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Are there any special problems in diagnosing asthma in children? Do they vary by age?

Angela Boque (Spain):

There are some problems. We can do prick tests and spirometry in only a few primary care centres, although this situation is improving. The other centres and doctors do not have these means and send children to a hospital for diagnostic tests. Small children are mainly diagnosed after an accurate clinical assessment.

Len Fromer (USA):

The biggest issue from our perspective is getting past the health system bias that you can't do skin testing for triggers on a young child. That's actually a non-issue because you can do the blood test, the CAP-RAST for specific IgE. All you need is 2 mL of blood; you get the result back in 24 to 48 hours. So teaching people that testing for triggers and learning what they are as a prevention approach to start with, along with appropriate medication, is a big issue. You can do the blood test down to the age of 3 months. Actually you can do a blood test on a 1-day old, and it will accurately measure the IgE, but it will be spurious because of placental transfer and swallowed amniotic fluid.

The other issue that is an obstacle to making the diagnosis is part of the steroid phobia on the treatment side: parents are very phobic about the word 'steroids,' and inhaled corticosteroids being one of the treatments, they don't want to hear the word 'asthma.' They think, "I don't want to put my kid on this medicine that's going to stop him from growing. It's going to make my kid's adrenal gland shut down, it's going to give him cataracts, it's going to cause osteoporosis," all the steroid phobia associations. So we have to deal with that upfront. That's one of the beauties of empowering children and parents by doing trigger testing: they're really motivated as a family to get those triggers away from the asthmatic. To be able to reduce the burden or get off the steroids completely.

Svein Høegh Henrichsen (Norway):

The problem is to be aware when children come with their [upper airway] infections that it might be something else, something underlying the infections.

Chris Hogan (Australia):

For children under the age of 2, you don't know what it is. Even if there's a response to treatment, you can't be sure that it's asthma. There's wheezing associated with respiratory infection. Children may present with a wheeze on only one or two occasions. Also in that age group you can have children presenting with a floppy larynx, with chondromalacia of their upper airway, with polyps, with a vascular ring; there are all sorts of differentials.

The other issue of course that's true in Australia and in a whole range of other countries as well is that there's a resistance to the diagnosis of asthma, and there's steroid phobia.

Another issue is that people with culturally and linguistically diverse backgrounds, those who come from traditional cultures, often don't have a concept of chronic illness. In a more traditional society, there's no such thing as a chronic illness. Because what happens if you've got a severe arthritis or respiratory illness or cardiac disease, in a traditional society these people are dead. So there isn't this philosophy or the support from the carers for a chronic disease. They're expecting either death or a cure. The idea of modification of lifestyle is very difficult. And we find this not only for asthma but more specifically for the epidemic of type 2 diabetes that we're experiencing not only in our own society but certainly in our traditional societies as well, both the indigenous Australians and also peoples from other countries, especially the Pacific islanders.

Alexandre Holanda (Brazil):

I think one of the major problems is the lack of spirometers, the technology, the lung function tests. Even peak flow meters, which are very cheap, we don't have here on a regular basis, which, while not the best, would help us in controlling asthma at home. A functional diagnosis of asthma is very rare in the public sector. In the private sector, with your health insurance, you're able to have a lung function test really easily. In the public sector, we don't have the machines. As an example, in the city of Fortaleza here, there are 2.3 million people. In the public sector I estimate there are two or three places here that can do lung function testing. And those places probably have only one machine. Brazil has universal health-care access, and the majority of people use the public sector health-care system.

Alan Kaplan (Canada):

You can't do objective measurements, which is how you make a diagnosis of asthma, until kids are closer to 6, so you are just taking your best guess at the situation and then applying therapy. Also with infants, the younger the child, the larger the differential diagnosis, and the more frequently viral infections occur, especially in day care situations, so all those are going to be factors in making the diagnosis. For children 6 to 12, at that point you can do objective measurements, although spirometry is underperformed in Canada. Probably less than 30% of the time is there an objective measurement of lung function, so most kids are treated with a trial of therapy rather than an objective measurement. In that situation, we can make the diagnosis but it's not being done on a regular basis. This is also true for adolescents and teenagers, and this is made more difficult by the fact that they're terrifically non-compliant, and our Canadian asthma guidelines say there aren't any data for how to manage their asthma, but the principles of course are the same.

Sarath Paranavitane (Sri Lanka):

We don't have many places where there are spirometers; those are some of the limiting factors that we have. There are only a few places in the capitol city of Colombo where they do pulmonary function tests, and there are none in the peripheries. So we have a problem in getting spirometry done for our children. Even peak flow meters are very difficult to come by. Sometimes drug companies provide us with peak flow meters, but what they give is only two or three, which is insufficient to meet the demand. Many patients cannot afford to buy peak flow meters. Cost is another limiting factor in developing countries such as ours. In this scenario, the diagnosis of asthma is clinical, reinforced by the therapeutic response.

Dermot Ryan (UK):

The big problem is the diagnosis in kids under the age of 3 because of the more likely diagnosis of viral-induced wheeze, which seems to be a different sort of disease. The situation is generally clearer in older children: the history is easier to obtain, the children themselves can often contribute more to the history, especially pertaining to when the parent is not around. Serial peak flow measurements and reversibility can be assessed from about the age of 5; these are useful adjuncts in making the diagnosis. Clearly, in all situations, we inquire about family history and personal history of atopy. If a child has a personal history of atopy or a strong family history, particularly a maternal history, of atopy, they are more likely to have asthma.

Björn Ställberg (Sweden):

There are a lot of problems! For really small children, the problem is you can't do any lung function test. In the teenage years, children may complain of having a lot of problems playing sports; however, testing, including lung function testing, allergy testing, it's all normal. Then you try medication and nothing helps. Is it real asthma or not? It's easier to have a correct diagnosis when you're having a lot of problems. When you're wheezing a lot, it's easy to say, "Okay, this is asthma." But if the child comes to the doctor and says, "Yesterday I had problems playing soccer, also 2 weeks ago I had problems." But when I see them everything is okay, that's a problem. We don't use exhaled nitric oxide, that's in the future. We're talking about it a lot in Sweden, because the machines are cheaper now, but it's still too expensive. And we need more studies.

Osman Yusuf (Pakistan):

That's something tough. If I were to speak from the perspective of a primary care physician, sitting in the community, where he's seeing children with all sorts of diseases, asthma would probably be one of the back benches on the diagnosis profile. He will most likely be looking first for any sort of acute viral exacerbation, viral pneumonia, bacterial pneumonias, very common here, a lot of chest infections. Asthma really takes the back seat to that. Then of course tuberculosis even in children is something to worry about; especially since they normally come in with a chronic cough. Primary care physicians don't have the facilities to diagnose the asthma very well; they don't normally use peak flow meters or spirometers, or any such tools. So the asthma patients usually end up being misdiagnosed and mismanaged. Only when they really exacerbate do they end up getting to someone who knows how to diagnose asthma. So that's why I would see that as the biggest problem in diagnosis: the lack of awareness on the part of the primary care physician. And that's what we're aiming through the IPCRG to change.