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Diagnosing asthma in children

Respiratory paediatrician Professor Adam Jaffe
Photo: Respiratory paediatrician Professor Adam Jaffe
While a diagnosis of asthma is important for children, there’s also increasing concerns surrounding overdiagnosis and overtreatment.


Asthma is a common and chronic long-term lung disease which affects about one in 10 Australian children.

Children with a diagnosis of asthma have sensitive airways in their lungs that react to triggers, such as respiratory infections, cigarette or bushfire smoke, allergies, a change in temperature, high emotions and particular medicines.

These triggers can cause flare-ups where the muscles around the airways compress, the airways swell and become narrow while getting thick with mucus, making it more difficult for the child to breathe.

People can develop asthma at any stage throughout their life. The signs or symptoms of asthma may come on gradually or suddenly.
Researchers are working to understand the causes of asthma, and are examining links between genetics and environmental factors.

There is no cure for the condition but in children with an asthma diagnosis, their asthma can be well controlled. Children can lead a healthy, normal life through managing their asthma.

Diagnosing asthma in children

There is no single reliable test and no standardised diagnostic criteria for asthma.

A diagnosis of asthma involves demonstrating excessive variation in lung function combined with respiratory symptoms.

When making a diagnosis of asthma, a GP or a paediatrician will examine a child presenting with symptoms of the condition, such as breathlessness, wheezing, a continuing cough and a tight feeling in the chest.

The doctor will consider the child’s medical history, including whether the child has allergies such as eczema or hay fever and a recurrent or persistent wheeze, conduct a physical examination, and consider other possible causes of the symptoms.

The doctor will also consider tests that support the diagnosis, such as a spirometry test to assess the child’s lung function, and may consider a treatment trial.

A spirometry test involves the child blowing forcefully into a mouthpiece or tube for several seconds, which is connected to a recording device. The spirometer measures the amount of air pushed through the tube, as well as lung capacity and other measurements.

Adam Jaffé is a Professor of Paediatrics at the University of New South Wales, a respiratory paediatrician at the Sydney Children’s Hospital, a member of Asthma Australia’s medical and scientific advisory committee and he helped write the National Asthma Council Australia’s Australian Asthma Handbook, which outlines national guidelines for asthma management.

“With every child that presents to the doctor, one would take a proper history, and you ask about the triggers, what the symptoms look like and there are a few clues on examining a child - the shape of their chest, and whether they’re sick at the time or they’re wheezing,” he says.

“In those aged over five, you should do lung function testing and look at the response to something like a reliever, to measure the response before and after.

“In older children, we can actually do a challenge test where they inhale a substance to try and make them wheeze, which helps with the diagnosis.

“Once you think you’ve got the diagnosis of asthma, then it will be about trying this medicine to see if it actually improves and relieves your symptoms or improves your lung function if it’s abnormal.”

Diagnostic challenges

It can be incredibly difficult to diagnose asthma with certainty in children under five. Young children are unable to perform the lung test to acceptable standards while wheezing and coughing are common in this age group.

There are many causes for coughing and wheezing, and a wheeze does not automatically mean a child has asthma.

Professor Jaffé says the most satisfying part of his work, and much of his job, involves undiagnosing asthma.

“Nothing gives me greater pleasure than seeing children in my clinic when I say - ‘you haven’t got asthma, take them off their medicines’,” he says.

“Children under five are getting six viruses on average a year so they’ll spend quite a bit of their time coughing or with a viral-induced wheeze.

“By the time they get to five or six years of age, for example, some children who are allergic, have eczema, who when they run around will cough or wheeze or if there’s a windy day and there’s thunderstorms will wheeze - those are symptoms for the classic asthma diagnosis.

“So whilst you can make the diagnosis in children under five I would urge caution not to call everyone asthmatic who wheezes under the age of five, simply because it is difficult to do the lung function testing which helps to make the diagnosis.”

Health practitioners should keep an open mind, read or review the Australian Asthma Handbook, and avoid overdiagnosing asthma and prescribing treatment, Professor Jaffé advises.

“Often what will then happen is that children will get an inhaled steroid or worse still, a combination medicine,” he says.

“We know that a lot of children get combination therapy which is an inhaled steroid combined with a long-acting beta2 agoinst medicine.

“Most children don’t need this sort of medicine at all - only five per cent of children need that sort of medicine.

“We know it’s overprescribed and a lot of doctors don’t stick to the guidelines, they don’t read the guidelines, and children are inappropriately prescribed this mixed dose combination therapy which has been linked to worsening asthma and in some cases concern about death.”

Professor Jaffé says it’s important to make a correct diagnosis of asthma, with research showing severe asthma in children is likely to result in adults experiencing severe asthma later in life.

“We do know that if you have bad asthma as a child, you’ll have bad asthma as an adult and that’s probably due to re-modelling of the airways, in other words the airways become thicker and less pliable,” he says.

“It’s important to start treatment probably when you’re younger to try and prevent it. The skill is not overdiagnosing and overtreating compared to underdiagnosis and undertreatment.

“When you look at the severe end of the spectrum, it’s really important to get that diagnosis right at the start - to start treatment early and to try, if possible, to stop that remodelling that may occur in the airways.”


Did you know?
  1. The Asthma Kids website enables parents and children to learn more about the condition in an interactive way. There is also a helpline for advice, phone 1800 ASTHMA (1800 278 462).  
  2. Asthma Australia offers Helping Others Live Well sessions for health professionals and a patient education referral service.

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Karen Keast

Karen Keast is a freelance health journalist who writes news and feature articles for HealthTimes.

Karen regularly writes for some of Australia’s leading health news websites and magazines.  In a media career spanning 20 years, Karen has worked as a senior journalist in newspapers and television. She has covered the grind of daily news and worked as a politics reporter at countless state and federal elections.

Since venturing into freelance writing five years ago, Karen has found her niche in writing about the health sector for editors, businesses and corporations.

Karen has interviewed the heads of peak health organisations in Australia and overseas, and written hundreds of news and feature articles covering the dedicated work of health professionals who tread the corridors of hospitals and health services, universities, aged care facilities and practices, day in and day out.

Follow Karen Keast on Twitter @stylemywords