Differential Diagnosis

(Children 5 years and younger)

Infections
  • Bronchiolitis, viral respiratory tract infections
    • RSV dominates in infants aged <12 months, human rhinovirus (HRV) >12 months
    • Obliterative bronchiolitis, usually post-infective in previously well children (adenovirus, Mycoplasma pneumoniae)
  • Viral laryngotracheitis (croup), epiglottitis
  • Chronic rhinosinusitis
  • Tuberculosis
  • Pertussis
  • Tonsillitis
  • Tonsillar, retropharyngeal abscess

Congenital problems
  • Bronchopulmonary dysplasia (chronic lung disease of infancy, CLDI)
  • Laryngotracheomalacia, bronchomalacia
  • Cystic fibrosis
  • Congenital malformation causing narrowing of the intrathoracic airways, TEF
  • Primary ciliary dyskinesia
  • Immunodeficiency, HIV
  • Congenital heart disease, heart failure
  • Sickle cell (acute chest)
  • Other: Diaphragmatic hernia, pulmonary lymphangiectasia, carnitine deficiency
  • Interstitial lung diseases


Mechanical/Airway problems
  • Foreign body aspiration
  • GER
  • Subglottic or tracheal stenosis
  • Vocal cord dysfunction, paralysis, laryngeal papilloma
  • Masses causing airway compression (lymph nodes, neoplasms, thyroglossal duct cyst)
  • Vascular rings or laryngeal webs

Other
  • Munchausen syndrome by proxy
  • Pulmonary langerhans cell histiocytosis
  • Neuromuscular disorder
  • Psychogenic cough


Wheezing_ddx_by_age.png



















Clues in History

Clue
Possible Diagnosis
Sudden onset
Foreign object
Intubation at birth
Subglottic stenosis, CLDI
Symptom onset in first days of life
Congenital malformation

Ciliary dyskinesia
Maternal papillomatosis
Laryngeal papilloma
Forceps delivery
Vocal cord injury
Difficulty/choking on feeds
Congenital heart defect, failure

Neurogenic defect

Laryngeal cleft
Symptoms worse after feed, lying down, vomiting
GERD
Irritability, vomiting, torticollis----
Sandifer syndrome
Recurrent pneumonia
Aspiration

TEF

CF

Ciliary dyskinesia

Immunodeficiency

HIV
Formula changes
Milk or soy allergy
Isolated episode
TB

RSV

Adenovirus

Histoplasmosis

Parainfluenza virus

Metapneumovirus
Eczema, urticaria
Atopic diseases associated with asthma----
Severe or recurrent infections
Immunodeficiencies
Recurrent (episodic) wheezing ≥4 episodes
Asthma
Continuous (non-episodic) symptoms
Unlikely to be asthma



Atypical wheezing

  • Features that should alert the physician to consider a diagnosis other than asthma should include:
    • Symptoms starting at or shortly after birth
    • Continuous wheezing
    • Failure to thrive
    • Complete failure to respond to anti-asthma medications
    • No association with typical triggers, such as viral upper respiratory infections or exposure to allergens

diffuse lung diseases of infancy.pngILD in children.png

Physical Exam

Severe asthma pediatric exam.png

Testing

  • Asthma Control Test questionnaire
  • Relevant allergy testing
  • Lung function tests
    • Spirometry - per the ATS, children as young as 5 years old are often able to perform acceptable spirometry, with appropriate coaching
      • FEV1 is generally normal in children with asthma (even severe persistent asthma) whereas the FEV1/FVC ratio decreases as asthma severity increases
    • Peak flow monitoring
    • Impulse oscillometry (IOS) - validated technique measuring respiratory impedance that is used as an indicator of lung function. It requires minimal cooperation and is useful in preschool children (who often cannot perform acceptable spirometry), older children and adults
    • Exhaled nitric oxide (FeNO) - FDA: NIOX MINO cannot be used with infants or by children approximately under the age of 7, as measurement requires patient cooperation
  • Adjunct tests
    • Chest X-ray - usually indicated in the initial evaluation of a child with asthma, particularly if none have been performed previously
      • Peribronchiolar inflammatory changes and atelectasis are commonly observed in children with persistent asthma
    • Serum eosinophil level - eosinophilia is supportive of asthma diagnosis
    • IgE level - elevated level is supportive of asthma diagnosis
    • 25(OH) Vitamin D level
    • Cotinine level - cotinine (nicotine metabolite with ~20 hour half-life) serum or urine level may document second-hand smoke exposure




Risk Factors for Developing Asthma


Asthma Predictive Indices

api_nonmodified.png
  • To have a positive API, a child must wheeze before age 3 years and have either 1 of 2 major criteria or 2 of 3 minor criteria.

asthma_predictive_indexes.png
API_strict_ppv.png

Note
  • Children who wheezed frequently before age 3 years and had a positive API at age 3 years were nearly 10 times more likely to have active asthma at age 6 years and nearly 6 times more likely to have active asthma at age 13 years than children with a negative API
  • Modified API (mAPI) used for enrollment of children in PEAK study



Wheezing Phenotypes and Natural History

TCRS.png


Treatment


Management of Early Childhood Asthma (Bacharier)


Early childhood asthma algo.png
Treatment strategies for severe intermittent or mild persistent asthma
Daily treatment
  • Daily ICS is most effective in preventing exacerbations (but more likely to elicit ICS-related adverse effects)
  • Daily montelukast
    • 6 months-5 years - 4 mg oral granules packet PO QD
    • 2-5 years - 4 mg chewable tablet PO QD
    • 6-14 years - 5 mg chewable tablet PO QD
    • ≥15 years - 10 mg tablet PO QD
  • Daily low dose ICS
    • PEAK study: Fluticasone MDI 44 μg - 2 puffs BID via spacer/mask for 2-3 year olds with positive mAPI
    • CAMP study: Budesonide DPI 200 μg - 1 puff BID for 5-12 year olds with mild/moderate asthma
    • TREXA study: Beclomethasone HFA MDI 40 μg - 1 puff BID for 5-18 year olds with mild persistent asthma
    • MIST study: Budesonide 0.5 mg nebulized QHS for 1-4 year olds with positive mAPI
Intermittent treatment
  • May be considered for children with predominantly viral-induced exacerbations who are otherwise asymptomatic when healthy (low impairment)
  • MIST study: intermittent treatment equivalent to daily treatment with less adverse effects
  • Consider as a step down from daily ICS treatment
  • Intermittent montelukast - limited data on effectiveness
  • Intermittent high dose ICS
    • TREXA study: Beclomethasone HFA MDI 40 μg - 2 puffs of ICS with each 2 puffs of albuterol needed for symptoms
    • MIST study: Budesonide 1 mg nebulized BID x 7 days during respiratory tract illness
  • Advair only FDA approved for ages ≥4 years old for moderate/severe asthma, but NAEPP guideline approved for 0-4 year olds
  • Frequent follow-up to monitor control, compliance, inhaler technique, medication step-up or step-down
  • Cigarette smoke avoidance
  • Aeroallergen avoidance if sensitized
  • Consider peak-flow monitoring and asthma action plan
  • Monitor height - affects prepubertal children on ICS; in CAMP follow-up study mean adult height was 1.2 cm lower (95% CI 0.5-1.9 cm lower) in the budesonide group



NAEPP 2007 Guidelines

0-4 years old

naepp_0-4_severity.png
naepp_0-4_control.png
naepp_0-4_treatment.png

5-11 years old

naepp_5-12_severity.png
naepp_5-12_control.png
naepp_5-12_treatment.png



Note:
  • Weinberger: for viral-induced acute exacerbations of asthma in pre-school children, use oral steroids 30 mg/m2 of BSA PO BID; given early in the course of an exacerbation, adequate doses of oral corticosteroids are likely to decrease the high prevalence of urgent care and hospitalization


References



















Patient Hand-outs and Resources