Diagnosing asthma in pediatrics presents a unique set of challenges for healthcare professionals. Unlike many conditions, there isn’t a single definitive test to confirm asthma. Instead, accurate Asthma Diagnosis Pediatrics relies on a comprehensive approach, integrating characteristic symptom patterns, demonstrable variability in airflow limitation alongside airway inflammation, careful consideration of alternative diagnoses, and observed responses to treatment. Achieving a precise diagnosis is paramount for effectively managing pediatric asthma and improving patient outcomes.
Diagnosing asthma diagnosis pediatrics in children over the age of 5 often incorporates lung function tests. Peak expiratory flow (PEF) and spirometry are frequently employed to evaluate airflow obstruction and its reversibility. PEF is particularly useful in detecting diurnal variation, a hallmark feature of asthma. The Global Initiative for Asthma (GINA) guidelines emphasize the importance of PEF or spirometry in the diagnostic process for children older than 5 years. Once a child can reliably perform these tests, they become invaluable tools if an asthma diagnosis pediatrics hasn’t been definitively established. However, lung function testing in children under 5 years is often impractical outside of research environments, significantly complicating asthma diagnosis pediatrics in this younger age group. It’s important to note that diagnostic criteria for asthma diagnosis pediatrics can vary across different countries and regions, as highlighted in Table 2. Beyond initial diagnosis, lung function tests are also crucial for monitoring the progress of children with asthma as part of their ongoing care. Objective testing should be repeated if a child shows a poor response to treatment or if diagnostic uncertainty persists.
Table 2. Summary of pediatric asthma national guidelines: focusing on diagnosis
| Guideline | Year | Diagnostic criteria | Recommended objective testing | When to refer to a specialist | When to consider alternative diagnoses |
|---|---|---|---|---|---|
| NICE Guidelines (UK)49 | 2017 | Under 5 years: findings in clinical history and examination that are suggestive of asthmaOver 5 years: findings in clinical history and examination that are suggestive of asthma and either spirometry demonstrating obstructive airflow and bronchodilator reversibility or a FeNO level of 35 ppb or more | Over 5 years: Spirometry and bronchodilator reversibility or FeNO first line.Additional tests, PEF, bronchial challenge test with histamine or methacholine | Children who are not responding to treatment and/or cannot complete objective testingIf there is obstructive spirometry but negative bronchodilator reversibility and negative FeNO | When children have symptoms of asthma but normal objective testing results |
| Global Initiative for Asthma (global)20 | 2021 | 6 years and over: findings in clinical history that are suggestive of asthma plus evidence of variability in expiratory airflow limitation with either spirometry and bronchodilator reversibility, repeated PEF measurements, positive exercise challenge or positive bronchial challenge | 6 years and over: either spirometry, PEF, exercise challenge or bronchial challenge to detect variability in lung function | Diagnostic uncertainty, previous life-threatening attack, no/poor response to asthma treatment | Atypical asthma features, atypical clinical examination findings, for example, cardiac murmurs |
| Canadian Thoracic Society (Canada)32 | 2021 | Aged 1–5 years: more than one presentation of asthma-like symptoms plus a response to asthma treatment trialOver 6 years: findings in clinical history that are suggestive of asthma plus spirometry showing obstructive expiration and demonstration of reversibility of airflow limitation of at least 12% | Over 6 years:spirometry and bronchodilator reversibility (first line) additional tests that may be useful: peak flow variability, bronchial challenge and exercise challenge | Diagnostic uncertainty, severe asthma, previous life-threatening attack, need for allergy testing, any hospitalisation as a result of asthma | |
| National Asthma Council Australia (Australia)30 | 2021 | Aged 1–5 years:findings in clinical history and examination that are suggestive of asthma plus a response to treatment trial with SABA and/or ICS6 years and over:findings in clinical history and examination that are suggestive of asthma plus spirometry demonstration of reversibility of airflow limitation of at least 12% | Aged 1–5 years: none6 years and over: spirometry first lineBronchial challenge test and exercise testing to be considered if spirometry results do not show a reversibility of airflow limitation of at least 12% | When child has characteristic asthma symptoms and diagnosis is not clear from objective testing results | Atypical asthma featuresNo response to treatment trialsResults of objective testing do not suggest asthma |
| ARF NZ (New Zealand)31 | 2020 | Aged 1–11: findings in clinical history that are suggestive of asthma plus a response to asthma treatment trial | Aged 5–11 years: Spirometry should be considered if asthma symptoms are atypical or in those with typical asthma symptoms that do not respond to a treatment trial. | When there is no response to asthma treatment trials and/or there is diagnostic uncertainty | Atypical asthma features |
| Irish College of GPs(Ireland)50 | 2020 | Under 6 years: findings in clinical history that are suggestive of asthmaOver 6 years: findings in clinical history that are suggestive of asthma plus evidence of obstructive airflow limitation and reversibility with bronchodilators | Under 6 years: treatment trialOver 6 years: PEF or spirometry. | Parental concern or request, failure to respond to treatment trial, failure to thrive, diagnostic uncertainty | |
| The Japanese Society of Allergology (Japan)27 | 2020 | All ages: findings in clinical history that are suggestive of asthma plus a response to asthma treatment trial | Lung function testing (non-specified), skin prick testing, bronchodilator reversibility testing, bronchial challenge | Poor response to multiple-agent therapy or multiple courses of oral steroids | Atypical asthma features, no response to treatment trial or atypical results on objective testing |
| International Consensus on Pediatric Asthma (global)25 | 2015 | Under 5 years: findings in clinical history that are suggestive of asthmaOver 5 years: findings in clinical history that are suggestive of asthma plus spirometry with bronchodilator reversibility demonstration of reversibility of airflow limitation of at least 12% | Over 5 years: spirometry first linePEF is useful for aiding. FeNO and skin prick testing for detecting allergic asthma can be useful. | ||
| GEMA (Spain)24 | 2009 | Under 6 years: findings in clinical history that are suggestive of asthmaOver 6 years: findings in clinical history that are suggestive of asthma plus spirometry with bronchodilator reversibility demonstration of reversibility of airflow limitation of at least 12% | 6 years and over:spirometry with combined bronchodilator reversibility. FeNO and allergy testing may be useful if diagnosis is unclear. | ||
| Ministry of Health (Singapore)26 | 2008 | All ages: findings in clinical history and examination that are suggestive of asthma | No objective testing normally required for diagnosis. PEF at every consultation and spirometry at least annually in children over 6 years to assess asthma severity.Tests that may be considered: CXR to exclude foreign bodies and chronic LRTIs, skin prick testing to detect atopy and exercise testing to assess exercise induced asthma | High-risk patients with poor control, young age and poor response to treatment trial, when requiring high doses of steroids to control symptoms | – |
Fractional exhaled nitric oxide (FeNO) testing is another valuable tool in asthma diagnosis pediatrics. FeNO is used to identify and quantify eosinophilic airway inflammation, which is often elevated in children with eosinophilic asthma. FeNO testing is relatively quick and practical to perform in school-aged children, provided staff are trained and equipment is available. However, the specific role and positioning of FeNO testing in asthma diagnosis pediatrics guidelines vary globally, as shown in Table 2. Furthermore, FeNO monitoring can also be beneficial in guiding the titration of inhaled corticosteroid (ICS) dosages in children with a confirmed asthma diagnosis pediatrics.
Allergy testing, including skin prick tests or measuring specific IgE levels, is not a routine part of the initial asthma diagnosis pediatrics process. However, many clinical guidelines recommend allergy testing as it can help identify specific triggers that exacerbate asthma in individual children.
Several factors contribute to the complexity of asthma diagnosis pediatrics. A significant challenge is that most diagnoses are made in primary care settings where access to objective testing is often limited. Despite guideline recommendations, objective testing is frequently only accessible in secondary or tertiary care, where specialized equipment and trained personnel are available. The COVID-19 pandemic has further strained these resources and created diagnostic backlogs. Solutions like community diagnostic hubs have been proposed to improve access to testing. In some healthcare systems, the cost of objective testing can also create health disparities in asthma diagnosis pediatrics. Adding to the complexity, asthma symptoms often begin before the age of 3, before lung function testing is feasible for asthma diagnosis pediatrics. In this younger age group, observing the response to an asthma treatment trial becomes a crucial element in making diagnostic decisions, and it is recommended by numerous national guidelines for asthma diagnosis pediatrics.
In conclusion, asthma diagnosis pediatrics is a multifaceted process that requires careful consideration of clinical history, symptom patterns, and objective assessments when possible. While lung function tests, FeNO, and allergy testing play important roles, especially in older children, the cornerstone of asthma diagnosis pediatrics, particularly in younger children, often relies on a therapeutic trial and a thorough clinical evaluation. Addressing the challenges in accessing objective testing and harmonizing diagnostic approaches remain crucial steps in optimizing care for children with asthma.
