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Making the diagnosis of asthma

The process of diagnosing asthma in young children is not easy. There is no single test that gives us a definitive diagnosis, but rather we progress through a series of steps to rule out other conditions before arriving at asthma. Adding to the complexity of a diagnosis is that the disease can vary from one year to the next and from one season to another in a single patient.

Difficulty with testing
In preschool children, diagnosis presents special challenges. One reason is that an important means of making the diagnosis is by performing pulmonary function testing. A pulmonary function test measures the ease with which air can go into and out of the lungs when breathing.

In asthma, the airways are obstructed, meaning that it is more difficult for air to go in and out of the lungs. This could be compared to trying to breathe through a drinking straw. In contrast to other causes of airway obstruction, this obstruction can be reversed in asthma with medication, and this is usually how we confirm the diagnosis.

A limitation of pulmonary function testing is that it requires the cooperation of the patient, a task not easily achieved in toddlers. This means that we have to rely on other information to rule asthma in or out. So at the Pediatric Asthma Clinic, we:

• Obtain a family history and the young child's medical history.
• Ask about what triggers such episodes, such as exposure to pet dander, having a virus or colds or exercise.
• Perform tests to rule out other conditions before settling on a diagnosis of asthma.
• Always treat existing symptoms.

Ruling out other causes
It is important to rule out conditions that present with respiratory symptoms consistent with asthma and yet are not asthma. This is because the treatment and course of these conditions may be completely different from asthma. Cystic fibrosis is one such condition that can be ruled out with a relatively simple test known as a sweat chloride test. These results are available quickly and for parents, learning that their child does not have cystic fibrosis gives a great deal of reassurance.

Imaging studies, including chest X-ray and airway fluoroscopy can show if there are abnormalities in the chest that are causing breathing difficulties. For example, we have had instances where young children have gotten something into their lungs—food, a toy, anything—that is the cause of months of wheezing. More recently, a baby who we suspected might have asthma was shown to have a physical defect that was pressing on his airway. We would not have known if we had not performed these tests.

Not all that wheezes is asthma
Dr. Strunk suggests never using the term asthma until a child is older and a pulmonary function test can be performed. It's important for people to realize that not all that wheezes is asthma. But I find that after we've done these tests to rule out other conditions and have reviewed the child's medical history, I will tell the parents this may be asthma. It's something they've heard of and can better understand and the treatment is the same.

As shown in the long-term studies reviewed by Dr. Martinez, not every toddler who wheezes or coughs will necessarily go on to have chronic asthma.

What are risk factors for asthma?
Over the years, many factors have been linked to contributing to the development of asthma, including smoking, family history, allergies and infection with RSV, among others. But this data is often conflicting and these two studies are no exception. For example, family history was not a major factor in Dr. Strunk's review, but it's something we always ask about because we and others believe that a connection does exist. While some studies have shown a connection between respiratory syncytial virus and asthma, Dr. Martinez found no such link. These uncertainties underscore the need for more research.

Dr. Strunk's article did show a positive connection between asthma and allergies. This is supported by other studies as well and has convinced more and more pulmonologists to look for allergies as a contributing factor.

One thing that is not always considered is a history of snoring and whether there is an association with asthma. Dr. Strunk found such an association, and this is a question we always ask when performing our evaluation. If there is a concern, we perform a sleep study and depending on the results we might recommend a referral to an ear, nose and throat specialist. In several cases, a child's asthma improved after the tonsils and adenoids were removed.

Is asthma "outgrown?"
One myth that I'd like to address is the notion that a child will outgrow asthma. This could mislead parents into thinking that it is not a serious disease. The nature of asthma is not predictable and all children with asthma need to be followed regularly. If you have concerns that your infant or child may have asthma, or your child ever experiences any breathing difficulties, contact your doctor right away. Studies are now showing what doctors have all along figured to be true: early intervention is best.

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Dr. Bazzy-Asaad is an attending pediatric pulmonologist at Yale-New Haven Children's Hospital and an associate professor of pediatrics in respiratory medicine at Yale University School of Medicine.