ASTHMA - Children 1 to 6 diagnosis and tx

Question 1

When should the diagnosis of asthma be considered in children 1 to 5 years old?

Answer 1

with frequent (≥8 days/month) asthma-like symptoms or recurrent (≥2) exacerbations (episodes with
asthma-like signs).

The diagnosis requires the objective document of signs or convincing parent-reported symptoms of airflow obstruction (improvement in these signs or symptoms with asthma therapy), and no clinical
suspicion of an alternative diagnosis. The characteristic feature of airflow obstruction is wheezing, commonly accompanied by difficulty breathing and cough. Reversibility with asthma medications is defined as direct observation of improvement with short-acting ß2-agonists (SABA) (with or without oral corticosteroids) by a trained health care practitioner during an acute exacerbation (preferred method).

However, in children with no wheezing (or other signs of airflow obstruction) on presentation, reversibility may be determined by convincing parental report of a symptomatic response to a three-month therapeutic trial of a medium dose of inhaled corticosteroids with as-needed SABA (alternative method), or as-needed
SABA alone (weaker alternative method).

Question 2

Why is it difficult for children <6 to be diagnosed with asthma?

Answer 2

In children <6 years of age, the forced expiratory manoeuvre
required for spirometry is difficult to perform, and alternative lung
function tests for preschoolers are limited to a few pediatric academic
settings or are insufficiently specific. Consequently, there is controversy as to when the diagnostic label of ‘asthma’ should be applied to
preschool-age children

Question 3

What age to kids usually show onset of asthma?

Answer 3

preschoolers!

Question 4

What is wheezing in early life associated with later on in terms of lung function?

Answer 4

Wheezing in early life has been
associated with reduced lung function at six years of age that generally
persists until adulthood (11); the magnitude of the reduction is
approximately a 10% lower predicted forced expiratory volume in 1 s
(FEV1), compared with healthy peers (11). Airway remodelling (ie,
irreversible damage to the airways) has been documented in toddlers
and may explain the altered lung function trajectory (12).

Question 5

What % of children become asymptomatic by 6 years?

Answer 5

60%

Question 6

Does preschool wheezing respond to ICS?

Answer 6

YES!

Question 7

What are the characteristic symptoms of asthma?

Answer 7

• episodic or persistent symptoms of dyspnea, chest tightness, wheezing, sputum production and cough.

Question 8

What is the most specific sign of airflow obstruction?

Answer 8

Wheezing

Occurring
predominantly during expiration, with increasing airflow obstruction,
wheezing can be heard during inspiration until it becomes absent withseverely diminished airflow
With increasing airflow
obstruction, tachypnea, prolonged expiration, signs of accessory
muscle use (eg, chest indrawing), hypoxemia and, in severe cases,
altered level of consciousness (eg, agitation or apathy) can be
observed. Cough is the most commonly observed sign and reported
symptom, but it is not specific to asthma

Question 9

Although cough is the most commonly observed sign and symptom it is not specific to asthma. When might it be more suggestive of asthma?

Answer 9

Apart from viral respiratory infections, a chronic cough that occurs during sleep or is triggered by allergen exposures, exertion, laughing or crying increases the likelihood of asthma (15)

Question 10

How is reversility of airflow obstruction defined?

Answer 10

More specifically,
reversibility is best defined as a documented response to short-acting
ß2-agonists (SABA) (with or without oral corticosteroids) by health
care professionals during an acute exacerbation (preferred diagnostic
method). In children with no objective signs of airflow obstruction
(ie, symptoms only), reversibility may be determined by convincing parental report of symptomatic response to a three-month
therapeutic trial of a medium dose of inhaled corticosteroids with
as-needed SABA (alternative diagnostic method), or convincingly
reported and repeatedly observed response to as-needed SABA alone
by parents (weaker, alternative diagnostic method) (Table 1).

Question 11

What are the operational diagnostic criteria for asthma in children 1 to 5 years old?

Answer 11

Question 12

What is the most frequent cause of recurrent cough in general?

Answer 12

Recurrent URTI with post nasal drip

Question 13

What is croup?

Answer 13

Croup presents with airflow obstruction in the upper airways with barking cough and inspiratory stridor; it is more common in children with asthma (and vice versa)

Question 14

What are 4 key messages regarding asthma diagnosis

Answer 14

3. Asthma can be diagnosed in children one to five years of age.
4. The diagnosis of asthma requires documentation of signs or
   symptoms of airflow obstruction, reversibility of obstruction
   (improvement in these signs or symptoms with asthma therapy)
   and no clinical suspicion of an alternative diagnosis.
5. Bronchiolitis usually presents as the first episode of wheezing in
   a child <1 year of age.
6. The diagnosis of asthma should be considered in children one to
   five years of age with recurrent asthma-like symptoms or
   exacerbations, even if triggered by viral infections.

Question 15

What are 6 alternative diagnosis to asthma ie. red flags?

Answer 15

1. Upper airway narrowing: croup
2. infectious/allergic rhinosinusitis
3. Foreign-body inhalation
4. Aspiration of food/gastric contents
5. Bronchiolitis
6. Pneumonia, TB, pertussis
7. GERD
8. Eosinophilic esophagitis
9. Swallow problem, aspiration
10. Immune dysfunction
11. Pulmonary edema (congenital heart disease, acute myocarditis)

Question 16

Describe the diagnostic algorithm for ages 1-5 for asthma

Answer 16

Question 17

When is improvement in airflow obstruction expected with SABA, or ICS?

Answer 17

1. SABA - 20 minutes - a suboptimal response to SABA is anticipated if most of the airflow obstruction is not due to bronchospasm, particularly in a child with long-standing, poorly controlled asthma
2. ICS - 4 hours but may take several days

Question 18

How long is a trial of ICS recommended as a determinant of reversibility of airflow obstruction?

Answer 18

3 months - because onset of action within one to 4 weeks

Question 19

Which has less effect on growth, budesonide or fluticasone?

Answer 19

FLUTICASONE

Question 20

What does a conclusive therapeutic trial hinge upon in regards to asthma meds?

Answer 20

• adequate inhaler technique
• Diligent documentation of signs and or symptoms
• and timely medical assessment

Therapeutic trials should be conducted during seasons where the child is most symptomatic

Question 21

WHat are the Corticosteroid inhalers approved with dosing in children 1 to 5 years old?

Answer 21

Question 22

What is the preferred diagnostic approach in the following situations:
1. In children one to five years of age with recurrent (≥2) episodes of asthma-like symptoms and wheezing on presentation
2. Children one to five years of age with recurrent (≥2) episodes of
asthma-like symptoms, no wheezing on presentation, frequent
symptoms or any moderate or severe exacerbation
3. Children one to five years of age with recurrent (≥2) episodes of
asthma-like symptoms, no wheezing on presentation, infrequent
symptoms, and mild exacerbations

Answer 22

1. In children one to five years of age with recurrent (≥2) episodes of asthma-like symptoms and wheezing on presentation, direct observation of improvement with inhaled bronchodilator (with or without oral corticosteroids) by a physician or trained health care
   practitioner confirms the diagnosis (preferred diagnostic method).
2. Children one to five years of age with recurrent (≥2) episodes of asthma-like symptoms, no wheezing on presentation, frequent symptoms or any moderate or severe exacerbation warrant a three-month therapeutic trial with a medium daily dose of ICS (with as-needed SABA). Clear consistent improvement in the
   frequency and severity of symptoms and/or exacerbations confirms the diagnosis (alternative diagnostic method)
3. . Children one to five years of age with recurrent (≥2) episodes of
   asthma-like symptoms, no wheezing on presentation, infrequent
   symptoms, and mild exacerbations can be monitored and
   re-assessed by a health care practitioner when symptomatic.
   Alternatively, a therapeutic trial with as-needed SABA is
   suggested. Convincing parental report of a rapid and repeatedly
   observed response to SABA suggests the diagnosis (weaker
   alternative diagnostic method)

To adequately interpret a therapeutic trial, clinicians should
ascertain adherence to asthma therapy, inhalation technique
and parental report of monitored symptoms, at an appropriately
timed medical reassessment.

Question 23

When should we refer to specialist?

Answer 23

.Referral to an asthma specialist is recommended in children
one to five years of age with diagnostic uncertainty, suspicion
of comorbidity, poor symptom and exacerbation control despite
ICS at daily doses of 200 μg to 250 μg, a life-threatening event
(requiring intensive care admission and/or intubation) and/or
for allergy testing to assess the possible role of environmental
allergens.

Question 23

What is the treatment management for kids 1 to 5 years old diagnosed with asthma?

Answer 23

Question 24

What is the preferred first-line management of asthma once the diagnosis is confirmed and control has been achieved?

Answer 24

Daily ICS at lowest effective dose

Question 25

What does the notes say about diagnosis of asthma in kids 1 to 6?

Answer 25

Children less than six years-old cannot properly be diagnosed with spirometry. Also, wheezing and coughing are common in those less than two years-old who do not have asthma. A clinical history, physical exam and trial of treatment are used to make a clinical diagnosis.

Given that up to 50% of children less than 6 outgrow their symptoms, a monitored stopping of medication may be tried when the asthma is well-controlled with exposure to the child’s typical triggers, including no exacerbations, for at least 3-6 months.

How to treat those less than 6 is controversial but you will see ICS used in combinations with a prn SABA in some cases while a prn SABA alone in others.