Asthma is defined clinically as the combination of variable respiratory symptoms (such as wheeze, shortness of breath, cough and chest tightness) and an excessive variation in lung function.1
With guidelines changing for the treatment of asthma in adults, it is important to remember that, as far as asthma goes, children are not small adults. The adult asthma treatment paradigm does not apply to children.
A 2019 Australian study found that only 54% of children being treated for asthma in primary care received care adherent to Australian and international paediatric asthma clinical practice guidelines.2
Asthma is sometimes overdiagnosed, leading to a risk of inappropriate treatment.3,4
Conducting spirometry to support an asthma diagnosis is not possible with young children. There are also additional barriers that make it difficult for health professionals to use spirometry, ranging from lack of time, training and equipment, to patient reluctance.
Furthermore, asthma control may not be optimal.5 It’s a delicate balance using relievers and preventers, and it is important to regularly reassess asthma treatment and update asthma action plans.
Spirometry – when and how to use it
Several conditions are often misdiagnosed or prematurely diagnosed as asthma.
Most children who have recurrent wheeze associated with respiratory tract infection at a young age are no longer wheezy by the age of 6 years.6 Misdiagnosis of asthma is problematic in children, as the symptoms of wheezing, breathlessness or cough may result from other conditions, such as upper airway dysfunction, bronchitis and habit-cough syndrome.7
Objective measures of lung function, made using spirometry, are underused8 and may not be possible to obtain with young children, meaning that only a preliminary asthma diagnosis can be made.
Other reasons for the underuse of spirometry are listed in the MedicineWise News article on spirometry in paediatric asthma, together with suggestions to address these issues.
This article also describes patient interaction suggestions to help encourage patients or their carers who may be reluctant to perform a spirometry test. GPs should consider referral to spirometry labs if they lack the time or equipment to conduct spirometry, or do not have adequately trained staff. On 1 November 2018, MBS items for spirometry changed, increasing rebates to promote the use of spirometry testing.
Treatment and asthma action plans
Asthma treatment should aim to use the lowest dose that maintains good asthma control. A stepped approach is recommended by guidelines, with most children using a SABA reliever, as needed.7 Only some children will need regular preventer treatment, which will be either a low-dose ICS or montelukast. Only a few need to step to higher doses of ICS or additional preventer medicines.7
Everyone with asthma should follow an individualised asthma action plan, but Australian statistics from 2019 showed that only 63% of children with asthma have one.9 Using a written asthma action plan improves symptoms and significantly reduces the rate of visits to acute care facilities, and the number of school days missed.10
It is important that health professionals ask regularly about symptom frequency and SABA use, and regularly review each asthma action plan. Overuse of SABA may be a sign that a review of the patient’s asthma plan is needed.7
NPS MedicineWise’s asthma program
The NPS MedicineWise visiting program on asthma, Paediatric asthma – breathing new life into diagnosis and treatment, aims to equip health professionals with tools and resources to diagnose and treat paediatric asthma.
It addresses important topics in the diagnosis and treatment of paediatric asthma, enabling health professionals to:
- discuss with parents and carers of children the factors involved in diagnosing asthma, including spirometry and treatment trials. A definitive diagnosis of asthma may not be possible for young children and asthma should not be diagnosed in infants aged less than 12 months old
- develop and implement asthma action plans for children with asthma or asthma symptoms
- review paediatric patients and update their asthma action plans as appropriate.
Find out more about the Paediatric asthma educational visiting program
Read the MedicineWise News: Spirometry and its role in diagnosing children's asthma
- Australian Medicines Handbook. Adelaide: AMH Pty Ltd, 2019 (accessed 19 November 2019).
- Homaira N, Wiles LK, Gardner C, et al. Assessing appropriateness of paediatric asthma management: a population-based sample survey. Respirology 2020;25:71-79.
- Lucas AE, Smeenk FW, Smeele IJ, et al. Overtreatment with inhaled corticosteroids and diagnostic problems in primary care patients, an exploratory study. Fam Pract 2008;25:86-91.
- Marklund B, Tunsater A, Bengtsson C. How often is the diagnosis bronchial asthma correct? Fam Pract 1999;16:112-6.
- Reddel HK, Sawyer SM, Everett PW, et al. Asthma control in Australia: a cross-sectional web-based survey in a nationally representative population. Med J Aust 2015;202:492-7.
- Oo S, Le Souef P. The wheezing child: an algorithm. Aust Fam Physician 2015;44.
- National Asthma Council Australia. Australian Asthma Handbook, Version 2.0. Melbourne: National Asthma Council Australia, 2019 (accessed 5 September 2019).
- Poels PJ, Schermer TR, Akkermans RP, et al. General practitioners’ needs for ongoing support for the interpretation of spirometry tests.Eur J Gen Pract 2007;13:16-9.
- Australian Bureau of Statistics. National Health Survey: First Results, 2017–18 Cat no 4364.0.55.001. Canberra: ABS, 2019 (accessed 12 September 2019).
- Zemek RL, Bhogal SK, Ducharme FM. Systematic review of randomized controlled trials examining written action plans in children: what is the plan? JAMA Pediatrics 2008;162:157-63.