How to PROPERLY Diagnose Asthma in Toddlers

Are you wondering if your provider properly diagnosed asthma in your toddler?  Or are you concerned about symptoms of asthma in your toddler and want to know whether you should worry?

Or perhaps you saw your primary care provider, and they told you that your baby girl has asthma… and you are curious how they got that answer?  Maybe you’re fact checking them and hope that their asthma-toddler diagnosis is ‘pants on fire?’

If you have questions like these, then look no further!   I will answer all your questions today!

How to properly diagnose asthma in toddler
Want to know about asthma in toddlers? This post is for you!

I wrote this article to help a small but growing group of worried parents:  those of you who have a toddler (less than age 4) with an asthma diagnosis OR those of you who’ve noticed possible symptoms of asthma and want to know whether you should worry.

Today, we will go through how to PROPERLY diagnose asthma in toddlers.

Who should read this article?

This article is not for everyone.  But for some of you, I hope it is EXACTLY what you were looking for.

You should read my asthma in toddlers article if:

  • Your son or daughter has an asthma diagnosis and you want to know why
  • Your provider told you that your son or daughter has asthma and you feel the diagnosis is wrong.
  • You’re curious about specific asthma symptoms in toddlers
  • Your toddler has asthma symptoms (like wheezing, nighttime coughing, shortness of breath, or frequent lung infections)
  • Your child has albuterol or a nebulizer (for any reason)

In addition, I would recommend this article if you are:

  • A medical provider wanting to review properly diagnosing asthma in toddlers
  • You are a teacher/caregiver wanted to review asthma symptoms in toddlers
  • If you, as a parent, have a history of asthma and have a small child… I also recommend you read this (at least the “symptoms of asthma in toddlers” section)

I have written this article to address asthma in toddler age kids.  I am working on a post for asthma in babies and a huge guide for asthma in children.

If you have a child with asthma, I recommend you read one of these articles instead (until I finish my full asthma in children post):

For everyone else, I’m guessing this article isn’t for you.  But while you’re here, why not take this time and read two of my recent articles and take control of your allergy/asthma/eczema/food reactions?

My goal for you—the parents worried about asthma in toddlers

I wrote this article because I feel parents of toddlers with asthma are a neglected group:  you’re not often given a proper asthma diagnosis, correct education or even long term prognosis and explanations.

I don’t think this neglect has happened on purpose.

It’s just that many asthma symptoms in toddlers are common, leading to a potential mis-diagnosis of asthma (or at the minimum a poor explanation) OR an under-diagnosis of asthma (leading to poor treatment).  But the initial treatment common and most kids respond well to it, so many primary care providers are less likely to refer you to an asthma specialist.

So you kind of get stuck.

I see a lot of stuck parents.  And most of them come to me with worries that fall into two categories:

  1. They’re worried about asthma symptoms in their toddler and want to KNOW whether they have asthma
  2. Their providers diagnosed their toddler with asthma but are not sure if that’s a correct diagnosis

Today, I will do my best to help both types of worries and, together, we will arrive at the right answer by the end of the article.

But if, at any point, you have questions or I don’t answer your worries to your satisfaction, email me and I will help you get the best answer for your son or daughter.


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It is different to diagnose asthma in a toddler than in an a child or adult
Diagnosing asthma in toddlers is different than in kids or adults

How his asthma normally diagnosed?

Diagnosing asthma in toddlers who cannot talk is neither easy nor precise. But there are good guidelines that, if followed, can help make sure your son or daughter is getting the correct diagnosis and treatment.

But first, it is important to know how we normally diagnose asthma.

Asthma belongs in a category known as a clinical diagnosis. This means that if something looks like asthma, sounds like asthma, and responds to treatment like asthma… then it can be correctly diagnosed as asthma.

As an asthma specialist, I know tons of nuances about asthma in toddlers, kids and adult patients.  I know I can make a correct clinical diagnosis… but I STILL want a measurement if possible.

The most common objective measurements used to diagnose asthma are:

  1. A spirometry consistent with asthma (with a 12% lung volume improvement after treatment)
  2. A methacholine challenge (with a 20% reduction in lung function after the test)
  3. Peak flow monitoring and improvement after treatment (this one is less precise)
  4. Or, at a minimum, a strong clinical improvement after treating (associated with an objective improvement in the childhood asthma control test or adult asthma control test)

Problems with these tests for asthma in toddlers

These tests are great, standardized, reproducible gold-standard tests that are reliable… maybe as early as age 5-6 (but likely 7-8 or older).

But if your beloved child can’t understand the phrase “grumble grumble it’s 6:30 in the morning go back to bed until 8” then they cannot do these tests (BTW thanks, Luke, for the 1:45-3am tantrum last night.  You’re the best.)

So does this mean you’re stuck with the “”’if it looks like asthma and sounds like asthma it must be asthma’ diagnosis?

The answer is no.

Wheezing in an infant or toddler

Wheezing is not alsways asthma toddlers
My boys, Luke and Emmett. Luke’s wheezes are because of snot… or the one time he swallowed an opal.

I’ve discussed what causes asthma symptoms and recognizing asthma attacks in your child, and these articles all focus on the main symptoms of asthma:

But with a toddler, “asthma symptoms” such as wheezing, shortness of breath or coughing are not always asthma.  In fact, about 40% of children wheeze during their first year of life.

Why?  The lungs of a youngling differ from the airways of an older child or adult.  Your toddler has less smooth muscle in their lungs resulting in more mucous.  Mucous can cause more coughing and wheezing, chest tightness, shortness of breath and even rapid breathing (sounds just like asthma symptoms, doesn’t it?!)

Want another wrench thrown into this diagnostic confusion?

If you look at wheezing (the most common symptom leading to a diagnosis of asthma in toddlers), most wheezing during the first 3 years of your son or daughter’s life are due to viruses (often a respiratory syncytial virus or RSV).

So if your primary care provider is using the childhood or adult signs and symptoms of asthma to diagnose asthma in toddlers… they’re going to over-diagnose asthma!

What you need to use to determine if what you’re seeing, as a parent, are asthma symptoms in your toddler is a combination of two unique elements of care:

  1. First, know the most specific asthma symptoms seen in toddlers
  2. Apply your toddler’s asthma symptoms to the asthma predictive index model

We’ll do these together to help predict whether your son or daughter REALLY has asthma.

Specific signs and symptoms of asthma in toddlers

Now you know your son or daughter will wheeze more than older children or adults (especially with colds or viral infections), you know you need to be more specific with your toddlers “asthma” symptoms.

I would rather you focus on two or more symptoms:

  1. Has your son or daughter had four or more wheezing episodes
    • lasting more than a day
    • in the past year
  2. Have these wheezing episodes affected their sleep?

This clarification seems minor, but is the best way to separate out wheezing from more ‘normal’ or viral causes from those that are more concerning for asthma.

Having at least four wheezing episodes lasting more than a day and affecting sleep is the key symptom of asthma in a toddler.

This is not the ONLY symptom, but as an asthma specialist if I hear wheezing that falls into this pattern then I am more worried for asthma (and will apply the asthma predictive index as listed next).  If the wheezing does not fall into this category, I am more likely to label your child with the symptom (in this case, “wheezing”) and not diagnose you asthma in your toddler.

The asthma predictive Index

The asthma predictive index (API) was first created and validated by Dr. Castro-Rodriguez in 2010 and reliably predict asthma in children < 3.

It is a list of highly correlated asthma risk factors which, when combined with the symptoms from above, can tell if your child is at an increased risk for lifelong asthma.

Think of it this way:

 

According to the asthma predictive index, a child under the age of 3 with four or more wheezing episodes in the last year (that lasted longer than a day and affected their sleep) is more likely to have persistent, lifelong asthma after the age of 5 if they have:

ONE of these major criteria

  • A parent with asthma
  • A physician diagnosis of atopic dermatitis (eczema)
  • Blood or skin tests showing positives to allergies (trees, grasses, weeds, molds or dust mites)

OR TWO of these minor criteria

  • Evidence of food allergies (diagnosed with a blood or skin test)
  • 4% or more eosinophils (found on a complete blood count, or CBC)
  • Wheezing NOT during colds

 Interpretation and asthma predictive index reliability

If a child under the age of 3 with four or more wheezing episodes in the last year (that lasted longer than a day and affected their sleep) also has ONE MAJOR criteria or TWO MINOR criteria then there is a 76% chance they will have lifelong asthma.

If a child under the age of 3 with the same wheezing symptoms has NO MAJOR OR MINOR criteria there is a 97% chance they will not have lifelong asthma.

If you follow this guideline, 76% of children age > 5 who developed lifelong asthma had a positive asthma predictive index.  97% of kids > 5 without asthma had a negative asthma predictive index.

This means that if your child has wheezing as described above but does NOT have a positive asthma predictive index, they do NOT have asthma (the test is wrong in only 3 out of 100 kids).  This means that the asthma predictive index is a great test to rule out asthma.

But if your child has wheezing as I described above and DOES have a positive asthma predictive index, they are likely to have asthma but about 1 out of 4 kids will grow up and NOT have asthma.  A positive asthma predictive index does not guarantee asthma in your toddler, but is positive enough I would treat your child as an asthmatic but monitor them as they grow up and hopefully remove the diagnosis.

Why place labels on my kid, anyway?

get a proper asthma in toddler diagnosis
A correct asthma diagnosis is important for the care of your child

Identifying the correct asthma symptoms in toddlers and using the asthma predictive index, I can tell you with relative accuracy whether your son or daughter will have asthma.  If they have a high likelihood, I will diagnose your toddler with asthma.  If not, they have a diagnosis of “wheezing” or something else.

And I might even treat them both with the same nebulizer medication regardless of the diagnosis.

So why is it important to get the right diagnosis and call it asthma?

First a note to my conspiracy theorists—I do not diagnose a kid with asthma because I am paid by Big Pharma to get kids hooked on medication at a young age.  I do not get reimbursed more for medical visits by diagnosing a child with asthma.  And I don’t have a Dr. House mentality where I fill my ego with a diagnosis of asthma then celebrate by mocking my staff, buying a motorcycle, and drinking bourbon at night.

Although I might prefer any of those answers over the truth.

Asthma is a very misunderstood diagnosis (even by medical professionals) and giving your child a correct label of asthma will help them get the correct monitoring and care over the next few years.

Specifically:

  • If I CORRECTLY diagnosed asthma in your toddler, other medical providers will know to watch out for colds, flus or other asthma attack symptoms.
  • If I diagnose your child with asthma and they need to go to the ER, they will have their lungs monitored closer than if they weren’t.
  • If I tell your child’s daycare they have asthma, they will be more mindful of colds, coughing and wheezing
  • And if I diagnose your child with asthma, then MAYBE you can use it to help influence family or friends to not smoke around your child (this works for adults, but doesn’t have the same impact on kids).

I admit it would be ideal that everyone would just know the warning signs and symptoms of asthma and just assess your child independent of having an asthma diagnosis.  But then again, many of you got to this article because you weren’t given all the information for your toddler’s asthma symptoms from your medical provider… so you can see how getting a proper diagnosis makes sense.

Summary

Today’s article was a very specific one aimed at helping you learn how to properly diagnose asthma in toddlers.

We discussed that although asthma is a clinical diagnosis, objective tests and measurements are a valuable aid in making the diagnosis… and that none of these apply to your child due to their age.

You learned that the normal symptoms of asthma do not apply to your toddler, and that the most important asthma symptoms in toddlers is having 4 or more wheezing episodes in a year (with each one lasting more than a day and affecting sleep).  And that if your son or daughter meets these symptoms, you can then apply the asthma predictive index to see if they are more or less likely to have a true diagnosis of asthma.

Finally, you learned that getting a correct diagnosis is not just a gee whiz exercise but an important part of the overall healthcare of your child!

Questions?

If you have questions thoughts please either leave them below OR add them to the post on my Facebook page.

And if you liked this article, you can easily get more of them by SUBSCRIBING BELOW.
I’d like MORE tips and tricks
 

 

Sources:

  1. Castro-Rodriguez JA, et al. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med 2000; 162: 1403-1406.
  2. Danielsen, Signe Elise et al.  A new diagnosis of asthma or COPD is linked ot smoking cessation – The tromso study.  Int J Chron Obstruc Pulm Dis. 2016; 11: 1453-1458.
  3. Leim, Joel J, et al.  Asthma is not enough:  continuation of smoking among parents with an asthmatic child.  Can Respir J.  2007 Sep; 14(6): 349-353.

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