Ambiguous labels contribute to underdiagnosis of asthma in children

Under-diagnosis of asthma remains a problem in children with acute cough who are being given ambiguous and outdated labels such as “viral-induced wheeze” when they present to emergency departments, a Queensland study suggests.

Cough-related illness poses a major burden for families with young children who are frequent attenders at GPs and emergency departments, according to a review of cases managed at the Royal Children’s Hospital in Brisbane between 2011 and 2014.

After excluding children who were given a diagnosis of asthma at the ED, researchers reviewed the history and management of 537 children  – mostly preschoolers – who presented with acute cough.

While the management of conditions such as croup and bronchiolitis was generally close to that recommended in best practice guidelines, there was considerable inconsistency and  variation from guidelines in management of wheeze and non-specific acute respiratory infection in young children.

The largest diagnostic group consisted of children with ‘non-specific acute respiratory infection’ for whom there was wide variation in management. More than one in three (35%)  underwent investigations  such as chest X-ray deemed unnecessary in best practice guidelines for cough-related ARI.

One in three children had a discharge diagnosis of wheeze or reactive airways disease (RAD), of whom almost all (96%) received bronchodilators and 73% received oral corticosteroids.

Writing in the Journal of Paediatrics and Child Health, the study authors noted that almost half these children had a previous diagnosis of asthma and one in four had been hospitalised for asthma. The characteristics of children with wheeze/RAD and their history of frequent prior treatment indicated that asthma was under-diagnosed in this group, they said.

“The management of many children with ‘wheeze/RAD’ suggests a reluctance to assign a diagnosis of asthma in our cohort, which may contribute to an ongoing burden for these families,” they wrote.

Ambiguous terms such as viral-induced and multi-trigger wheeze are still being used by some clinicians but should be abandoned, they advised.

“Another factor that may have contributed to asthma being under-diagnosed despite recurrent episodes is the incorrect perception that children aged <5-years should not be diagnosed with asthma,” they added.

“The wide variation in care combined with the high burden to families suggests that greater attention to the application of best-practice guidelines could have a significant impact on the care of children with acute cough,” they concluded.

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