by Warren P. Silberstein, M.D.
06/09/97
The diagnosis of asthma may be obvious in children who have recurrent episodes of wheezing with difficulty breathing, but in many children who don't experience such severe symptoms, the diagnosis may not be obvious. The diagnosis of asthma should be considered in any child who has recurrent bronchitis or recurrent cough, especially nighttime or early morning cough. This is especially true if the child has allergies or eczema, or there is a family history of asthma or allergies. Additional clues that might point to a diagnosis of asthma include:
Most children who have asthma will have increased symptoms when they have colds. Many young infants only have wheezing when they have viral upper respiratory infections.
Infants may often have wheezing for the first time with bronchiolitis. Bronchiolitis is a respiratory infection caused by respiratory syncitial virus (RSV) and other viruses. The peak incidence of bronchiolitis is in the winter and early spring, and the peak age incidence is around 6 months. In older children it tends to cause cold symptoms, but in infants, after the cold symptoms develop, they start to wheeze. Most infants will never have a second or third bout of bronchiolitis, so that recurrent wheezing, even if it is associated with upper respiratory symptoms, should raise the suspicion of asthma. Infants' often have a frequent, tight cough at the onset of symptoms just like older children; however their respiratory symptoms often differ from older children. Rather than breathing heavily, their first respiratory symptoms may be very rapid breathing. Management of infant asthma presents some unique problems. Since infant airways are small, a tiny amount of mucus production and airway edema (tissue swelling) can cause a significant amount of airway narrowing. Infants have proportionately less smooth muscle around their airways resulting in less support for the airway, but also less spasm of the airway. As a result, infants also have less response to the bronchodilator medicines which open up the airways and provide older asthmatics such quick relief.
Toddlers present a diagnostic challenge because wheezing occurs mostly as the air is coming out and so does crying. Since most toddlers cry when being examined by a physician, their crying obscures the wheezing. Parents can help to make the examination successful in several ways. First, remove your child's shirt and undershirt as soon as you enter the examining room. Children often start to cry when they are undressed for an examination because they have some idea what will happen. If the child's shirt is off when the physician enters the room, it provides the physician with an opportunity to observe the child's breathing while he is quiet. Even if he starts to cry when the doctor enters the room, the baby can usually be calmed faster if he doesn't first have to be undressed. The examination should be carried out with the toddler held by a parent, either in the parent's arms or in her lap. The parent should talk softly to the baby during the entire examination. The conversation should be about something likely to interest the child and not the examination. Toys, pictures in the room, windows, keys, and any variety of objects can be used to distract the child. If an older sibling or another parent or grandparent is present, a game of peek-a-boo can be very effective distraction. And then, the pediatrician must be patient in order to hear a few good breaths without crying. Unfortunately, a quiet toddler who has just finished crying will probably breathe very quietly. In order to hear any wheezing, the pediatrician may need to gently squeeze the chest as the air is coming out, but putting a hand between Mom and child to squeeze the chest may result in more crying.
If there is a question of whether the child is wheezing, sometimes a therapeutic trial of asthma medication maybe helpful. Since the definition of asthma includes not only recurrent symptoms, but also, reversible airway spasm, a good response to medication may help to make the diagnosis.
Next article in sereies: Asthma Medications - Part I - Rescue Medications
For additional information, you might like to check out a Multimedia Tutorial about asthma or this article about Recognizing Asthma Signs and Symptoms.
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