Primary Care Challenges: Children Under Age Five with Asthma
from Practice Update, Summer 2007
Monica Federico, MD, Director of Outpatient Asthma,The Children’s Hospital,Assistant Professor of Pediatrics, University of Colorado at Denver and Health Sciences Center
Dr. Federico evaluates a patient
using a metered dose inhaler
Sam, a four-year-old boy, comes to your office with a persistent cough. Mom reports that he has been coughing almost every night for a month. When you ask her when this started, she reminds you he was sick twice as a baby with “bronchiolitis” but got better with breathing treatments in the emergency department. Now he coughs several nights per week and whenever he runs too much. On exam, he is growing at the 50th percentile, his saturation is normal at over 90 percent, his lungs are clear, his cardiac exam is normal with no murmur and he has no clubbing.
Does Sam have asthma? How do we make the diagnosis in children under the age of five?
According to the National Asthma Education and Prevention Program (NAEPP) guidelines, a child has asthma if he has recurrent symptoms of airway obstruction such as cough, shortness of breath, chest tightness or wheezing, that improve with a bronchodilator, and the physician is sure that the patient does not suffer from another respiratory illness. Studies show that physicians are reluctant to diagnose asthma in young children. Physicians are also less likely to diagnose asthma if they don’t hear wheezing, or if the symptoms happen only in the setting of an illness.
In fact, using the NAEPP definition, the diagnosis of asthma can be made at any age. In addition, in most children with asthma, the physical exam is normal. Finally, many children with asthma report recurrent cough at night or with exercise and only wheeze with illness.
So does Sam have asthma?
The answer is probably yes since he has recurrent cough and a history of a positive response to an inhaled medication, which was probably albuterol. Before making the diagnosis, it is important to consider the differential. Usually the physical exam will show clues for more serious disease. If the child is not growing, the lung exam reveals crackles or the child has clubbing, than a more chronic lung disease such as cystic fibrosis, immunodeficiency or interstitial lung disease may be the cause. If the exam reveals unilateral or monophonic wheezing, than an airway anomaly or the presence of a foreign body is possible. If you are uncertain about making the diagnosis of asthma or if you are concerned that the child may have another diagnosis, a pediatric pulmonologist can evaluate the child at The Children’s Hospital.
Once the diagnosis of asthma has been made, the next step is to decide whether the asthma is intermittent or persistent. The designation of asthma severity is important because all patients with persistent asthma need to be on a controller medication. The Colorado Clinical Guidelines Collaborative (CCGC) has created a decision tree for defining the severity of asthma: If a patient of any age has daytime symptoms more than twice a week or nighttime symptoms more than twice a month, the patient has persistent asthma. Sam has persistent asthma based on his almost nightly cough and daily exercise symptoms.
How should we treat Sam, and how can we treat any child who does not have the coordination for adult style Metered Dose Inhaler (MDI)?
Because Sam has persistent asthma, he will need both a quick relief medication and a controller medicine. Relief medicine, such as albuterol, can be delivered in children either by nebulizer or MDI with a valved holding chamber. Younger children can use an MDI with a valved holding chamber, such as an AeroChamber® or Optichamber® with a mask that makes it easier for them to receive inhaled medicines without the need for timing their inspiration with the inhaler. They will also need a controller medication. The first line for controller medications in children is inhaled corticosteroids (ICS). Multiple studies and the NAEPP guidelines make this recommendation based upon the fact that ICS work better than any other alternative. ICS decrease the severity of virally induced exacerbations, the number of emergency room visits and hospitalizations, and the chance of death from asthma. The major side effect of the daily use of ICS in young children is a very small (less than 1 cm) effect on height even at low dose. However, parents should be advised that the effect of a chronic illness or recurring doses of systemic steroids are an even more significant inhibitor of growth. Therefore, it is important to help them understand that the risks of ICS are much less than the benefits in children with persistent asthma.
When making a diagnosis of asthma in children, families need more than medication, they also need:
- Education about asthma and the need for chronic controller medications
- To avoid environmental triggers including tobacco smoke
- A clear plan for what to do when the child gets sick (Asthma Action Plan)
The family will also need close follow up (within the month) to assess the response to the medication and every three months to follow asthma control. Asthma therapy may be stepped up and down according to the level of asthma control. However, if a child is on moderate to high dose ICS or is not improving with therapy within three months, he should be referred to a pediatric asthma specialist for further evaluation.
By working closely with Sam and his family, we can expect to control his asthma. Not only will his cough improve, but he will be able to fully and actively join his family and friends for sports, and school, and have a healthy childhood.
Monica Federico, MD, is Director of Outpatient Asthma at The Children’s Hospital and an Assistant Professor of Pediatrics at the University of Colorado at Denver and Health Sciences Center.
Helpful Childhood Asthma Web Links
Asthma, Breathing and Lung Care at The Children’s Hospital
National Asthma Education and Prevention Program (NAEPP)
Colorado Clinical Guidelines Collaborative (CCGC) Asthma Guidelines
