This text aims to clarify the decision-making process for determining when a general practitioner should consider asthma in children up to the age of 12, how to diagnose it, and how to establish the correct treatment. The general practitioner will treat episodes of cough and wheezing and will consider asthma when these symptoms recur. The general practitioner is in a favorable position to recognize the recurring nature of these symptoms due to the continuity of care they provide.
Asthma is the most common chronic condition in children. Its prevalence is high and likely increasing. Some even speak of underdiagnosis and undertreatment of asthma in children. As a result, many children do not achieve the primary treatment goals: maximum quality of life, minimal symptoms with minimal medication, no limitations on physical activity, and normal lung function. This guideline aims to address this shortfall by raising awareness among general practitioners about asthma diagnosis, leading to quicker and more accurate treatment of asthma in children.
Concepts
Asthma is a syndrome resulting from reversible airway obstruction caused by airway inflammation. It is characterized by coughing, wheezing, and dyspnea. The definition of asthma, as accepted by the international consensus group in 1992, is particularly vague, describing it as a condition with episodic wheezing and/or cough in a clinical picture suggestive of asthma, with other rare diseases excluded.
In population studies conducted with children over 10 to 25 years in the same region using the same methods, high prevalence rates were found. However, this may be insufficient evidence as objective measuring instruments were lacking in most studies.
BURR ML, BUTLAND BK, KING S, VAUGHAN-WILLIAMS E. Changes in asthma prevalence: two surveys 15 years apart. Arch Dis Child 1989; 64: 1452-6.
MAGNUS P, JAAKKOLA JJ. Secular trend in the occurrence of asthma among children and young adults: critical appraisal of repeated cross-sectional surveys. BMJ 1997; 314: 1795-9.
Only one reference could be found on this topic. Even after consulting local quality groups, there is a general impression that asthma is insufficiently diagnosed.
SPEIGHT AN, LEE DA, HEY EN. Underdiagnosis and undertreatment of asthma in childhood. BMJ 1983; 286: 1253-6.
This consensus group consists of various representatives (pediatricians, primary care workers, and pediatric pulmonologists) from 22 countries.
ANONYMOUS. Asthma: a follow-up statement from an international pediatric asthma consensus group. Arch of Dis in Childhood 1992; 67: 240-8.
We can describe asthma in different aspects:
Pathologically: Asthma is a chronic inflammatory disease of the airways, where a chronic cellular infiltrate consisting of lymphocytes, eosinophils, macrophages, and neutrophils is present in the walls of the small airways. With each exacerbation of asthma, the inflammation increases.
Pathophysiologically: Asthma is characterized by diffuse airway obstruction, spread in the peripheral airways. This obstruction is reversible, either spontaneously or after treatment. There is an increased airway response to various stimuli, to which healthy individuals do not react. This increased response is also referred to as bronchial hyperreactivity. Bronchial hyperreactivity can usually be demonstrated but is neither mandatory nor specific for asthma in children. During obstruction, lung functions are impaired. In the early stages of asthma, lung function tests between crises should be completely normal.
Clinically: We define asthma as a syndrome with episodic wheezing and/or cough in a clinical setting suggestive of asthma, with other diseases excluded. Symptoms of asthma include dyspnea, excessive mucus in the chest, coughing, and/or wheezing due to increased airway sensitivity to allergenic and non-allergenic stimuli. Asthma is, in other words, a syndrome.
The clinical presentation of asthma can be nonspecific. In some children, asthma may manifest through a “variant clinic,” such as chronic cough, hypersecretory airways (mucus formation, chronic bronchitis), or recurrent infections (e.g., recurrent pneumonia).
GODFREY S. Airway inflammation, bronchial reactivity and asthma. Agents Actions Suppl 1993; 40: 109-43.
KERREBIJN KF. Consensus asthma in children. Ned Tijdschr Geneeskd 1993; 137: 25.
ANONYMOUS. Asthma: a follow-up statement from an international pediatric asthma consensus group. Arch of Dis in Childhood 1992; 67: 240-8.
RECOMMENDATION: ASTHMA IN CHILDREN PEF or peak flow measurement is the determination of the maximum airflow during forced exhalation using a peak flow meter. PEF variability (%) is the difference between the highest value (in the evening) and the lowest value of the day (in the morning), divided by the average of these values multiplied by one hundred. The personal “best value” is the highest PEF measurement achieved when the child’s asthma is under control.
Exercise-induced asthma is a form of asthma where a temporary increase in airway resistance occurs a few minutes after intense exercise.
Wheezing is a prolonged (>200 ms) or continuous musical respiratory sound of varying intensity, which can be expiratory and/or inspiratory. It indicates partial obstruction of the larger bronchi.
Atopy is the predisposition to produce abnormally high amounts of IgE in response to exposure to common environmental allergens.
Epidemiology
Asthma is the most common chronic disease in children. The prevalence of asthma in children in the general population is 5 to 10%, and it has been increasing in recent years. Asthma is more common in young children (0-4 years). Asthma is 1.4 to 2 times more common in boys than in girls. Asthma is also more common in atopic children. Asthma is increasingly prevalent among the lower socio-economic class. The mortality rate due to asthma in the general population has been rising since 1980, although the percentage of mortality within the group of asthma patients is declining.
The symptoms and complaints of asthma in children disappear in 30-50% of cases before or around puberty. Negative prognostic factors include the severity of the disease.