22 Diagnosis Confirm the diagnosis with objective measures. Spirometry is the “gold standard.” Diagnosis Some children experience severe and life-interfering exacerbations … periods of normal lung function and no symptoms. Any child with asthma can experience a life- threatening episode. If the initial symptoms suggest asthma, then suspect asthma! Establish the diagnosis with a careful history. Focus on symptom patterns. Diagnosing the Child with Asthma How do you diagnose asthma in children? The clinician must …

Diagnosis Some children experience severe and life-interfering exacerbations separated by long periods of normal lung function and no symptoms. Any child with asthma can experience a life- threatening episode. If the initial symptoms suggest asthma, then suspect asthma! Establish the diagnosis with a careful history. Focus on symptom patterns. Diagnosing the Child with Asthma How do you diagnose asthma in children? The clinician must determine that: •Episodic symptoms of airflow obstruction (coughing, wheezing, shortness of breath or rapid breathing, chest tightness) are present. Airflow limitation is at least partially reversible. Alternative diagnoses are excluded. Note: Signs and symptoms of asthma can vary widely and may mimic other common childhood illnesses. Diagnosis can be difficult and has important implications. ?On the one hand, asthma is frequently underdiagnosed and, thus, many infants and young children do not receive adequate therapy. ?On the other hand, not all wheeze and cough are caused by asthma, and caution is needed to avoid giving infants and young children inappropriately prolonged asthma therapy. Recurrent episodes of cough with or without wheezing are almost always due to asthma. Coughing may be the only symptom present. Diagnosis 23 In early childhood, asthma is often misdiagnosed. Many infants and young children do not receive appropriate therapy. Consider that in children… •Wheezing does not always mean asthma. •Asthma may be present without wheeze . . . . . Signs and symptoms suggesting that the child does NOT have asthma: •Failure to thrive •Cyanosis at feeding •Vomiting at feeding •Failure to respond to appropriate treatment •Clubbing Consider alternate diagnoses! Diagnosis of children who wheeze with respiratory infections can be difficult. •Underdiagnosis of asthma is a frequent problem, especially in children who wheeze when they have respiratory infections. ?These children are often labeled as having bronchitis, bronchiolitis, or pneumonia. Infants and young children (< 6 years) often wheeze with viral upper respiratory infections (URIs), and may benefit from asthma treatment. Infants with indications of allergy (eczema, chronic rhinitis, positive skin tests) are more likely to wheeze throughout childhood, and may be at risk for asthma even without early symptoms. For most nonallergic infants, the wheezing lessens and ultimately disappears in the preschool years. Consider asthma in children with repeated diagnoses of: Reactive airway disease Allergic bronchitis Wheezy bronchitis Asthmatic bronchitis Recurrent pneumonia Recurrent bronchiolitis Less Common Masqueraders of Asthma in Children Upper airway noise/congestion Cystic fibrosis Tracheoesophageal fistula Gastroesophageal reflux Bronchopulmonary dysplasia Foreign body aspiration Vascular ring Primary immunodeficiency Congenital heart disease Vocal cord dysfunction

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