Diagnosis and Management

of Asthma under 5

GINA 2019
COURSE 5

TACKLING COMPETITON WITH HUF PUF KIT

 When Does Asthma Begin?

By 1 year – 26%
1-5 years – 51.4%
> 5 years – 22.3%

77% Of Asthma Begins In Children Less Than

5 Years

Ind J Ped 2002;69:309-12

 Common symptoms in asthmatic children

• Cough – 90%
• Wheezing – 74%
• Exercise induced wheeze or cough – 55%

Ind J Ped 2002;69:309-12

Asthma in Children below 5 years : Challenge
To Diagnose
• Classical symptoms of childhood asthma are seen in many other conditions

• Wheeze - All asthmatic children do not wheeze; all that wheezes is not
asthma
• Most of the children are below 5 years of age, who cannot tell their
problems

• Parents are proxy story teller, who may mislead the doctor

• PEF cannot be performed in children below 5 years of age

Asthma Diagnosis: Key Clinical
Features
Feature Characteristics suggesting asthma

Cough Recurrent or persistent non-productive cough that may be worse at night or

accompanied by some wheezing and breathing difficulties.
Cough occurring with exercise, laughing, crying or exposure to tobacco smoke in the
absence of an apparent respiratory infection

Wheezing Recurrent wheezing, including during sleep or with triggers such as activity, laughing,
crying or exposure to tobacco smoke or air pollution

Difficult or heavy breathing Occurring with exercise, laughing, or crying

or shortness of breath

Reduced activity Not running, playing or laughing at the same intensity as other children; tires earlier
during walks (wants to be carried)
Differentiating between asthma and recurrent
wheezing
Differentiating between asthma and recurrent
wheezing
Differential diagnosis: When NOT to consider
Asthma
• Neonatal or very early onset of symptoms
• Vomiting associated with respiratory symptoms
• Continuous wheezing
• Failure to respond to asthma controller medications
• Unexplained weight loss
• Focal lung or cardiovascular signs, or finger clubbing
• Hypoxemia outside context of viral illness
 Differential Diagnosis: Common diseases
Condition Typical features

Recurrent viral respiratory infections Mainly cough, runny congested nose for <10 days; wheeze usually mild; no
symptoms between infections

Gastroesophageal reflux Cough when feeding; recurrent chest infections; vomits easily especially after large
feeds; poor response to asthma medications

Foreign body aspiration Episode of abrupt severe cough and/or stridor during eating or play; recurrent
chest infections and cough; focal lung signs
 Differential Diagnosis: Common diseases
Condition Typical features

Cystic fibrosis Cough starting shortly after birth; recurrent chest infections; failure to
thrive (malabsorption); loose greasy bulky stools

Tracheomalacia or bronchomalacia Noisy breathing when crying or eating, or during URTIs; harsh cough; inspiratory or
expiratory retraction; symptoms often present since birth; poor response to asthma
treatment

Tuberculosis Persistent noisy respirations and cough; fever unresponsive to normal antibiotics;
enlarged lymph nodes; poor response to BD or ICS; contact with someone with TB;
weight loss

Congenital heart disease Cardiac murmur; cyanosis when eating; failure to thrive; tachycardia; tachypnea or
hepatomegaly; poor response to asthma medications
 Questions to elicit asthma diagnosis
• Does your child wheeze? High pitched noise from the chest and not from the
nose
• Does your child wake up in the night because of coughing, wheezing or
breathlessness?
• Does your child have to stop running or play less hard because of cough,
wheeze or shortness of breath?
• Does your child cough, wheeze or have difficulty in breathing when laughing,
crying, playing with pets, or when exposed to strong smells or pets?
• Has your child ever been diagnosed with any other allergic condition viz.
eczema, allergic rhinitis?
• Has anyone in your family had asthma, allergic rhinitis, food allergy, eczema,
breathing problems due to any disorder?
Therapeutic Trial
• Trial treatment with regular low dose ICS + SOS Reliever
• Review after 2-3 months
• Evaluate response
▪ Symptom control (daytime/night-time)
▪ Frequency of wheezing episodes
▪ Exacerbations
• Marked Clinical Improvement during treatment and deterioration
after treatment is stopped, supports a diagnosis of asthma
 Assessing Asthma Control
A. Symptom control
In the past 4 weeks, has the child had: Well-controlled Partly controlled Uncontrolled
• Daytime asthma symptoms for more than
few minutes, more than once/week? Yes❑ No❑
• Any activity limitation due to asthma?
(runs/plays less than other children,
tires easily during walks/playing) Yes❑ No❑ 1-2 of 3-4 of
None of these
these these
• Reliever needed* more than once a
week? Yes❑ No❑
• Any night waking or night coughing
due to asthma? Yes❑ No❑

B. Risk factors for poor asthma outcomes

ASSESS CHILD’S RISK FOR:
• Exacerbations within the next few months
• Fixed airflow limitation
• Medication side-effects
 Evaluating the future risk
Risk factors for exacerbations in the next few months

• Uncontrolled asthma symptoms

• One or more severe exacerbation in previous year
• The start of the child’s usual ‘flare-up’ season (especially if autumn/fall)
• Exposures: tobacco smoke; indoor or outdoor air pollution; indoor allergens (e.g. house dust
mite, cockroach, pets, mold), especially in combination with viral infection
• Major psychological or socio-economic problems for child or family
• Poor adherence with controller medication, or incorrect inhaler technique
 Evaluating the future risk
Risk factors for fixed airflow limitation

• Severe asthma with several hospitalizations

• History of bronchiolitis

Risk factors for medication side-effects

• Systemic: Frequent courses of OCS; high-dose and/or potent ICS

• Local: moderate/high-dose or potent ICS; incorrect inhaler technique; failure to protect skin or eyes when
using ICS by nebulizer or spacer with face mask
Long-term Management
Treatment Steps

Consider specialist
referrel
Before Considering Step Up
• Confirm that symptoms are due to asthma and not due to any other
disorder
• Check and correct inhaler technique
• Check adherence to treatment
• Consider trial of one of the other treatment options
• Enquire about exposure to risk factors
 Inhalation devices

Age Preferred device Alternate device

0–3 years Pressurized metered dose inhaler plus Nebulizer with face mask
dedicated spacer with face mask

4–5 years Pressurized metered dose inhaler plus Pressurized metered dose inhaler plus
dedicated spacer with mouthpiece dedicated spacer with face mask, or
nebulizer with mouthpiece or face mask
Summary
• Asthma below 5years is common
• Diagnosis is difficult as presenting symptoms are similar to other
respiratory conditions
• Confirmation with lung function tests not possible, hence response to
therapeutic trial is performed
• Treatment is basically with Inhaled corticosteroids with addition of
LTRAs if required
• pMDI+spacer is the preferred device for this age group