inhaler technique and its potential impact on asthma control inpatients attending an asthma clinic. J Asthma. 2014; 51: 440-5.

56.

Hardwell, A., Barber, V., Hargadon, T., et al. Technique training does not improve the ability of most patients to use pressurisedmetered-dose inhalers (pMDIs). Prim Care Respir J. 2011; 20: 92-6. Available from: http://www.nature.com/articles/pcrj201088

57.

VERSION 2.0 DIAGNOSIS

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