Asthma in Children - Diagnosis and Management

Effective Date: October 28, 2015

Recommendations and Topics

• Scope
• Key Recommendations
• Definition
• Epidemiology
• Diagnosis
• Management
• Ongoing Management
• Resources
• Appendices

This guideline provides recommendations for the diagnosis and management of asthma in patients aged 1-18 years, in the primary care setting. For recommendations regarding asthma in patients aged ≥ 19 years see BCGuidelines.ca – Asthma in Adults – Recognition, Diagnosis and Management.

• Send children aged ≥ 6 years for spirometry when they are symptomatic to improve accuracy.
• Send patients for spirometry regularly as part of the assessment of asthma control.
• Prescribe controller medication daily and not intermittently.
• Controller medication does not need to be increased with an acute loss of asthma control in children.
• At each visit, assess for proper use of asthma medication devices and medication compliance as these are common reasons for poor asthma control.
• Prescribe an age-appropriate spacer device for patients using metered dose inhalers (MDI).
• Send all patients and families to an asthma education center to learn self-management (where available).
• Given that many children aged < 6 years outgrow their asthma symptoms, reassess the persistence of symptoms every 6 months in this age group.
• There is insufficient evidence to recommend one inhaled corticosteroids (ICS) molecule over another with respect to efficacy or safety.
• Ensure children have normal activity levels and do not limit physical activity to control asthma symptoms.*
• Complete a written asthma action plan with all patients and reassess this plan with the patient on a regular basis.

Asthma is a chronic inflammatory disease of the airways that is characterized by bronchial hyperreactivity and variable airway obstruction which results in recurrent episodes of wheezing, breathlessness, chest tightness and/or coughing that can vary over time and in intensity.

In British Columbia, the prevalence of asthma in children ranges from 83-162 per 1000 and is highest in 5-9 year olds although likely there is underestimation of asthma in 0-5 years olds due to variable diagnostic labels used.¹  

Clinical History

Patients < 6 years old

Diagnosing children < 6 years is difficult due to:

• lack of  pulmonary function testing (as children < 6 typically cannot do the test reliably), and
• overlap of viral symptoms with asthma symptoms.

Diagnosis is based on: a compatible history (recurrent episodes of wheezing, cough, difficulty breathing and chest tightness) (see Table 1. Clinical features to assess the probability of asthma in children), a physical exam confirming airway obstruction (e.g., wheezing) that improves with short acting beta agonist (SABA), and the absence of an alternative explanation (Refer to Appendix A: Differential Diagnosis of Recurrent Respiratory Symptoms (PDF, 91KB)).

 

Wheezing is the most specific sign of asthma

• it is a high-pitched whistling sound typically heard on expiration, and
• confirm with a physical exam since wheezing is a term commonly used to describe many types of noisy breathing unrelated to asthma.

Asthma symptoms can be triggered by irritants, allergens, respiratory infections, and exercise; although the most common trigger in this age group is respiratory infections.

A therapeutic trial can be used to clarify the diagnosis

• Suggest using a daily moderate dose of inhaled corticosteroids (ICS) and SABA as needed
• Trial should be at least 8-12 weeks
• Discuss with the family in advance expected clinical improvements
• Suggest that families record symptoms in a diary and discuss this with their care provider when assessing the response of the trial of treatment

Patients 6-18 years old

Diagnosis is based on: a compatible clinical history (recurrent episodes of wheezing, cough, difficulty breathing and chest tightness) (see Table 1. Clinical features to assess the probability of asthma in children), documented evidence of reversible obstruction or bronchial hyperreactivity with lung function testing (see Investigations or Tests), and if lung function testing is not available, a physical exam finding of wheezing or signs of increased work of breathing that definitively improves with SABA can be used as a surrogate marker of reversible airway obstruction although lung function testing should be done when available.

 

Table 1. Clinical features to assess the probability of asthma in children

Investigations or Tests

1. Spirometry in children aged ≥ 6 years^†

• Forced expiratory volume in 1 second (FEV₁)/forced vital capacity (FVC) < 80% with a 12% improvement in FEV₁ after SABA is specific for the diagnosis of asthma.³
• NOTE: Negative spirometry results do not necessarily exclude a diagnosis of asthma, particularly if a child is asymptomatic or is well controlled on asthma medication.
• For diagnostic purposes, the most useful time to do this test is when patients are symptomatic.
• Performing spirometry is an important part of the diagnostic process to ensure an accurate diagnosis, as 30% of patients with a diagnosis of asthma have been found not to have asthma when lung function testing was done.²
• Spirometry is used as part of asthma control assessment, as patients with poor lung function are at risk for remodeling despite having well-controlled symptoms.

2. Tests of bronchial hyperreactivity

• If spirometry is normal and asthma is still suspected, methacholine challenge or an exercise challenge can be done, particularly if a child is not responding to standard asthma therapy (see Indications for Referral).
• Useful for ruling out a diagnosis of asthma in a symptomatic patient.²

3. Peak flow monitoring

• Not recommended for diagnosing asthma in children.
• Can be used in patients with an asthma diagnosis who are poor perceivers of their asthma symptoms, as part of an asthma management plan
• Given the variability of normal values, determine a patient’s personal best peak flow when well to establish a baseline

4. Chest x-ray

• Not useful for diagnosing asthma but is useful to evaluate for an alternative diagnosis.

Care Objectives

At each visit assess the following with the patient and caregivers (see Associated Documents: Asthma Patient Care Flow Sheet: aged < 6 years [PDF, 64KB] and Asthma Patient Care Flow Sheet: aged 6 - 18 years [PDF, 63KB]):

• asthma control (see table under Asthma Symptom Control),
• medication adherence (confirm through pharmacy records if possible) and inhaler technique (see Asthma Education),
• effectiveness and understanding of patient’s written action plan (see Associated Documents: Asthma Action Plan for Children: aged < 6 years [PDF, 923KB] and Asthma Action Plan for Children: aged 6 -18 years [PDF, 870KB]),
• height and weight of patient.

If a treatment plan is initiated or changed, schedule a follow-up visit within 3 months to evaluate the effectiveness of the plan.

Frequency of ongoing visits depends on the patient’s severity of symptoms, their risk of a future asthma attack and their level of asthma symptom control

Assessment of Asthma Control

Assess asthma control and risk factors for asthma attacks at the time of diagnosis, when creating/modifying a treatment plan and when monitoring treatment outcomes.

1. Asthma Symptom Control^{4, 8}

0 points = well controlled asthma symptoms

1-2 points = partly controlled asthma symptoms

≥ 3 points = uncontrolled asthma symptoms

2. Risk of a Future Asthma Attack^{4, 8}

Does the patient have any of the following risk factors:

• Uncontrolled asthma symptoms (see above)
• ≥ 1 severe attack (e.g., requiring systemic steroids, ER visit or hospitalization) in last year, previous intubation or intensive care unit (ICU) admission for asthma
• Not prescribed or not taking an ICS properly (used intermittently, poor adherence or inhaler technique)
• Low FEV₁ (especially if < 60%)
• Exposure to tobacco smoke
• Exposure to allergens that the patient is sensitized to
• Food allergy or past history of anaphylaxis

If the patient has any of these risk factors they are at risk for future asthma attacks. Consider strategies to eliminate modifiable risk factors (e.g., tobacco cessation programs, allergen avoidance, etc.).

Self-Management

1. Asthma Education

Ensure patients and their caregivers understand:

• how to take their medication properly (have patient demonstrate this, not just describe it),
• the difference between a reliever and controller medication,
• how to use their written action plan (including when to seek help),
• how to monitor for symptom control, and
• what triggers their asthma and how to avoid their triggers when appropriate (e.g., irritants, allergens, respiratory infections, and exercise, although exercise should never be limited as the goal is to have asthma controlled such that there is no activity limitation). See Appendix B: Timing of Environmental Aeroallergens in British Columbia (PDF, 97KB).

Refer patients and their caregivers to an asthma education program where available (see Patient Resources). Particularly if patients experience the following:

• poor medication compliance,
• poor understanding of proper use of medications,
• poor understanding of their action plans, or
• language barriers.

Tobacco smoke

Consider the following messaging for patients and caregivers regarding a patient’s exposure to tobacco smoke:

• children experience more viral infections,⁵
• steroid medications decrease in efficacy,⁶
• smoking outside of the home and car is better than smoking inside,
• third hand smoke (i.e., smoke residue left on clothes, hair etc.) has been found to increase respiratory symptoms in children,⁵ and
• discuss quitting and offer assistance to patients and families who want to quit (see Patient Resources).

Recommend annual influenza vaccination for the patient and their family.  Asthma patients should also receive pneumococcal vaccines^‡ as appropriate for their age.

2. Written Asthma Action Plan

Action plans help patients know:

• when to use their medications,
• what to do when asthma symptoms worsen, and
• when to seek medical help (see Asthma Action Plan).

Use symptom monitoring rather than peak flow in children because symptom monitoring has been shown to be as effective as monitoring peak flows.  Peak flows are useful for children that are poor perceivers of their asthma symptoms.³  If peak flow meters are used, the child’s personal best peak flow should be used as their baseline as “normal” peak flows differ between devices.

Pharmacological Management

Medication Delivery Devices

• The most important factor in selecting a medication delivery device is to ensure that the patient uses it properly. 

Recommend that metered dose inhaler (MDI) always be used with a spacer device in children and are as effective as nebulizers.⁷ Spacers increase the amount of medication in the lungs and decrease side effects from medication (see Table 2. Recommended inhaler device by age). 

Table 2. Recommended inhaler device by age

Stepwise approach to pharmacologic treatment^{2-4, 8}

(See Appendix C: Asthma medication table for children aged ≤ 18 years [PDF, 117KB] and Appendix D: Asthma Inhaler Guide [PDF, 617KB])

Schedule a follow-up visit within 2-4 weeks of any severe exacerbation (requiring ER visit, hospitalization, systemic steroids).

• At this visit assess:
• modifiable risk factors for the exacerbation (e.g., compliance with medication , inhaler technique),
• whether they used their action plan correctly, and
• whether changes need to be made to their action plan.

Assessing persistence of asthma symptoms in children < 6yrs

• 50% of preschool age children with wheeze outgrow this condition by age 6,³⁸ therefore the need for ongoing therapy should be re-evaluated every 6-12 months.
• Risk factors for the presence of asthma symptoms at 6 years of age include:³⁸
  • a personal or family history of atopy,
  • onset of symptoms after 2 years of age, and
  • frequent or severe episodes of wheezing in childhood.

Indications for Referral^§

• Atypical asthma symptoms or diagnosis in question
• Poor asthma control (poor lung function, persistent asthma symptoms) or severe asthma exacerbations (≥ 1 course of systemic steroids per year) despite moderate doses of inhaled corticosteroids (with proper technique and good compliance)
• Patient requires detailed assessment and management of potential environmental triggers 
• ICU admission for asthma

Controversies in Care

1. Intermittent vs. Daily Inhaled Corticosteroids (ICS)

In children with persistent asthma, daily use of inhaled steroids is strongly recommended as it improves asthma control and lung function and decreases frequency of reliever medication use.^9-15

In children with intermittent asthma (brief exacerbations of symptoms with no interim symptoms), there is a weak recommendation to use daily inhaled steroids.  Although a popular strategy, intermittent use of low-high doses of intermittent inhaled steroids have not been shown to be of benefit. 

Trials of intermittent ICS have used very high doses (e.g., fluticasone 1500ug/day) and have found a decrease in systemic steroid use and duration of symptoms.^19-21 These studies have found a decrease in height and there are concerns about widely recommending this approach given the potential use of multiple courses of very high dose ICS in young children with frequent viral induced exacerbations.^{16, 21, 22} In this group of children, there is only one comparative trial of intermittent versus daily ICS which did not find a benefit of daily ICS.¹⁴ However, multiple trials of daily ICS versus placebo have shown an improvement in exacerbation rate and lung function,¹⁶ with mixed results on symptom free days and symptom scores.^16-18  

2. Increasing ICS with flares and viruses

It is strongly recommended that children on ICS do not increase their dose during acute loss of asthma control (i.e., in the yellow zone of an action plan), as this has not been shown to decrease the need for oral corticosteroids.^23-29

3. Choice of ICS

There is currently not enough evidence in terms of improved efficacy or safety profile to recommend one ICS molecule over another.^30-37

References

¹ McLeod C, Bogyo T, Demers P, et al. Asthma in British Columbia. Vancouver, BC: Centre for Health Services and Policy Research; 2007.

² British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: A national clinical guideline. 2014.

³ Lougheed MD, Leniere C, Ducharme FM, et al. Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults: executive summary. Can Respir J. 2012;19:e81-8.

⁴ Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2015.

⁵ Duff AL, Pomeranz ES, Gelber LE, et al. Risk factors for acute wheezing in infants and children: viruses, passive smoke, and IgE antibodies to inhalant allergens. Pediatrics. 1993;92:535-540.

⁶ Chalmers GW, Macleod KJ, Little SA, Thomson LJ, McSharry CP, Thomson NC. Influence of cigarette smoking on inhaled corticosteroid treatment in mild asthma. Thorax. 2002;57:226-230.

⁷ Cates CJ, Crilly JA, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2006:000052.

⁸ National Asthma Education Prevention Program (NAEPP). Expert Panel Report 3: Guidelines for the diagnosis and management of asthma. Bethesda: National Heart, Lung, and Blood Institute (NHLBI); 2007.

⁹ Chauhan BF, Chartrand C, Ducharme FM. Intermittent versus daily inhaled corticosteroids for persistent asthma in children and adults. Cochrane Database of Systematic Reviews. 2013:CD009611.

¹⁰ Martinez FD, Chinchilli VM, Morgan WJ, et al. Use of beclomethasone dipropionate as rescue treatment for children with mild persistent asthma (TREXA): a randomised, double-blind, placebo-controlled trial. Lancet. 2011;377:650-657.

¹¹ Papi A, Nicolini G, Baraldi E, et al. Regular vs prn nebulized treatment in wheeze preschool children. Allergy. 2009;64:1463-1471.

¹² Papi A, Canonica GW, Maestrelli P, et al. Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma. N Engl J Med. 2007;356:2040-2052.

¹³ Turpeinen M, Nikander K, Pelkonen AS, et al. Daily versus as-needed inhaled corticosteroid for mild persistent asthma (The Helsinki early intervention childhood asthma study). Arch Dis Child. 2008;93:654-659.

¹⁴ Zeiger RS. Mauger D. Bacharier LB., et al. CARE Network of the National Heart, Lung,and Blood Institute. Daily or intermittent budesonide in preschool children with recurrent wheezing. N Engl J Med. 2011;365:1990-2001.

¹⁵ Boushey H, Sorkness C, King T, et al. Daily versus as-needed corticosteroids for mild persistent asthma. N Engl J Med. 2005;352:1519-1528.

¹⁶ Guilbert TW, Morgan WJ, Zeiger RS, et al. Long-term inhaled corticosteroids in preschool children at high risk for asthma. N Engl J Med. 2006;354:1985-1997.

¹⁷ Barrueto L, Mallol J, Figueroa L. Beclomethasone dipropionate and salbutamol by metered dose inhaler in infants and small children with recurrent wheezing. Pediatr Pulmonol. 2002;34:52-57.

¹⁸ Doull IJ, Lampe FC, Smith S, Schreiber J, Freezer NJ, Holgate ST. Effect of inhaled corticosteroids on episodes of wheezing associated with viral infection in school age children: randomised double blind placebo controlled trial. BMJ. 1997;315:858-862.

¹⁹ Connett G, Lenney W. Prevention of viral induced asthma attacks using inhaled budesonide. Arch Dis Child. 1993;68:85-87.

²⁰ Wilson NM, Silverman M. Treatment of acute, episodic asthma in preschool children using intermittent high dose inhaled steroids at home. Arch Dis Child. 1990;65:407-410.

²¹ Ducharme FM, Lemire C, Noya FJD, et al. Preemptive Use of High-Dose Fluticasone for Virus-Induced Wheezing in Young Children. N Engl J Med. 2009;360:339-353.

²² Teper AM, Colom AJ, Kofman CD, Maffey AF, Vidaurreta SM, Bergada I. Effects of inhaled fluticasone propionate in children less than 2 years old with recurrent wheezing. Pediatr Pulmonol. 2004;37:111-115.

²³ FitzGerald J, Becker A, Sears M, et al. Doubling the dose of budesonide versus maintenance treatment in asthma exacerbations. Thorax. 2004;59:550-556.

²⁴ Foresi A, Morelli M, Catena E, Italian Study Grp. Low-dose budesonide with the addition of an increased dose during exacerbations is effective in long-term asthma control. Chest. 2000;117:440-446.

²⁵ Garrett J, Williams S, Wong C, Holdaway D. Treatment of acute asthmatic exacerbations with an increased dose of inhaled steroid. Arch Dis Child. 1998;79:12-17.

²⁶ Harrison T, Oborne J, Newton S, Tattersfield A. Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial. Lancet. 2004;363:271-275.

²⁷ Oborne J, Mortimer K, Hubbard RB, Tattersfield AE, Harrison TW. Quadrupling the Dose of Inhaled Corticosteroid to Prevent Asthma Exacerbations A Randomized, Double-blind, Placebo-controlled, Parallel-Group Clinical Trial. American Journal of Respiratory and Critical Care Medicine. 2009;180:598-602.

²⁸ Quon BS, Fitzgerald JM, Lemiere C, Shahidi N, Ducharme FM. Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children. Cochrane Database of Systematic Reviews. 2010:(12)-2010.

²⁹ Yousef E, Hossain J, Mannan S, Skorpinski E, McGeady S. Early intervention with high-dose inhaled corticosteroids for control of acute asthma exacerbations at home and improved outcomes: a randomized controlled trial. Allergy Asthma Proc. 2012;33:508-513.

³⁰ Baran D. A comparison of inhaled budesonide and beclomethasone dipropionate in childhood asthma. Br J Dis Chest. 1987;81:170-175.

³¹ Gustafsson P, Tsanakas J, Gold M, Primhak R, Radford M, Gillies E. Comparison of the efficacy and safety of inhaled fluticasone propionate 200 micrograms/day with inhaled beclomethasone dipropionate 400 micrograms/day in mild and moderate asthma. Arch Dis Child. 1993;69:206-211.

³² Hoekx JC, Hedlin G, Pedersen W, Sorva R, Hollingworth K, Efthimiou J. Fluticasone propionate compared with budesonide: a double-blind trial in asthmatic children using powder devices at a dosage of 400 microg x day(-1). Eur Respir J. 1996;9:2263-2272.

³³ Pedersen S, Garcia Garcia ML, Manjra A, Theron I, Engelstatter R. A comparative study of inhaled ciclesonide 160 microg/day and fluticasone propionate 176 microg/day in children with asthma. Pediatr Pulmonol. 2006;41:954-961.

³⁴ Pedersen S, Engelstatter R, Weber HJ, et al. Efficacy and safety of ciclesonide once daily and fluticasone propionate twice daily in children with asthma. Pulm Pharmacol Ther. 2009;22:214-220.

³⁵ Springer C, Avital A, Maayan C, Rosler A, Godfrey S. Comparison of budesonide and beclomethasone dipropionate for treatment of asthma. Arch Dis Child. 1987;62:815-819.

³⁶ Zhang L, Prietsch SO, Ducharme FM. Inhaled corticosteroids in children with persistent asthma: effects on growth. Evid Based Child Health. 2014;9:829-930.

³⁷ von Berg A, Engelstatter R, Minic P, et al. Comparison of the efficacy and safety of ciclesonide 160 microg once daily vs. budesonide 400 microg once daily in children with asthma. Pediatr Allergy Immunol. 2007;18:391-400.

³⁸ 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;172:1253-1258.

Practitioner Resources

Provincial Asthma Guidelines on the Initial Management of Pediatric Asthma in the Emergent/Urgent Care Settings (2019) 

• Developed by Child Health BC
• Website:  https://www.childhealthbc.ca/initiatives/asthma-care-across-community-settings

Pediatric Asthma Management: New ONLINE Learning MODULE (launched May 2019)

• Developed in partnership by UBC CPD, Child Health BC and the Division of Respiratory Medicine at BC Children's Hospital
• Website:  https://ubccpd.ca/course/pediatric-asthma-management

Patient Resources

Asthma Education Video

• Childhood Asthma: A Guide for Families and Caregivers 
• Developed by Division of Respiratory Medicine at BC Children's Hospital and Child Health BC
• Website:  http://bit.ly/pediatric-asthma-video

The Asthma Society of Canada – website provides a variety of free educational materials about asthma.

• Website:  www.asthma.ca/

About Kids Health – website provides comprehensive information about asthma in children.

• Website: www.aboutkidshealth.ca

Alberta Health Services – ICAN – website that provides asthma information including trigger avoidance and device instructions in 13 languages.

• Website: https://cumming.ucalgary.ca/research/icancontrolasthma/languages

The Canadian Lung Association – Provides listings of available Asthma Clinics across the province and videos on how to use asthma devices.

• Website: www.lung.ca/lung-health/get-help

QuitNow – an internet based quit smoking service, available free of charge to B.C. residents.

• Website: www.quitnow.ca

BC Smoking Cessation program - A PharmaCare program that helps patients stop smoking or using other tobacco products by helping with the cost of smoking cessation aids.

• Website:  www.health.gov.bc.ca/pharmacare/stop-smoking/

Cartoon for children on what asthma is and how medications work.

• URL: www.youtube.com/watch?v=Et_alsghel8

Diagnostic Code

493 (Asthma)

Appendices

• Appendix A: Differential Diagnosis of Recurrent Respiratory Symptoms (PDF, 91KB)
• Appendix B: Timing of Environmental Aeroallergens in British Columbia (PDF, 97KB)
• Appendix C: Asthma Medication Table for Children and Youth Aged ≤ 18 Years (PDF, 117KB)
• Appendix D: Asthma Inhaler Guide (PDF, 617KB)

Associated Documents

The following documents accompany this guideline:

• Asthma Action Plan for Children: aged <6 years (PDF, 923KB)
  • Punjabi (PNG, 1.1MB)
  • Chinese (PDF, 955KB)
• Asthma Action Plan for Children: aged 6-18 years (PDF, 870KB)
  • Punjabi (PDF, 1.2MB)
  • Chinese (PDF, 966KB)
• Asthma Patient Care Flow Sheet: aged < 6 years (PDF, 64KB)
• Asthma Patient Care Flow Sheet: aged 6-18 years (PDF, 63KB)
• Summary of Guideline: Asthma in Children - Diagnosis and Management (PDF, 514KB)

 

This guideline is based on scientific evidence current as of the Effective Date.

This guideline was developed by Child Health BC and the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association, and adopted by the Medical Services Commission.