Challenges in diagnosing asthma in children
BMJ 2024; 384 doi: https://doi.org/10.1136/bmj-2023-075924 (Published 13 February 2024) Cite this as: BMJ 2024;384:e075924
- Kendra Chisholm, paediatric trainee1,
- Luke Daines, GP2,
- Steve Turner, consultant paediatrician1
- 1Women and Children’s Division, NHS Grampian, Aberdeen, UK
- 2Usher Institute, University of Edinburgh, Edinburgh
- Correspondence to S Turner s.w.turner{at}abdn.ac.uk
What you need to know
Asthma in children is a clinical diagnosis based on history and examination, and in many cases a response to a trial of inhaled corticosteroid treatment
Asthma can be diagnosed in children under 5, but is unlikely to explain recurrent respiratory symptoms in children under 2
Tests can be done to help support (or exclude) a clinical diagnosis but should not be used solely to make (or exclude) a diagnosis of asthma
Asthma is characterised by recurrent episodes of cough and wheeze and difficulty in breathing. It affects more than 10% of children in the UK,1 but no universally agreed definition or diagnostic test exists for asthma in children or adults.2 Diagnosis in children mostly relies on a suggestive history and response to a trial of preventer treatment. Lack of objectivity in diagnosing asthma leads to both overdiagnosis and underdiagnosis.34 Clinicians and researchers have explored the role of objective tests, such as spirometry, peak flow variability, and exhaled nitric oxide in diagnosing asthma, and despite the lack of evidence, several organisations have incorporated these objective tests into diagnostic algorithms. But how helpful are these objective tests and algorithms?
This review:
Describes current diagnostic algorithms (also called pathways) for childhood asthma
Considers the feasibility of diagnostic algorithms in “real world” healthcare settings for children over 5
Describes areas of uncertainty in diagnosing asthma in children.
What do guidelines say?
This review focuses on algorithms from four recent and commonly cited guidelines: European Respiratory Society (ERS), British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN), National Institute for Health and Care Excellence (NICE), and Global Initiative for Asthma (GINA).5678 At the time of writing, a joint BTS/SIGN and NICE asthma guideline is being created, but this article considers the currently separate guidelines.
Table 1 summarises the characteristics and recommendations for each …
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