Clinician-to-Clinician Update Clinician-to-Clinician Update

Challenges in Diagnosing Asthma in Children

September 2017

Asthma is the most common chronic condition in children1, currently affecting approximately 6.2 million in the United States.2 It is the leading cause of missed school days among children ages 5 to 17 and the third leading cause of hospitalization among children under the age of 15.3 In Minnesota, the percentage of children with asthma, 6.4 percent4, is lower than the national average of 8.4 percent2, although the likelihood of having asthma differs by race and ethnicity (Table 1).

Sept-2017-Peds-Consult-Urology Pulmonary Table 09

The triggers for asthma include exercise, infection, allergens (e.g., pollen), occupational exposures (e.g., chemicals), and airborne irritants (e.g., tobacco smoke).

A child who presents to his or her primary care provider with coughing, wheezing, shortness of breath or chest tightness may not necessarily have asthma.

“The biggest challenge, especially in young children, is that there is no one test that gives us a clear answer as to whether or not a child has asthma,” says University of Minnesota Health pediatric pulmonologist Gail Brottman, MD.

University of Minnesota Health pediatric pulmonologists evaluate hundreds of patients each year who have been referred because their pulmonary symptoms do not fit a clear diagnosis or they have not responded to standard drug therapy. For these patients, the pulmonologists complete a physical examination and obtain a detailed medical history, noting whether any of the risk factors for persistent wheezing5 are present and whether there is any history of recurrent wheezing or wheezing between colds. They ask detailed questions about a child’s environment, exposures, and physical endurance. They may prescribe inhaled corticosteroids as a therapeutic trial to see if they produce a positive response and reduce airway inflammation. Spirometry is usually performed; however, this lung function test is difficult to conduct in children under 6 years of age.

Symptoms of asthma are common and can be seen with other diagnoses. Wheezing or cough can also occur with vocal cord dysfunction, habit cough (see case study), or bronchiolitis, a self-limiting viral infection. Other diseases, such as pulmonary fungal infections, which are endemic in the Minnesota River Valley, may be present. “In this area, we see infections caused by histoplasmosis and blastomycosis,” says Brottman. Other possibilities include interstitial lung disease and primary ciliary dyskinesia.

If the diagnosis is asthma, a multidisciplinary team comprising respiratory therapists, nurse educators, psychologists, speech therapists, a social worker, and a dietitian provides comprehensive services.

When corticosteriods are suboptimally effective, pulmonologists may prescribe biologics, including omalizamub (Xolair) and mepolizumab (NUCALA), 2 of the newer medications that target specific cells and mediators involved in the inflammation of the airway. Ongoing international studies of potential biomarkers for different types of asthma may help enable more targeted therapies in the future.

Community providers who would like more information on diagnosis and treatment can contact a University of Minnesota Health pediatric pulmonary staff member through the physician consultation line: 612-365-6777.

References

  1. Data Resource Center for Child & Adolescent Health. National Survey of Children’s Health. NSCH 2011/12. http://childhealthdata.org/browse/survey. Accessed August 2, 2017.
  2. Centers for Disease Control and Prevention. National Center for Health Statistics: Asthma. https://www.cdc.gov/nchs/fastats/asthma.htm. Accessed August 2, 2017.
  3. Centers for Disease Control and Prevention. National Surveillance of Asthma: United States, 2001-2010. https://www.cdc.gov/nchs/data/series/sr_03/ sr03_035.pdf. Accessed July 27, 2017.
  4. Minnesota Department of Health. Asthma Program Quick Facts – Asthma in Minnesota, May 2013. http://www.health.state.mn.us/divs/hpcd/cdee/asthma. Assessed July 27, 2017.
  5. Castro-Rodriguez JA. The asthma predictive index: A very useful tool for predicting asthma in young children. J Allergy Clin Immunol. 2010;126(2): 212-216

When to refer

The pediatric pulmonary and sleep medicine program at University of Minnesota Masonic Children’s Hospital is ranked among the top programs in the nation by U.S. News & World Report. The members of the care team provide services for children with a host of lungrelated concerns, including cystic fibrosis, asthma, allergies, neuromuscular disorders, congenital and growth disorders, lung disease of prematurity/BPD, and pediatric sleep disorders.

The Minnesota Cystic Fibrosis Center, which for 50 years has been at the forefront of cystic fibrosis care nationally and internationally, includes our pediatric pulmonologists. We are also known for our pediatric sleep program that provides consultation for sleep disorders and oversees sleep studies.

The pediatric pulmonology care team also includes respiratory therapists, nurse coordinators, psychologists, speech therapists, a social worker, an allergist, and a dietitian.

Multidisciplinary, Collaborative Care

Our specialists work closely with other pediatric specialists at the hospital, for example rheumatologists in treating lung complications that arise from rheumatoid arthritis and lupus erythematosus. We also provide consultation to hematologists/oncologists in the care of pulmonary complexities associated with organ transplantation/immunosuppression. We work with pediatric neurologists to help care for children with neuromuscular conditions that result in underventilation. These children occasionally require a non-invasive form of ventilation to assist their breathing, especially at night during sleep.

Locations and Referrals

Services are provided at our clinics in Minneapolis, Burnsville, Maple Grove, and Woodbury. To request a referral, visit mhealth.org/childrens-lungcare or call our clinics in Minneapolis (612-365-6777), Burnsville (952-892-2920), Maple Grove (763-898-1220), and Woodbury (888-543-7866). For a complete listing of services and locations, visit mhealth.org/childrens-lungcare.

Clinical Trials

Our physicians are conducting 19 research trials currently. Find pulmonary studies at studyfinder.umn.edu. To learn about our cystic fibrosis research, visit: mhealth.org/care/conditions/cystic-fibrosis/cystic-fibrosis-research.

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