Asthma in Children Younger Than 12 Years - Initial Evaluation and Diagnosis - UpToDate

7/7/2021 Asthma in children younger than 12 years: Initial evaluation and diagnosis - UpToDate
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Authors: Gregory Sawicki, MD, MPH, Kenan Haver, MD
Section Editors: Robert A Wood, MD, Gregory Redding, MD
Deputy Editor: Elizabeth TePas, MD, MS
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2021. | This topic last updated: Dec 04, 2020.
INTRODUCTION
Asthma is a significant health problem worldwide, and it is one of the most common chronic
diseases of childhood in many countries [1,2]. The prevalence in different countries ranges from 1 to
18 percent. In the United States, for example, over nine million children have been ever told they
had asthma, and 5.5 million still have asthma [3]. Establishing a diagnosis of asthma involves a
careful process of history taking, physical examination, and diagnostic studies. The differential
diagnosis of wheezing must be carefully considered, particularly in infants and very young children,
for whom testing for reversible airflow obstruction is not done routinely.
The epidemiology, initial evaluation, and diagnosis of childhood asthma are reviewed here. The
assessment of severity/control and monitoring, and treatment of childhood asthma are discussed
separately. (See "Asthma in children younger than 12 years: Initiating therapy and monitoring
control" and "Asthma in children younger than 12 years: Management of persistent asthma with
controller therapies" and "Asthma in children younger than 12 years: Quick relief (rescue) treatment
for acute symptoms".)
The pathogenesis, genetics, risk factors, and natural history of asthma are also reviewed
separately. (See "Pathogenesis of asthma" and "Genetics of asthma" and "Risk factors for asthma"
and "Wheezing phenotypes and prediction of asthma in young children" and "Natural history of
asthma".)
EPIDEMIOLOGY
A wide global variation exists in the prevalence of asthma, with higher rates typically seen in higher-
income countries [4]. Asthma is the most common chronic disease in childhood in resource-rich
countries. A significant increase in the estimated prevalence of asthma was seen in resource-rich
countries in the 1980s and 1990s, with slower rates of increase in the 2000s and a plateau
thereafter [5]. Approximately 7.5 percent of US children had asthma in 2018, down from 9.4 percent
in 2010 and 8.7 percent in 2001. However, asthma prevalence continues to increase in other
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countries such as China [6]. Possible causes for the increase in asthma prevalence are reviewed in
detail separately. (See "Increasing prevalence of asthma and allergic rhinitis and the role of
environmental factors".)
Prevalence rates for current asthma in children under age 18 years increased in the United States
from 2001 to 2009 (8.7 to 9.7 percent), then decreased, with a prevalence of 7.5 percent in 2018
[7,8]. Disparities in prevalence remained, with increasing prevalence seen in poor children and
those living in the Southern US and the highest prevalence still seen in Puerto Rican and non-
Hispanic Black American children, particularly for those living in inner cities. Before the onset of
puberty, boys have a higher current prevalence of asthma than girls (9.2 versus 7.4 percent) [3,9].
This trend reverses in adolescence. Lifetime asthma prevalence for children was 12.7 percent in
2013 and 2016. The prevalence of asthma appears to have plateaued in other countries as well [10-
14].
Asthma exacerbation rates among children with current asthma in the United States decreased from
a rate of 62 percent among children <18 years old in 2001 to 48 percent in 2014 but increased in
2016 to 54 percent [3,8].
HISTORY
The history in a child with suspected asthma should focus on the presence of symptoms, typical
symptom patterns, precipitating factors or conditions (ie, atopy), and known asthma risk factors (
table 1).
Additional history that should be obtained in a child with established asthma who presents for
disease monitoring includes previous and current therapy (controller and quick-relief medication
use), exposure to triggers, utilization of health care services (emergency department [ED], hospital,
unscheduled clinic visits), school attendance and performance, and participation in physical activity.
Review of an asthma questionnaire such as the Asthma Control Test may provide additional useful
information. (See "Asthma in children younger than 12 years: Initiating therapy and monitoring
control", section on 'Assessment of control'.)
The evaluation of a child who presents with an acute asthma exacerbation is discussed separately.
(See "Acute asthma exacerbations in children younger than 12 years: Emergency department
management".)
Symptoms — Approximately 80 percent of children with asthma develop symptoms before five

years of age, but the disease is frequently misdiagnosed or not suspected, particularly in infants and

toddlers [15]. Evaluating the presence of asthma symptoms is an important first step in establishing
a proper diagnosis.
Coughing and wheezing are the most common symptoms of childhood asthma. Breathlessness,
chest tightness or pressure, and chest pain also are reported. Poor school performance and fatigue
may indicate sleep deprivation from nocturnal symptoms.
Cough — The presence of a nocturnal cough, a cough that recurs seasonally, a cough in

response to specific exposures (eg, cold air, exercise, laughing, allergen exposure, or crying), or a
cough that lasts more than three weeks should raise the suspicion for asthma [16]. Although
wheezing is considered the hallmark of childhood asthma, cough is frequently the sole presenting
complaint [17]. The most common cause of chronic cough in children older than three years is
asthma, even if it is not accompanied by wheezing. The cough is typically dry and hacking but may
be productive; when the cough is productive, clear or whitish sputum may be expectorated (which
often contains eosinophils). It is not unusual for chronic cough lasting more than three weeks to be
labeled "bronchitis" and to be treated with medications, such as cough suppressants,
decongestants, or antibiotics. However, these types of cough may be manifestations of asthma and
are likely to respond to asthma therapy. (See "Approach to chronic cough in children".)
Wheeze — Wheezing is a high-pitched, musical sound produced when air is forced through

narrow airways. The wheezing of asthma tends to be polyphonic (varied in pitch), reflecting the
heterogeneous distribution of affected airways. When airflow obstruction becomes severe,
wheezing can be heard on both inspiration and expiration. In contrast to asthma, central airway
obstruction may cause a harsh expiratory monophonic wheeze, as occurs with tracheomalacia.
Upper airway obstruction (eg, vocal cord dysfunction) should be suspected if an inspiratory
monophonic (of single pitch) wheeze (typically called stridor) is the only audible sound during an
exacerbation. (See "Assessment of stridor in children".)
A silent chest in the context of an asthma exacerbation implies airflow limitation of such severity that
audible wheezes cannot be produced; this represents a medical emergency. (See "Acute asthma
exacerbations in children younger than 12 years: Emergency department management".)
Seasonal symptoms — Symptoms that are worse in certain pollen seasons are characteristic of
atopic asthma. Trees in temperate climates pollinate in early spring, grasses in summer, and weeds
in the fall. Children who are sensitive to molds tend to wheeze or cough during rainy seasons or if
they are exposed to flooding or indoor dampness. Other allergic symptoms, such as rhinitis,
conjunctivitis, or eczema, may flare concurrently with the chest complaints. (See "Chronic
rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis" and "Allergic conjunctivitis:

Clinical manifestations and diagnosis" and "Atopic dermatitis (eczema): Pathogenesis, clinical
manifestations, and diagnosis".)
Symptom patterns — Chronic asthma symptoms assume several typical patterns:
● Intermittent exacerbations superimposed upon an asymptomatic baseline
● Chronic symptoms punctuated by periods of worsening symptoms
● Morning "dipping" (an accentuation of the physiologic cycle of pulmonary function in normal
individuals, characterized by worsening of symptoms and decreased peak flow in the early
morning, with improvement as the day progresses)
Precipitating factors — Wheezing or cough may occur at any time, but certain patterns and
precipitating factors ( table 2) are typical. Depending upon the type and intensity of the
provocative agent, most acute asthma exacerbations have a slow onset over several days.
Uncommonly, severe attacks may occur suddenly and with minimal warning, resulting in life-
threatening exacerbations [18-22]. (See "Acute asthma exacerbations in children younger than 12
years: Emergency department management" and "Trigger control to enhance asthma
management".)
Respiratory tract infections — Viral upper respiratory infections (URIs) are the most important
triggering factor for patients with asthma of all ages, including infants and young children [23].
Clustering of asthma attacks between fall and spring suggests viral illness-induced phenomena
[24,25]. Among children who are hospitalized for wheezing, respiratory syncytial virus, influenza
virus, and rhinovirus are most common in those younger than three years (depending upon the
season); rhinovirus is most common among older children [24]. (See "Role of viruses in wheezing
and asthma: An overview".)
One study found that clusters of asthma hospitalizations in school-aged children in Canada
occurred predictably after they returned to school following summer vacation and other breaks [26].
Specifically, there was a "September asthma epidemic" approximately 18 days after Labor Day (the
first Monday of September), with a lesser increase in attacks two days later in preschool children
and six days later in adults. Viral infections were the presumed cause, although a reduction in daily
asthma medication use (eg, therapeutic holiday) during the summer months has also been
implicated.
Chronic sinusitis (which is often bacterial) and respiratory infections due to Mycoplasma
pneumoniae and Chlamydia pneumoniae may precipitate worsening of asthma [27-31]. (See

"Pneumonia caused by Chlamydia pneumoniae in children" and "Mycoplasma pneumoniae infection

in children", section on 'Other respiratory manifestations'.)
Exercise — Exercise-induced bronchospasm (EIB) may be the only manifestation of asthma in

children [32]. It occurs in up to 90 percent of children with asthma [33].
Typical symptoms are shortness of breath, chest tightness, and cough. Exercise-triggered
symptoms typically develop several minutes into prolonged exercise. Symptoms usually resolve
with rest over 30 to 60 minutes. Lung function changes little or may even improve somewhat during
most of the actual period of exercise. Lung function may begin to deteriorate towards the end of the
exercise period and can fall quite markedly in some patients. The major fall in lung function normally
occurs 5 to 10 minutes after stopping the exercise. Lung function then normally returns
spontaneously to baseline over 30 to 45 minutes. A late-phase reaction occurs in a small proportion
of patients with asthma [34], and some patients have both an immediate and a late-phase response
to exercise [35]. (See "Exercise-induced bronchoconstriction".)
Certain types of exertion (eg, swimming) appear to be less provocative of asthma than others (eg,
running, skating), probably because they produce less airway cooling and drying, which are thought
to be provocative of EIB [32]. In a systematic review, patients with stable asthma who participated in
swimming training had improved lung function and physical fitness, with no change in asthma
symptoms or exacerbations [36]. However, there is an ongoing debate about potential lung damage
caused by repeated respiratory exposure to chlorine byproducts in recreational swimmers [37-40].
We allow our patients to swim and only advise against it if chlorine appears to be an irritant trigger
in a particular patient.
Short bursts of activity tend to be better tolerated than prolonged exercise. Repeated short periods
of exercise tend to result in diminishing EIB with each episode. Nonetheless, children with asthma
do not need to be steered toward particular sports, since they can participate in sports at any level
(including the Olympics) with proper treatment, and improved exercise tolerance leads to lower
respiratory rates with the same level of activity.
If untreated, longstanding EIB may result in poor overall fitness, decreased exercise stamina, a
preference for a sedentary lifestyle, and exercise avoidance due to the distress brought on by
physical activity. EIB that is difficult to control often indicates inadequately controlled underlying
asthma.
Weather — Cold air; hot, humid air; changes in barometric pressure; rain; thunderstorms; or
wind may be provocative factors for asthma in individual patients. (See "Trigger control to enhance
asthma management", section on 'Temperature and weather'.)

Tobacco smoke — Exposure to secondhand cigarette smoke is the single, most common,

external risk factor for the development and progression of asthma symptoms in children [41-43].
(See "Secondhand smoke exposure: Effects in children".)
Allergens — Indoor and outdoor allergens are an important trigger of childhood asthma for the
80 percent of children with asthma and allergies, particularly those older than three years of age
(see "Allergen avoidance in the treatment of asthma and allergic rhinitis"). These include [44]:
● House dust mites, cockroaches, and rodents [45-48]
● Pet exposures; cats and dogs are especially provocative, but other furry animals (gerbils,
rabbits, hamsters, etc) may be suspect, especially if symptoms only occur in settings where
these animals reside [49]
● Pollens [50]
● Molds
Irritant exposures — Asthma symptoms that occur after prolonged time indoors (eg, winter
months or during periods of inclement weather) should raise a suspicion of sensitivity to indoor
exposures to allergens (see 'Allergens' above) or inhaled airway irritants, such as [44,51]:
● Nitrogen dioxide (from gas stoves) [52]

● Particulates and smoke from wood fires, pellet stoves, or kerosene space heaters
● Exposure to chemicals via vaping
● Propellant cleaning sprays
● Perfumes, hair sprays
● Paint
● Room deodorizers
● Cleaning products with strong odors
Stress — Various types of stress can trigger or exacerbate asthma [53], although asthma can
also cause stress. However, asthma symptoms and exacerbations should not be attributed to stress
unless all other exacerbating factors have been excluded. In addition, asthma should be sufficiently
well controlled to allow patients to tolerate stressful situations and other unavoidable triggers without
asthma exacerbations.
Additional history — Additional history that should be obtained in children with suspected asthma
includes a personal history of other atopic diseases, family history of asthma or other atopic
diseases (eg, allergic rhinitis, atopic dermatitis, and food allergy), environmental history, past
medical history, medication use, medical utilization, school attendance, and psychosocial factors.
Allergic history — Allergic disease is associated with the development, severity, and

persistence of asthma. As an example, up to 80 percent of children with atopic dermatitis develop
asthma and/or allergic rhinitis later in childhood [54]. Approximately 30 percent of children with food
allergy have asthma and respiratory allergy compared with 10 percent of children without food
allergy [55]. Food allergy is also a risk factor for life-threatening asthma, as evidenced by a
substantially higher rate of food allergy in children requiring intubation for asthma compared with a
control group of asthmatic children [56]. Sensitivity to many mold allergens is associated with
increased asthma severity and persistence [57,58]. (See "Role of allergy in atopic dermatitis
(eczema)" and "Allergen avoidance in the treatment of asthma and allergic rhinitis" and "Risk factors
for asthma", section on 'Atopy and allergens'.)
In a study of children who were hospitalized for wheezing (cases), total serum immunoglobulin E
(IgE) concentrations in the subgroup <3 years of age were similar to hospitalized children without
wheezing (controls) but were significantly elevated among the cases in the subgroup >3 years old
[24]. In addition, a higher percentage of cases were sensitized to at least one inhaled allergen (84
versus 33 percent).
In atopic infants, sensitization to common foods, such as egg white and cow's milk, may occur and
peaks at approximately eight months of age [59]. IgE antibodies to inhalant allergens generally
appear beginning at two years of age and increase throughout childhood [59]. Food allergy and
eczema are the most common manifestations of atopy in early life, whereas asthma and allergic
rhinitis are more common in older children. (See "Atopic dermatitis (eczema): Pathogenesis, clinical
manifestations, and diagnosis" and "Clinical manifestations of food allergy: An overview" and "Food
allergy in children: Prevalence, natural history, and monitoring for resolution".)
Sensitization to foods and the presence of atopic dermatitis represent an atopic diathesis, whereas
sensitization to airborne allergens also represents a trigger for asthma exacerbations.
Family history — The influence of genetics in the development of asthma has not been fully
defined [43,60-66]. Because families also share environments, determining the influence of the
genetic contribution to asthma is complicated. Nonetheless, a family history of asthma or other
atopic disease (ie, allergic rhinitis, atopic dermatitis, or food allergy) certainly strengthens the
likelihood that a child with a compatible history has asthma.
Children with one asthmatic parent are 2.6 times more likely to have asthma; with two asthmatic
parents, the odds ratio rises to 5.2 [60]. Maternal asthma appears to make a bigger contribution
than paternal asthma to asthma in offspring, although this finding is inconsistent [62-64].
Environment — A thorough review of all regular environments, including home, school, daycare,
and relatives' homes, is essential to evaluate possible provocative situations in the child with
asthma. The table outlines some questions that may be helpful in obtaining this history ( table 3).
A strategy to avoid asthma triggers is one of the essential elements for managing the disease. (See
"Trigger control to enhance asthma management" and "Allergen avoidance in the treatment of
asthma and allergic rhinitis".)
Past medical history — A careful survey of all aspects of the child's medical history is critical to
formulate a differential diagnosis of the child's complaint. Questions about the neonatal course,
early respiratory symptoms, and the coexistence of systemic symptoms (failure to thrive, fever,
developmental delay, recurrent infections) may point toward other diagnoses. Additional questioning
may reveal evidence of comorbid conditions, such as obstructive sleep apnea (OSA),
gastroesophageal reflux, or chronic rhinosinusitis.
Sleep disordered breathing, for example, was associated with a 3.6-fold increased risk of severe
asthma in one study [67]. Another large, observational study found an improvement in asthma
control (eg, decreased exacerbations, hospitalizations, and medication use) following
adenotonsillectomy [68]. The latter results did not show, however, that adenotonsillectomy caused a
reduction in the severity of childhood asthma. It is possible that the children who underwent
adenotonsillectomy shared another unknown factor that led to improvements in their asthma over
time, such as a reduction in upper respiratory tract infections. (See 'Differential diagnosis' below and
"Evaluation of severe asthma in adolescents and adults", section on 'Assessing comorbid
conditions'.)
Medications — A careful review of prior and present medications (including over-the-counter

and alternative remedies) provides information on adherence to therapy, drug efficacy, drug delivery
systems in use, accuracy of diagnosis, and control of asthma. Response to treatment with albuterol,
as demonstrated by a decreased respiratory rate, diminished retractions, increased aeration, and/or
decreased cough or wheezing, can be helpful in making the diagnosis of asthma, particularly in
children unable to perform spirometry. The onset of action is within 20 minutes, and the benefits
should last four to six hours.
Common reasons for poor response to asthma medications include:
● Nonadherence to the prescribed regimen. Parents and children often over-report adherence
with controller medications; objective measures (eg, an inhaler with a dose counter) may be
necessary to verify adherence [69]. Overuse of quick-relief medications (eg, short-acting beta
agonists) with resultant tolerance can also be an issue. (See "Enhancing patient adherence to
asthma therapy" and "Beta agonists in asthma: Acute administration and prophylactic use",
section on 'Tolerance'.)

● Improper inhaler technique. Since the efficacy of many asthma medications depends upon their
deposition in the lung, inhalation technique figures strongly in the success or failure of inhaled
therapies. Metered dose inhalers (MDIs) require a significant degree of coordination for optimal
drug delivery, and there is considerable evidence that many patients and health care
professionals do not regularly perform or teach proper inhalation technique [70,71]. Errors also
can be made with dry powder inhalers (DPIs). Patient education materials, use of spacers (with
MDIs), and frequent reappraisal of technique contribute to greater success with this form of
therapy. Spacers with masks are especially helpful to the very young child. (See "Delivery of
inhaled medication in children" and "The use of inhaler devices in children".)
● Ineffective drug dose or dosing interval. (See "Asthma in children younger than 12 years:
Management of persistent asthma with controller therapies".)
● Complicating medical problems (eg, chronic sinusitis, vocal cord dysfunction, gastroesophageal
reflux, environmental allergies) [72,73]. (See "Chronic rhinosinusitis: Clinical manifestations,
pathophysiology, and diagnosis" and "Inducible laryngeal obstruction (paradoxical vocal fold
motion)" and "Clinical manifestations and diagnosis of gastroesophageal reflux disease in
children and adolescents" and "Relationships between rhinosinusitis and asthma".)
● Complicating psychosocial factors (which can interfere with regularly obtaining and properly
using medications).
● Inappropriate treatment (eg, antibiotics, antitussives, over-the-counter or alternative

medications).
● Different response to controller medications depending upon the child's intrinsic characteristics
[74-77].
Health care utilization — The degree of asthma control is usually linked to health care
utilization, such that more severe or poorly controlled patients with asthma tend to be treated more
often in EDs, urgent care centers, or doctors' offices. A history of more than a few such
interventions is often indicative of poorly controlled asthma, regardless of the level of chronic
symptoms [78]. In addition, a history of prior hospitalizations, ED visits, or exacerbations requiring
oral glucocorticoids confers an increased risk for future asthma exacerbations.
School attendance — One-third of children with asthma suffer noticeable disability [79].

Interference with regular school attendance or achievement is a good measure of disability from
childhood asthma. A pattern of significant numbers of lost days from school and a deteriorating
academic performance should prompt more aggressive asthma management.

Nearly 14 million school days are missed each year due to asthma, although the percent of children
with asthma who reported one or more missed school days declined significantly from 2003 to 2013
(61.4 versus 49 percent) [3] and held steady at 49 percent in 2016 [8]. Childhood asthma is also a
major cause of parental work absenteeism [80,81].
Physical activity — Most children with asthma can have symptoms brought on by intensive
activity; therefore, many children limit their level of exertion. In one study, children with newly
diagnosed, untreated asthma were less fit and spent less time in vigorous activity than their healthy
peers [82]. However, physical activities need not be restricted. Rather, appropriate treatment should
allow full participation, which should be encouraged. With appropriate therapy, children with asthma
can participate in all activities, including sports at every level up to and including participation in the
Olympics [83], without restriction.
Psychosocial profile — Chronic asthma may create or exacerbate psychosocial problems for

patients and their families. Conversely, psychosocial factors can affect asthma symptoms and
health behaviors [84]. Stressors surrounding asthma can include:
● Anxiety about the often sudden, life-threatening nature of attacks
● Fear of dying
● Fear of peer rejection because of being "different"
● Concern regarding the adverse effects of asthma drugs (particularly glucocorticoids, also called
corticosteroids)
● Sleep deprivation due to nocturnal symptoms
● Poor school performance
● Financial consequences
● Disruption in family routines
● Siblings' resentment of the patient's special status within the family
● Limitation of social or geographic venues because of potential triggering of asthma (eg, cannot
visit places where environmental tobacco smoke or allergen exposure is likely)
● Family discord over asthma treatment
Predictive tools — Parents often ask if their young child with recurrent cough or wheeze has
asthma and if he or she might outgrow it. Various predictive models or clinical indicators of risk have
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been studied to help the clinician identify young children who will continue wheezing later in
childhood, although these tools were primarily designed to enrich study populations rather than
actually predict asthma. These models have employed various risk factors associated with the
development of asthma in longitudinal epidemiologic studies, such as baseline forced expiratory
volume in one second (FEV1)/forced vital capacity (FVC), parental history of allergic sensitization
and asthma, wheezing history, atopic disease in the child, IgE levels, and cytokine secretion
profiles. However, none of these clinical tools have been validated in populations different from the
study group. These tools and risk factors are discussed in greater detail separately. (See "Wheezing
phenotypes and prediction of asthma in young children", section on 'Predictive tools in children with
wheezing' and "Natural history of asthma", section on 'Infants and children'.)
PHYSICAL EXAMINATION
Examination findings during an acute exacerbation include tachypnea, hypoxia, wheezing,

accessory muscle use, retractions, and prolonged expiratory phase. These findings are discussed in
detail separately. (See "Acute asthma exacerbations in children younger than 12 years: Emergency
department management".)
Physical examination of a child with asthma is generally normal if performed when the patient does
not have an acute exacerbation. Abnormal findings in the absence of an acute exacerbation may
suggest severe disease, suboptimal control, or associated atopic conditions. Abnormalities that may
be observed include [78]:
● Decreased air entry or wheezing on auscultation
● A prolonged expiratory phase on auscultation
● Dry cough
● Signs of rhinitis, conjunctivitis, and sinusitis (nasal discharge, inflamed nasal mucosa, sinus
tenderness, dark circles under the eyes) (see "Chronic rhinosinusitis: Clinical manifestations,
pathophysiology, and diagnosis")
● Signs of an acute respiratory infection
● A transverse nasal crease due to frequent itching (allergic salute)
● Halitosis due to chronic rhinitis, sinusitis, and mouth breathing
● Eczema/atopic dermatitis

● Nasal polyps ( picture 1 and picture 2) (glistening, gray, mucoid masses within the nasal
cavities, which may be associated with asthma and aspirin sensitivity in adolescents and
adults, but should prompt evaluation for cystic fibrosis in children of any age) (see "Cystic
fibrosis: Clinical manifestations and diagnosis")
● An increased anterior-posterior diameter of the chest due to air trapping
Obesity — Results are conflicting regarding the relationship between obesity and asthma severity
[67,85-88]. Obesity and higher percent body fat are associated with an increased incidence of
asthma [89] and are more commonly seen in children with newly diagnosed, untreated asthma than
their healthy peers [82]. Higher body mass index (BMI) is also associated with greater asthma
severity [85,89]. However, biologic causality has not been proven, and reverse causation may also
occur (ie, asthma limiting physical activity leading to obesity). (See "Risk factors for asthma" and
"Evaluation of severe asthma in adolescents and adults", section on 'Assessing comorbid
conditions'.)
DIAGNOSIS
A history of intermittent or chronic symptoms typical of asthma plus the finding on physical
examination of characteristic musical wheezing (present in association with symptoms and absent
when symptoms resolve) strongly point to a diagnosis of asthma (see 'History' above and 'Physical
examination' above). Confirmation of the diagnosis of asthma is based on three key additional
elements [78,90,91]:
● The demonstration of variable expiratory airflow limitation, preferably by spirometry, when

possible
● Documentation of reversible obstruction
● Exclusion of alternative diagnoses (see 'Differential diagnosis' below)
Evidence of airway obstruction on spirometry, especially if acutely reversible with a bronchodilator,

strongly supports the diagnosis of asthma. However, normal spirometry, or the lack of reversibility of
obstruction in the setting of an acute exacerbation, does not exclude the diagnosis. A trial of asthma
medication is warranted in patients with symptoms suggestive of asthma who have normal or near-
normal spirometry or who are unable to perform spirometry due to age or other factors.
Improvement on medications is sufficient to make the diagnosis in these patients. If a trial of asthma
medication fails to improve symptoms, bronchoprovocation testing with methacholine, cold air, or
exercise may be warranted. (See 'Spirometry' below and 'Medications' above and 'Ancillary studies'
below.)

Spirometry — Demonstration of reversible airflow obstruction establishes the diagnosis of asthma

and facilitates the assessment of severity ( figure 1) [78]. Spirometry is the preferred method of
diagnosis of airflow obstruction. The National Asthma Education and Prevention Program (NAEPP)
expert panel recommends performing spirometry in patients five years of age and older if a
diagnosis of asthma is suspected [78]. (See "Overview of pulmonary function testing in children".)
Spirometry measurements include forced vital capacity (FVC) and the forced expiratory volume in
one second (FEV1). Airflow obstruction is defined as FEV1 reduced to less than 80 percent
predicted and an FEV1/FVC ratio of less than 0.85 (85 percent) ( table 4A). Reference values are
based on age, height, sex, and race [92]. FEV1/FVC appears to be a more sensitive measure of
impairment than FEV1, whereas FEV1 may be a more useful measure of risk for future
exacerbations [78,93-96] (see "Asthma in children younger than 12 years: Initiating therapy and
monitoring control", section on 'Assessment of control'). Forced expiratory flow between 25 and 75
percent of vital capacity (FEF25-75) less than 65 percent correlates with reversible airflow
obstruction in children with normal FEV1 and may be a useful measure in this subgroup, although
further studies are needed [97].
Spirometry should be performed before and after administration of a bronchodilator to assess for
reversibility (bronchodilator response [BDR]) even in children with a normal baseline FEV1 because
many of these children will still have a BDR (both within the normal range and sometimes also
supranormal) after treatment. Significant reversibility is indicated by an increase in FEV1 of ≥12
percent from baseline after administration of a short-acting bronchodilator. This definition for BDR
positivity was established primarily in adults. An increase in FEV1 of ≥8 percent may be a better
definition for BDR in children [98-100]. (See "Overview of pulmonary function testing in children".)
There is some evidence from cross-sectional studies to suggest that the NAEPP criteria for percent
predicted FEV1 ( table 4A-B) do not accurately categorize asthma severity in children and that
symptom frequency and rescue medication use may be more sensitive measures [93,94,101-103].
In the Childhood Asthma Management Program (CAMP) study, for example, the mean FEV1 of all
children studied was 94 percent predicted [94], although this study included only children with mild-
to-moderate asthma based upon symptoms, use of medications, and response to methacholine
[104]. Nonetheless, percent predicted FEV1 remains a useful measure because it is strongly
associated with the risk of asthma exacerbation in the 12 months after measurement [95,96].
Another potential spirometric measure of risk for asthma severity and poor control (asthma
instability) is the air-trapping obstruction phenotype, defined as a FVC Z-score of <-1.64 (equivalent
to fifth percentile in a healthy population) or a ≥10 percent change in the predicted value of FVC
after bronchodilation. In a study of 560 children aged 6 to 17 years from low-income, urban areas
who had physician-diagnosed asthma, the risk of ≥2 asthma exacerbations during the 12-month
study period was more than fourfold higher (odds ratio 4.41, 95% CI 2.37-8.21) in those with this
phenotype compared with those without any evidence of obstruction on spirometry [105]. Children
with the air-trapping obstruction phenotype also had higher Composite Asthma Severity Index
scores and asthma treatment steps, as well as greater sensitivity to methacholine challenge and
variability in FEV1 over time.
Measurements of peak expiratory flow using a peak flow meter are more variable and effort
dependent. In addition, there is wide variability in the published predicted peak expiratory flow
reference values and in the reference values from brand to brand [78]. Thus, peak flow
measurements alone should not be used to diagnose asthma. Peak flow measurements may be
more useful in monitoring a patient's symptoms and response to therapy over time, although serial
spirometry is preferred ( table 4B) [78]. (See "Peak expiratory flow monitoring in asthma".)
Children <5 years — In infants and children younger than five years of age, the diagnostic steps
should remain the same as described above, except that spirometry often cannot be performed in
this age group. A trial of asthma medications may help to establish the diagnosis in these children.
Reversal of symptoms and signs in the time expected for albuterol to work is suggestive of the
diagnosis of asthma. Impulse oscillometry (IOS) is an alternative to spirometry in younger children
since it only requires passive cooperation [106,107]. However, it is not readily available to most
clinicians treating children with asthma, limiting its clinical utility [108]. IOS measurements at
baseline and postbronchodilator differed significantly between children aged three to six years with
and without asthma, whereas no significant differences were seen with traditional spirometry. IOS
may detect alterations in respiratory mechanics not seen with spirometry even in older children
[109-111]. (See 'Diagnosis' above and 'Medications' above.)
Debate is ongoing regarding how to best classify infants and young children with recurrent
wheezing. The terms asthma, reactive airway disease, wheezy bronchitis, bronchiolitis, asthmatic
bronchitis, wheezing-associated respiratory illness, and postinfectious bronchial hyperreactivity
have all been employed. This jargon reflects an attempt to describe and define a subgroup of
wheezing children with a more benign prognosis than is implied by "asthma," which is, by definition,
chronic. "Wheezy bronchitis" usually defines nonatopic babies or toddlers with recurrent, virus-
induced wheezing (the majority of this group of wheezing young children) that tends to disappear by
five years of age [112,113]. Asthma, on the other hand, has been taken to mean a chronic condition,
frequently associated with atopy, provoked by a number of triggers in addition to viruses, and
carrying a poorer prognosis for spontaneous resolution. (See "Asthma in adolescents and adults:
Evaluation and diagnosis", section on 'Definition' and "Natural history of asthma", section on 'Infants
and children' and "Wheezing phenotypes and prediction of asthma in young children" and "Role of

viruses in wheezing and asthma: An overview" and "Evaluation of wheezing in infants and children"
and "Approach to chronic cough in children".)
Ancillary studies — The history and physical examination, in conjunction with spirometry, are
usually adequate to establish the diagnosis of asthma. Ancillary studies are most helpful to exclude
competing diagnoses or to identify comorbid conditions.
Allergy testing — Allergy testing, done either by skin or in vitro testing, is helpful even in the
very young child when used selectively. Specifically, when the environmental history uncovers
exposure to furry animals (pets or pests), molds, cockroaches, or dust mites, it is worthwhile to test
for these or other limited allergens to formulate proper avoidance strategies. Outdoor aeroallergens
are unusual triggers in infants and very young children but may be triggers in older children. Food
allergy testing is not helpful unless there is a sound history of gastrointestinal complaints, worsening
eczema, urticaria, shortness of breath, throat tightness, cough, hoarse voice, or asthma that is
temporally associated with the ingestion of certain foods. Children with this type of history should be
evaluated by a clinician familiar with food allergies and prescribed epinephrine since ingestion of a
food allergen can be life threating in a patient with food allergies, particularly in a patient with
concomitant asthma. In addition, when indicated testing reveals the presence of IgE antibody to any
allergen, an atopic diathesis is demonstrated, increasing the likelihood that chest symptoms are due
to asthma. (See "Overview of skin testing for allergic disease".)
Bronchoprovocation testing — We advise performing bronchoprovocation testing (with

methacholine, cold air, or exercise) when the clinical features are suggestive of asthma but
spirometry is normal and there is no response to asthma medications. An exercise challenge of
sufficient magnitude may provoke symptoms in children with asthma [114-116]. A negative
bronchoprovocation study may also be useful in reducing the likelihood that a child has asthma,
although it cannot be used to exclude the diagnosis. For safety reasons, these tests should be
conducted in a specialized facility with trained technicians and should not be performed if a patient
has severe airflow limitation (FEV1 <50 percent predicted) [117]. Exercise challenge has a high
specificity, whereas methacholine challenge had a high sensitivity. Bronchial challenge tests are
discussed in greater detail separately. (See "Overview of pulmonary function testing in children" and
"Bronchoprovocation testing".)
Chest radiograph — We advise performing a chest radiograph (chest x-ray [CXR]) only in
children who do not respond to initial therapy. In those children, the chest radiograph may display
findings suggestive of causes for wheezing other than asthma including congenital malformations
(eg, a right aortic arch suggestive of a vascular ring); evidence of airspace disease consistent with
aspiration or cystic fibrosis; or findings consistent with asthma, such as hyperinflation, peribronchial
thickening, and mucoid impaction with atelectasis.
Sweat chloride test — A sweat chloride test below established cut-off values reduces the
likelihood of the diagnosis of cystic fibrosis in children with respiratory complaints in association with
frequent foul-smelling stools or other evidence of malabsorption (eg, undigested food or oil),
recurrent pneumonia, edema, and/or failure to thrive. There should be a low threshold to perform
this test in children with this clinical picture, even if prenatal maternal screening or newborn
screening was negative, since identifying a patient with cystic fibrosis has major implications for the
patient, the family, and future reproductive decisions. Mutation analysis should be performed even if
the sweat chloride is below established cut-off values if the suspicion for cystic fibrosis remains
high. (See "Cystic fibrosis: Clinical manifestations and diagnosis".)
Barium swallow — A modified barium swallow should be included in the diagnostic evaluation if
swallowing dysfunction with aspiration is a consideration. (See "Clinical manifestations and
diagnosis of gastroesophageal reflux disease in children and adolescents" and "Evaluation of
wheezing in infants and children".)
Exhaled nitric oxide — Exhaled nitric oxide testing is not recommended. (See "Exhaled nitric
oxide analysis and applications", section on 'Clinical use in asthma'.)
DIFFERENTIAL DIAGNOSIS
Although wheezing is most commonly caused by asthma, it is not a pathognomonic finding. The
lack of objective measures of pulmonary function in very young children and the relatively high
prevalence of congenital and inherited disorders that present with wheezing make it imperative to
consider the differential diagnosis of wheezing illnesses before making a diagnosis of asthma solely
on the basis of wheezing ( table 5 and table 6). In particular, other causes of wheezing in
children must be excluded if there is a failure to respond to asthma therapy or if the history and/or
physical examination suggest alternative diagnoses. Cough is the primary manifestation in some
children with asthma; therefore, the differential diagnosis for chronic cough in children should also
be considered ( table 7 and algorithm 1). Clinical features suggestive of a diagnosis other than
asthma are seen in the table ( table 8) and are discussed in detail separately. (See "Evaluation of
wheezing in infants and children" and "Approach to chronic cough in children" and "Causes of
chronic cough in children".)
INDICATIONS FOR REFERRAL
Consultation with an asthma specialist, either a pulmonologist or an allergist, is warranted when the
diagnosis of asthma is uncertain, the asthma is difficult to control, medication side effects are

intolerable, or a patient has frequent exacerbations. Pulmonologists may be most helpful if

alternative pulmonary diseases are suspected or if further pulmonary testing or bronchoscopy may
be needed. Referral to an allergist may be most helpful if allergic triggers need further evaluation or
if concomitant nasal and ocular allergy symptoms are difficult to control.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: Asthma in children".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for patients
who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topic (see "Patient education: Cough in children (The Basics)")
● Beyond the Basics topics (see "Patient education: Asthma symptoms and diagnosis in children
(Beyond the Basics)" and "Patient education: Asthma treatment in children (Beyond the
Basics)")
SUMMARY AND RECOMMENDATIONS
● Establishing a diagnosis of asthma involves a careful process of history taking, physical

examination, and diagnostic studies; other causes of wheezing must be excluded. (See
'Introduction' above.)
● The history in a child with suspected asthma centers on the presence of symptoms (cough and
wheeze are the most common), precipitating factors or conditions ( table 1 and table 2),
typical symptom patterns, and response to asthma therapy. (See 'History' above.)
● Additional history that should be obtained in children with suspected asthma includes a history
of atopy, family history of asthma, environmental history, and past medical history. (See
'Additional history' above.)
● Important aspects of the history in a child with asthma who presents for monitoring include
previous and current therapy, exposure to triggers, medical utilization, school attendance and
performance, comorbidities, and psychosocial stressors. (See 'Additional history' above.)
● Physical examination of an asthmatic child is generally normal if performed in the absence of

an acute exacerbation. Abnormal findings may suggest severe disease, suboptimal control, or
associated atopic conditions. (See 'Physical examination' above.)
● Other causes of wheezing in children must be excluded if there is a failure to respond to

asthma therapy or if the history and/or physical examination suggest alternative diagnoses (
table 5 and table 6 and table 7 and algorithm 1 and table 8). (See 'Differential
diagnosis' above and "Evaluation of wheezing in infants and children".)
● The diagnosis of asthma requires a history of episodic symptoms of airflow obstruction or

bronchial hyperresponsiveness, demonstration (with spirometry if possible) that airflow
obstruction is reversible, and exclusion of alternate diagnoses. If spirometry cannot be
performed, a trial of medications may help to establish reversibility. (See 'Diagnosis' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
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Asthma in Children Younger Than 12 Years - Initial Evaluation and Diagnosis - UpToDate

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7/7/2021 Asthma in children younger than 12 years: Initial evaluation and diagnosis - UpToDate

Symptoms — Approximately 80 percent of children with asthma develop symptoms before five

uptodate.yabesh.ir/contents/asthma-in-children-younger-than-12-years-initial-evaluation-and-diagnosis?search=asthma in children&source=search_r… 2/27

Cough — The presence of a nocturnal cough, a cough that recurs seasonally, a cough in

Wheeze — Wheezing is a high-pitched, musical sound produced when air is forced through

uptodate.yabesh.ir/contents/asthma-in-children-younger-than-12-years-initial-evaluation-and-diagnosis?search=asthma in children&source=search_r… 3/27

Symptom patterns — Chronic asthma symptoms assume several typical patterns:

● Intermittent exacerbations superimposed upon an asymptomatic baseline

● Chronic symptoms punctuated by periods of worsening symptoms

uptodate.yabesh.ir/contents/asthma-in-children-younger-than-12-years-initial-evaluation-and-diagnosis?search=asthma in children&source=search_r… 4/27

"Pneumonia caused by Chlamydia pneumoniae in children" and "Mycoplasma pneumoniae infection

Exercise — Exercise-induced bronchospasm (EIB) may be the only manifestation of asthma in

uptodate.yabesh.ir/contents/asthma-in-children-younger-than-12-years-initial-evaluation-and-diagnosis?search=asthma in children&source=search_r… 5/27

Tobacco smoke — Exposure to secondhand cigarette smoke is the single, most common,

● House dust mites, cockroaches, and rodents [45-48]

● Nitrogen dioxide (from gas stoves) [52]

Allergic history — Allergic disease is associated with the development, severity, and

Medications — A careful review of prior and present medications (including over-the-counter

Common reasons for poor response to asthma medications include:

uptodate.yabesh.ir/contents/asthma-in-children-younger-than-12-years-initial-evaluation-and-diagnosis?search=asthma in children&source=search_r… 8/27

● Inappropriate treatment (eg, antibiotics, antitussives, over-the-counter or alternative

School attendance — One-third of children with asthma suffer noticeable disability [79].

uptodate.yabesh.ir/contents/asthma-in-children-younger-than-12-years-initial-evaluation-and-diagnosis?search=asthma in children&source=search_r… 9/27

Psychosocial profile — Chronic asthma may create or exacerbate psychosocial problems for

● Anxiety about the often sudden, life-threatening nature of attacks

● Fear of peer rejection because of being "different"

● Sleep deprivation due to nocturnal symptoms

● Poor school performance

● Disruption in family routines

● Siblings' resentment of the patient's special status within the family

● Family discord over asthma treatment

Examination findings during an acute exacerbation include tachypnea, hypoxia, wheezing,

● Decreased air entry or wheezing on auscultation

● A prolonged expiratory phase on auscultation

● Signs of an acute respiratory infection

● A transverse nasal crease due to frequent itching (allergic salute)

● Halitosis due to chronic rhinitis, sinusitis, and mouth breathing

uptodate.yabesh.ir/contents/asthma-in-children-younger-than-12-years-initial-evaluation-and-diagnosis?search=asthma in children&source=search_… 11/27

● An increased anterior-posterior diameter of the chest due to air trapping

● The demonstration of variable expiratory airflow limitation, preferably by spirometry, when

Evidence of airway obstruction on spirometry, especially if acutely reversible with a bronchodilator,

uptodate.yabesh.ir/contents/asthma-in-children-younger-than-12-years-initial-evaluation-and-diagnosis?search=asthma in children&source=search_… 12/27

Spirometry — Demonstration of reversible airflow obstruction establishes the diagnosis of asthma

uptodate.yabesh.ir/contents/asthma-in-children-younger-than-12-years-initial-evaluation-and-diagnosis?search=asthma in children&source=search_… 14/27

Bronchoprovocation testing — We advise performing bronchoprovocation testing (with

INDICATIONS FOR REFERRAL

uptodate.yabesh.ir/contents/asthma-in-children-younger-than-12-years-initial-evaluation-and-diagnosis?search=asthma in children&source=search_… 16/27

intolerable, or a patient has frequent exacerbations. Pulmonologists may be most helpful if

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

● Basics topic (see "Patient education: Cough in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Establishing a diagnosis of asthma involves a careful process of history taking, physical

● Physical examination of an asthmatic child is generally normal if performed in the absence of

● Other causes of wheezing in children must be excluded if there is a failure to respond to

● The diagnosis of asthma requires a history of episodic symptoms of airflow obstruction or

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