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 Considering that up to 80% of children with asthma develop symptoms before age 5, it is no surprise that the medical community has focused increasingly on catching the disease earlier.1
"We're seeing it more and more at our center," said Stanley Szefler, MD, head of pediatric clinical pharmacology at National Jewish Health in Denver.
"More primary care providers are referring younger children to be certain of the diagnosis and to get help with the teaching, medication administration and early treatment strategies."
A growing body of research and updated professional recommendations are supporting them to make this early diagnosis accurately. The American Thoracic Society and European Respiratory Society in June 2007 issued recommendations for performing pulmonary function testing in preschool-aged children.2
And the National Asthma Education and Prevention Program released its updated EPR-3 guidelines with expanded recommendations for childhood asthma just 2 months later.3
"There's much more attention being paid to asthma diagnosis in early childhood," said Mark A. Brown, MD, a pediatric pulmonologist at the Arizona Respiratory Center in Tucson. "The primary reason is the recognition over the past decade that asthma is a disease that starts in early childhood for the vast majority of people who have it."
Catching it early
The Tucson Children's Respiratory Study last year released extensive data demonstrating that lung function in early childhood plays a significant role in determining lung function in early adulthood.4 Thus, researchers suggest that early recognition and intervention could be the key to changing the course of the disease later on.
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Is insurance ready to take the leap?
While limited diagnostic tools may cause some providers to delay diagnosis, others might hold off because of potential financial ramifications for their patients.
"Insurance coverage is still a barrier," said Mark A. Brown, MD, a pediatric pulmonologist at the Arizona Respiratory Center in Tucson. "It's less of a barrier than when I first started out about 20 years ago, but it is still a concern that many pediatricians have in terms of actually giving the child a diagnosis of asthma."
Todd A. Mahr, MD, has heard about these insurance woes firsthand from distraught parents who said their child was dropped from health insurance after receiving an asthma diagnosis and switching providers. Others said their insurance company placed riders on their children to refuse coverage for any problems related to the respiratory tract.
As a result, a number of providers shy away from labeling a child with asthma and instead identify the issue by another name such as "wheezy bronchitis" or "reactive airways disease."
While this may save parents hassle with insurance companies, it often creates deleterious clinical effects. "The dilemma comes in that the parents don't perceive the child as having asthma, so they don't take the steps necessary for proper management," said Mahr, who serves as director of pediatric allergy at Gundersen Lutheran Health Systems in La Crosse, Wis.
Providers need to understand these children definitely benefit from having the diagnosis made and appropriate therapy started, Brown noted.
Appropriate diagnosis also can enable providers to help families tailor a nontherapeutic intervention to reduce asthma triggers. This might include removing pets from the home; not smoking in the house; using filters to improve indoor air quality; and encasing the mattress, box spring and pillows for dust mites.
Some insurance companies have begun to recognize the benefits of such interventions. "A few have actually taken the lead in chronic disease management and have asthma management programs," Brown said.
For instance, if they detect a patient getting a number of albuterol refills in a short amount of time, but not receiving a controller medication, they will contact the prescriber to review the case and determine if the person needs more aggressive therapy.
"It's a rather enlightened approach to the problem," Brown said.
-- Colleen Mullarkey
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"Without timely diagnosis and treatment of asthma, there certainly is a risk for recurrent episodes," Szefler said. "Repeated episodes of wheezing may [warn of] more severe asthma down the road that could lead to a greater loss of pulmonary function."
Delays in diagnosis also may increase the risk of morbidity and fatality, permanently decrease lung function, and increase the number of school absences and days with symptoms.5
"All of that really adds up to a significant impact on society and on families," said Todd A. Mahr, MD, director of pediatric allergy at Gundersen Lutheran Health Systems in La Crosse, Wis.
But despite all of the evidence supporting early diagnosis, a 2008 study found that of 276 children with asthma, 179 had delayed diagnosis with a mean delay of 3.3 years.6
"It's very hard to define asthma in young children -- it's more of a symptom pattern that evolves that helps to confirm the diagnosis," Szefler explained.
Expanding measures
Many healthcare providers note that diagnosis in older children has become more easily attainable as spirometry has improved.
"I think primary care providers are quite familiar with asthma, but the earlier it presents and the more difficult it is to achieve control, the more I would encourage them to involve a specialist to help oversee the care," Szefler said.
Specialists now have more tools at their fingertips to aid in diagnosis of these tricky cases, such as exhaled nitric oxide measurement. "[eNO] is gaining wider and wider acceptance as a way to detect airway inflammation in children, which can assist in diagnosis," Brown said.
A recent study conducted in Israel confirmed its usefulness in early diagnosis of pediatric asthma, especially in cases where the diagnosis is unclear.7
However, Brown cautioned that it is not reliable on its own as a diagnostic tool and must be used in conjunction with other measures like physical exam, clinical response to bronchodilators, and spirometry.
Spirometry still remains one of the most reliable diagnostic tools, and research now has enabled providers to extend its utility to children under age 5.
In very young infants, they can perform rapid thoracic compression, also known as "baby spirometry" or "the squeeze technique." The infant is sedated and placed in a vest that is filled with different pressure levels of air, which causes rapid exhalation. Using a mask with a pneumotach, clinicians measure the child's flow limitation. However, Brown noted that the technique does not work as well in children older than 18 months.
"That's why it was really quite important for researchers to publish [spirometric] values down to age 3," Brown said. "It reduces the blind spot that we have from infant pulmonary function testing to standard spirometry."
Colleen Mullarkey is assistant editor at ADVANCE for Respiratory Care and Sleep Medicine. Reach her at
cmullarkey@advanceweb.com.
References
1. Kemp, JP, Kemp, JA. Management of asthma in children. Am Fam Physician. 2001;63(7):1341-8.
2. Beydon N, Davis, SD, Lombardi E, et al. An official American Thoracic Society/European Respiratory Society statement: pulmonary function testing in preschool children. Am J Crit Care Med. 2007;15:175(12):1304-45.
3. National Heart, Lung, and Blood Institute. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma. Item 08-4051. 2007.
4. Stern DA, Morgan WJ, Wright AL, et al. Poor airway function in early infancy and lung function by age 22 years: a non-selective longitudinal cohort study. Lancet. 2007;370(9589):758-64.
5. Lieberman PL. The great asthma raft debate: delayed asthma diagnosis [powerpoint presentation]. Seattle (WA): American College of Allergy, Asthma & Immunology Annual Meeting;2008.
6. Molis WE, et al. Timeliness of diagnosis of asthma in children and its predictors. Allergy. 2008;63(11):1529-35.
7. Sivan Y, Gadish T, Fireman E. The use of exhaled nitric oxide in the diagnosis of asthma in school children. J Pediatric. Epub 2009 Apr 23.
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