April 1997
SAN FRANCISCO — Diagnosing and treating infants and young children with asthma presents a special challenge to the clinician, according to the "Report of the Second Expert Panel on the Guidelines for the Diagnosis and Management of Asthma," which was released here recently. The report updates the asthma treatment guidelines that originated in 1991.
The problem: Asthma in young children is frequently underdiagnosed, and children who should be treated are missed. The differential includes chronic bronchitis, recurrent pneumonia, gastroesophageal reflux and recurrent upper respiratory infections. Episodic or chronic wheeze, cough and breathlessness also may be seen in other conditions, such as cystic fibrosis, primary immunodeficiency and congenital heart disease.
Yet, not all wheeze and cough are caused by asthma, and clinicians need to avoid unnecessary treatment.
![[bar]](/art/gradred.gif){kind=small}
As many as 50% to 80% of children with asthma develop these symptoms before they turn 5. Yet, asthma is difficult to diagnose in this age group because it is near impossible to obtain. The report recommends taking a good history, evaluating symptoms, giving a physical examination and assessing the quality of the child's life. A therapeutic trial with bronchodilators and anti-inflammatory medications may be helpful.
There are no clear markers to predict the prognosis for an individual child. Among young children, the most common cause of asthma symptoms is viral respiratory infection (URI). There appears to be two general patterns of illness in infants and children who have wheezing with acute URIs: a remission of symptoms in the preschool years and persistence of asthma throughout childhood.
Factors that affect asthma are allergy, a family history of allergy or asthma and perinatal exposure to passive smoke and airborne allergens. "The data continue to accumulate that exposure of children to tobacco smoke increases the prevalence of asthma in children. In those that do have asthma, the severity is increased by exposure to passive smoke," said Harold S. Nelson, MD, senior staff physician, department of medicine at the National Jewish Medical and Research Center in Denver. Nelson was a member of the expert panel.
It is important to develop a rational approach to asthma care, said William Busse, MD, professor of medicine at the medicine/allergy and immunology department of the University of Wisconsin at Madison. "Ten years ago, we really looked at asthma as a disease characterized by acute exacerbations. People would present to the emergency room where the treatment was directed primarily at relieving the airway smooth muscle contraction events.
"We were treating episodes of asthma, but we were not treating the disease. In the last 10 years, there have been tremendous advances made in understanding one of the major features of asthma, that is chronic airway inflammation. This has been further substantiated in the last five years, and we have increasing evidence to indicate that the definition of asthma is correct — chronic airway inflammation," Busse said.
The new guidelines recommend a step-wise approach to asthma care in all asthmatics. For children younger than 5 years old, the steps follow:
Step one is mild intermittent asthma and requires no daily medication. A bronchodilator can be used if the child is symptomatic. Children who require treatment more than twice a week should be given an anti-inflammatory agent.
Step two is mild persistent asthma and requires daily anti-inflammatory medication. The panel suggested either cromolyn or nedocromil or a low-dose inhaled corticosteroid. Cromolyn and nedocromil have high safety profiles.
Step three is moderate persistent asthma and requires a medium-dose inhaled corticosteroid and either nedocromil or a long-acting bronchodilator (theophylline).
Inhaled corticosteroids are a double-edged sword. Studies show that anti-inflammatory treatment can reduce morbidity from wheezing in early childhood. Studies also suggest that in older children, there is a risk of delayed growth from the use of inhaled corticosteroids.
Therapy should be monitored and stepped down after two or three months, if possible.
Step four is severe persistent asthma and requires daily anti-inflammatory medicine with a high-dose inhaled corticosteroid. If needed, add oral corticosteroids and taper once symptoms stabilize.
"We feel that the chronic airway inflammation is a driving factor in the disease severity, the tendency that people have to experience asthma symptoms and the tendency that people have acute attacks of asthma. The guidelines indicate that treatment directed toward underlying airway inflammation is a principal mode of treatment," Busse said. Bronchodilators are added to all of these steps as needed for symptoms.
Primary care physicians should consider consulting with an asthma specialist for infants and young children requiring step 2 care; the panel recommends consultation for any child requiring step three or four, the panel said.
You can express your
views on this article, or other relevant themes, in the
Infectious Diseases in Children
Specialty Forums.